Investigation: # 03MI022
Indoor Amusement Manager Killed When Struck By a Moving Roller Coaster
|Figure 1. Derailed Roller Coaster|
On March 1, 2003 a 43-year old male amusement manager was killed when he was struck from behind by a moving roller coaster. On March 3, 2003, MIFACE investigators were informed by the Michigan Occupational Safety and Health Act (MIOSHA) personnel who had received a report on their 24 hour-a-day hotline that a work-related fatal injury had occurred on March 1, 2003. On March 27, 2003 the MIFACE researcher visited the indoor restaurant and game room, spoke with the manager, and viewed the incident site. During the course of writing the report, the death certificate, autopsy results, police report and the MIOSHA citations were obtained. All figures in this report were photos from the MIOSHA report file.
The company received 3 alleged serious citations that all related to the Control of Hazardous Energy sources, Part 85. These citations were that the company did not develop, document and utilize procedures for the control of potentially hazardous energy when employees are engaged in service or maintenance of machines or equipment where unexpected energization, start-up or release of stored energy could occur and cause injury (the coaster was not locked out and the employee was struck by the lead car of the roller coaster while checking a section of the track), there was no training for authorized employees on the recognition of applicable hazardous energy sources, the type and magnitude of the energy available in the workplace, and the methods and means necessary for energy isolation and control, and that training was not provided for affected employees on the purpose and use of the energy control procedure.
This franchise has been in business for approximately 10 years and has franchises located within Michigan and the U.S. The franchise has been at the same location for approximately 7 years. The company has a variety of indoor attractions, such as roller coasters and other mechanical rides, games, and a restaurant/snack area. The victim was a salaried, full-time employee, and had been employed with the company for 7 months. He was the amusement park manager. His responsibilities included maintenance and repair of all equipment (rides, games, etc.) used at the facility. He was also responsible for safety talks with other employees. The victim had 20+ years experience in machine maintenance and repair.
The company did not have a written health and safety program or a health and safety committee; the company had a written health and safety policy statement that gave a general overview of the company’s safety philosophy, but few specifics for MIOSHA-required programs. All employees go through a new hire orientation that included a safety orientation. The safety orientation involved safe ride operation and passenger safety; employees must read and provide a signature indicating that they have read and understand all company policies, including the health and safety policy. The company had a ride operator training checklist that must be completed and signed and dated by the manager and crewmember, certifying that the individual understands how the ride operates and how to ensure the safety of passengers and what to do in case of emergency. All new hires were required to successfully complete a quiz concerning company policies and procedures. The ride operators were trained using the standard operating procedures detailed in the equipment operator’s manual. The company had a permit to operate the roller coaster. The ride had previously passed inspection in 2002 by a Michigan Carnival Amusement act inspector.
Ride operators are trained to run the coaster through three complete circuits, and then stop the coaster, and let the passengers disembark. The company has a safety meeting at least once per month.
The company leases this 5-car roller coaster from the manufacturer. The coaster is designated as a free-fall coaster. The coaster is pulled up the lift hill (the first hill), using a chain wound around gears at both the top of the hill and bottom of the lift hill. (See Figure 2) A motor powers the chain loop and it turns the loop of chain so that the coaster can be raised up the lift hill. The chain is grabbed by 2 sturdy hinged hooks (chain dogs) under the track at the bottom of the lift hill. When the ride starts, the motor powers the chain and the chain/chain dogs pull the cars up the lift hill. At the top of the hill, the chain dogs are released and the roller coaster begins its descent down the hill. Once at the top of the lift hill, the coaster travels by its own power along the tracks and cannot be stopped until the coaster enters the chain area again, where brakes can be applied, and the chain dogs hook onto the chain. The chain area begins before the operator’s position. An emergency stop is present and was functional at the time of the researchers visit.
