Death of 6-year-old girl on Glenwood Caverns drop ride blamed on operator error

This is why I still check to see if my son is secured on a ride before I get in. I know the instances of this sort of thing are a tiny fraction, but still. That they ignored the machine telling them something was wrong is just astounding.

This is horrible. A child is dead and the operator will forever be haunted by the thought that they didn't check the restraint. Awful all around.

Dave's recommendations for modifications to the ride to prevent this from ever happening again--

a) Modify the restraint block so that when the block is unlocked, a spring or other method automatically ejects the rod from the block. That is, switch from auto-unlock to auto-unfasten. It's worth noting that most push-button seat belt releases are designed so that pressing the release button also ejects the buckle tongue; this system should operate the same way.

b) Add automatic retractors to the secondary seat belt, or eliminate the secondary belt altogether (although ASTM F2291-20:6.4.3.8 and 6.4.3.9 may apply here, which would require the use of a secondary restraint).

c) Replace the webbing on both belts with a high visibility or uniquely patterned material. Ideally, the belts should be different; more ideally, contrasting colors or patterns.

Of course, actually following training and ride procedures goes without saying.

--Dave Althoff, Jr.

I've got a simpler solution: Don't let the ride dispatch if the belt sensor fails. Done.

Jeff said:

I've got a simpler solution: Don't let the ride dispatch if the belt sensor fails. Done.

This. The computers should have never allowed an over ride. Stop everything and go get a technician.

Go back and read the report (it’s linked in the news story). Yes, it says on Page 1 that they override the safety system, but in my opinion that is a mischaracterization of what happened. They actually didn’t override it; they took a series of actions which made the system happy. But they didn’t do those things right.
The alarm was an indication that one or more of the restraints was not cycled; that is, the belt was not unfastened. Hence my recommendation (a) above. In response to this they manually released all of the restraints, then re-locked and re-fastened them…STILL failing to notice that the belt wasn’t routed over the passenger. The passenger contributed to this because she had the loose tail of the secondary belt across her lap (see my recommendation (b)). That means the restraints were checked at least twice, and the computer was not overridden but rather made happy still without making sure this rider was secure. Hence my recommendation (c) to make it blindingly obvious if the primary belt isn’t where it is supposed to be.

Oh, I forgot to add…
d) Properly and appropriately label the restraint fault indicators on the HMI so that the operators know why the ride is throwing a restraint fault.

Such restraint faults are non-critical faults. They will (and did) inhibit cycle start, but they are intended to be cleared through normal operations, and in this case the fault was cleared in the expected way. But the operators managed to make the same operational errors in checking restraints more than once. I’m not sure how to fix that.

—Dave Althoff, Jr.

Scratch recommendation (d). Now that I have seen the ride manual (linked in the report) I've seen the photos of the HMI showing the properly-labeled indicators for restraint status and restraint lock. Which is a good thing, because if those indicators were not labeled, the ride would probably be in violation of ASTM F2291-16:17.3

17.3 Operator controls shall be identified in the English language as to their function.

Instead let's add a training requirement--
(d) All operators shall be trained on the meaning of the restraint fault indicators, and the proper procedure for clearing those faults.

Even better, why not set it up so that when they hit the DISPATCH button with the fault present, the HMI should tell them how to fix it, i.e.

RESTRAINT ON SEAT(S) 3 DID NOT CYCLE.
RELEASE ALL RESTRAINTS AND VERIFY ALL PASSENGERS ARE PROPERLY SECURED.

...or for the fault they apparently *thought* they had...

RESTRAINT ON SEAT(S) 1 2 3 4 5 6 NOT [ENGAGED|LOCKED]
RELEASE ALL RESTRAINTS AND RE-SECURE.

Even basic control systems are smart enough to do that!

--Dave Althoff, Jr.

Awful. As a former ride operator, I know how redundant it can get to check restraints for 8 hours. But you do encounter people that have problems with seat belts and have even seen someone tie them in a knot rather than buckle them. Also, once had a woman with an Arrow horse collar restraint down with a child on her lap. She said "it's ok she can handle it".

Also this situation is really strange. We could never override the safety system without a supervisor or maintenance person with a key. They would occasionally override when a sensor was malfunctioning to get trains/cars back in the station until it could get sorted out. I can't imagine why anyone would override at a dispatch.

Once again, the operators did not override the safety system.

