The following case study does not relate to a client of Pharos Response. This is merely an opinion based on information publicly available to highlight some learning outcomes to help avoid future tragic incidents of this nature.
In June 2012 a four year old child received significant and life-changing head injuries after falling approximately four metres from a raised wooden walkway. The accident occurred at a major theme park and the immediate cause was identified as a gap in the railings on one side of the walkway, caused by one of the uprights having fallen out due to wood rot. The theme park was prosecuted by the Health and Safety Executive and received a fine of £150,000, plus costs of a further £21,614. A civil claim is of course another avenue that will continue now that the criminal case has concluded. Whilst the financial business costs are high, clearly the personal ‘costs’ to the child and her family are not numerical.
Accidents like this don’t just happen. There are always deeper causes, even in an organisation that has an otherwise good safety record. In an attempt to find the root cause of this case, the investigating Health and Safety Executive discovered that other railings had been repaired and some rotten areas were simply painted over with wood stain rather than treated or replaced. So this wasn’t an isolated case and should have been foreseeable, especially given the walkway’s height and consequence of a fall from it. A maintenance programme was evidently in place since rotten areas had been addressed but for me, this is a management issue rather than maintenance. Safety tours are common in industrial settings such as factories, where managers are scheduled to ‘walk the floor’ and ask questions of ground level operating staff. I have found this approach to be an effective way of proactively managing safety in the adventure and travel sectors, helping to discover creative ways of further developing safety systems. Managers might see things from a different perspective than other staff, not because of their position of responsibility, but because they don’t routinely perform the function or routinely see and normalise the hazard. Clearly in this terrible case, the maintenance and repair system was ineffective. A good old system of checks and records should have identified the faulty railings.
The case has some parallels to that in which a pensioner fell and tragically died after a fall from a drawbridge at Warwick Castle in 2007 into the dry moat, 4m below. There are probably more differences than similarities but they both should serve as a reminder of the need to specifically assess and manage areas where falls could result in significant injury.
So what can adventurous activities venues and schools learn from this? Well, there are a whole host of lessons that apply to property-based hazards and some immediate thoughts are as follows:
- Operators should assess the premises and venue safety to the same level as the activities themselves
- Instigate a routine maintenance and repair inspection regime for the venue, formalised and signed off by management
- A suitable and sufficient risk assessment will identify locations where a sole prevention measure (such as railings or a low barrier above a drop) prevent a serious injury. These should be given specific attention
- Involve management in the inspection regime, including reporting of faults
- Managers need to manage safety in a variety of ways. This often means getting out from behind the desk and observing all the potential risks and asking some basic questions.
Pharos can help with this. Please contact us to find out how.