Figure 2. First Hill of Roller Coaster
The lead car of the roller coaster has a “python” head design; the other 4 cars follow that theme. The roller coaster runs along a 2-inch dual rail track. The track width is 28 inches, with 24 inches between the rails. At the point where it is believed that the victim was hit by the car, the track was 18 inches off of the floor. The python head is approximately 30 inches tall. The coaster’s speed is approximately 10-12 miles per hour, or approximately 24-28 feet per second. The ride circuit begins at the operator station where passengers are seated and secured in the coaster cars. A track circuit begins and ends at the operator’s station. The normal ride is three times around the track circuit. (See Figure 3)
Figure 3. Overview of Ride
The area the roller coaster operates within is fenced and has only one entrance/exit location for passengers, which is controlled by the ride operator. Within the ride area, there is scenery in support of the coaster theme to add to the enjoyment of the ride.
Two maintenance issues had been addressed by the company prior to the fatality. A few days prior to the fatality, the victim performed repair on the clutch to operate the coaster so it would tow the cars up the first hill. Two weeks prior to the incident, a city building inspector inspected the facility and notified the facility owner that he had to install a metal support plate on the floor to stabilize the roller coaster track. The plate the company had ordered to be installed was a ¼ inch steel plate, 12 inches wide and 40 inches long.
On the day of the incident, the company manager stated that the company was running a normal operation. The company had a morning meeting requiring all employees to attend. At this meeting, the victim as well as the company manager reinforced company policies and procedures.
The victim entered the ride area while the ride was running without the knowledge of the ride operator. The ride operator was at the operator station. It is believed that the victim entered through the tunnel area from the back portion of the ride. When the MIFACE researcher stood at the operator’s control panel, the location where the victim was struck is hidden by a plant decoration.
It is unknown if the ride operator stopped the coaster at the end of the 3rd circuit, or if the operator let the coaster continue around the track for a 4th time. Patrons on the ride witnessed the death. The location where the victim was stuck was at a descent from a hill that curves toward the tunnel area. This location is also the location where the building inspectors indicated the track required the metal floor support plate. Witness statements do not concur concerning the location of the victim. It is thought that the victim was inside of the tracks when he was struck, but he may have been standing along side of the track. It is unknown if the victim was facing toward the approaching coaster or if his back was facing the coaster. As the roller coaster came to the position of the victim, the “Python” head on the first car of the roller coaster either struck the victim or caught on a piece of his clothing. A part of the victim’s pant leg near the cuff was ripped. The victim was struck from behind by the first car in the right neck/shoulder area. The victim was run over by the car and dragged approximately 5 feet before the car derailed. The right front wheel assembly of the first car derailed after breaking a 6 inch section of track. The victim’s screwdriver was on the floor near the track and a type of screw identical to those found on the roller coaster was found near his shoe.
Figure 4. Approximate Location of Victim
The ride operator heard the “crash”, then left the operator area and went to see what was wrong. He saw the victim under the coaster, and as trained, went to the manager of the facility. The manager and other employees escorted the passengers on the coaster off of the coaster into a waiting area. Company employees lifted the car off of the victim. When the owner arrived at the scene, he stated the victim was lying on his back with the car on top of him.
State inspectors for the carnival and amusement division did not find any mechanical problems with the roller coaster that would play a role in this fatality. In fact, they stated that a metal plate was not required due to the design of the coaster.
CAUSE OF DEATH
The cause of death as listed by the medical examiner on the death certificate was death by multiple injuries. Toxicological results were negative.
MIOSHA Standards cited in this report can be directly accessed from the Consumer and Industry Services, MIOSHA website http://www.michigan.gov/lara/0,4601,7-154-61256_11407_15368---,00.html.
The Standards can also be obtained for a fee by writing to the following address: Department of Consumer and Industry Services, MIOSHA Standards Division, P.O. Box 30643, Lansing, MI 48909-8143. MIOSHA phone number is (517) 322-1845.
MIFACE (Michigan Fatality and Control Evaluation), Michigan State University (MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East Lansing, Michigan 48824-1315. This information is for educational purposes only. This MIFACE report becomes public property upon publication and may be printed verbatim with credit to MSU. Reprinting cannot be used to endorse or advertise a commercial product or company. All rights reserved. MSU is an affirmative-action, equal opportunity employer. 10/16/03
To contact Michigan State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.
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