The operators corrected the fault, which allowed the ride to operate. This is equivalent to a coaster with a lap bar position switch, where the dispatch is inhibited and the operator fixes it by giving the bar a shove. When the ride started, the computer thought everything was OK, not because the fault was overridden, but because the condition the computer was complaining about was corrected.
The computer detected that the restraint on Seat #3 had not cycled. They cycled the restraint, and in doing so made the computer happy. In cycling the restraint, the operators failed to do the most basic thing possible and make sure that the restraint was actually fastened around the passenger.
The theory is that the operators did not understand what it meant that the restraint had not cycled, and thought the system was merely complaining that the pin wasn't engaged. Correcting either fault involves cycling the restraint.
Why, when you are manually manipulating the restraint anyway, would you not look at it and make sure it is secured around the rider?

--Dave Althoff, Jr.

The ultimate cause of this rests with the manufacturer and the park for not having a more foolproof restraint system. If one is not under a lap bar or shoulder harness, it’s obvious.

The race to minimalistic restraints leads to this. The Mountain Mionster with only seat belts is ridiculous.

If the cause is that the restraint was not utilized, how is it the fault of the restraint system when, if utilized properly, would have done the job it is supposed to do

And before you claim this couldn’t happen with a rigid restraint, look up the Lightnin’ Loops incident in 1987.

—Dave Althoff, Jr.

Yes it happened with Lightnin Loops, But that had to be glaring neglect. IMO

It’s much easier to sit on a seat belt. A seat belt does not change ones sitting position at all. Sitting on a lap bar or shoulder restraint does and should be more visually obvious

Seat belts in general are more flimsy and should only be secondary or used in a ride without ejecting forces if primary.

I will guess the manufacturer will be named in the lawsuit

I disagree. Rigid restraints are not inherently safer, they just accommodate a wide range of body dimensions quickly and without adjustment, which is ideal in an amusement park. I've seen a similar restraint to this one on the defunct Absolutely Insane rides, and they're quite secure.

Seat belts work on Tower of Terror just fine.

What happens to the ride operators when things like this happen? Obviously fired, but are civil charges filed or are they just left with their guilt? I just couldn’t imagine living with this…

super7* said:

The ultimate cause of this rests with the manufacturer and the park for not having a more foolproof restraint system.

There is no such thing as a foolproof system. The operators (including their training) are a part of that system, and that's where the fault lies.

I see nothing wrong with a minimalist approach to restraints. Most humans have no idea what is perfectly safe with regards to restraints, and less is more when it comes to the thrill-factor.

super7* said:

Yes it happened with Lightnin Loops, But that had to be glaring neglect. IMO

It’s much easier to sit on a seat belt. A seat belt does not change ones sitting position at all. Sitting on a lap bar or shoulder restraint does and should be more visually obvious

Seat belts in general are more flimsy and should only be secondary or used in a ride without ejecting forces if primary.

I will guess the manufacturer will be named in the lawsuit

From 1994 to 2003, Tower of Terror at Walt Disney World ran with lap bars and one seatbelt seat in each car. Each seating position of 3 or 4 riders had a single lap bar with no seatbelt to restrain riders. The 22nd passenger? You sat in front of the accessway and had a seatbelt restraint. Starting in 2003, as cars were sent for annual inspection and repairs, they were modified to remove the lap bars and go to a 21 passenger configuration, with an individual seatbelt for each rider. After that, the Tower of Terror attractions at both Disney California Adventure and Walt Disney Studios Paris opened with the same 21 passenger with seatbelts cars. Tokyo is the oddball here: as japanese guests are smaller, they kept the 8th seat in the back row and each seat has a seat cushion and tighter 3 point seatbelt.

The one glaring mistake that I keep going back to in the report: why didn't the ride operators do what cast members at Tower of Terror, Test Track, Soarin', etc. are trained to do? Why don't they ask guests to lift their arms in the air and check to see if the belt is really across the lap or waist? When I worked Star Tours at Disneyland Paris, we didn't even have a height restriction back then and it was standard procedure to have guests buckle up, lock them up pneumatically and then go up and down the cabin to make sure no one is sitting on the belt. It happened occasionally, which was why the visual inspection was necessary.

I saw someone say that the loading area is kinda dark and its hard to see the seatbelts: buy a pile of 5$ flashlights and make it a standard procedure for your operators to check with them every belt. It works out well enough at Test Track and other dimly lit seatbelt check.

The report and all stories I’ve read on this incident fail to mention who, if anyone, was with the 6-year-old at the time.

Obviously operators are ultimately to blame here.

From a personal non-legal perspective, I have a difficult time understanding how or why a responsible adult...besides disinterested ride operators…weren’t there to notice a six year old sitting on top of two seat belts.

I watched my kids and the operators like hawks when my kids were that age.

For me it is like watching a 6-year-old at a community swimming pool. Sure you could ignore your kid and hope the teenage lifeguards do their job... But it is prudent to check on minors you’re responsible for regardless.

My 17-year-old lifeguards:…and every day he leaves for a shift I remind him to take it seriously…less a horrible accident like this happens on his watch.

Just sickening all around…