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.STATE
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09-22-01
Date/Invest.
Permanent
OF CALIFORNIA
DEPARTMENTOF n-mUSTRIAL RELAnONS
DIVISION OF OCCUPAnONAL SAFE'IY AND REALm
AMUSEMENT RIDE UNIT
BRYAN ECKMAN
ACCmENT INVESTIGATION REPORT
-E6414
ANAHEIM
AssociateSafetyEngineer(AmusementRides)
Office
0
Temporary
(714) 456-1872
TelephoneNumber
Nameof ResponsibleParty: CedarFair LP dba Knott's Berrv Farm
Mailing Address: 8039B~achBlvd.
Street
BuenaP~k. CA
90620
BuenaPark. CA
90620
City
Zip
(114)220-5490
ext
(114)220-5490
ext.
TelephoneNumber
Placeof Accident: Knott's Berrv farm
Addressof Accident: 803~BeachBlvd.
Street
City
nz
Nameof Injured (Listadditional
injured
withnarrative.)
39
Age
N/A
Nameof Injured (Listadditional
injured
withnarrative.)
N/A
Age
Natureof Injury: Fatal-Multiple extensiveblunttraumaticinjuries
Zip
.
AttractionName: PerilousPlunge
TelephoneNumber
09-21-01
Dateof Injwy
09-21-01
Date of Death
N/A
Dateof Injwy
N/A
, -Date of Death
StateI.D. Number:
TradeName: River Plunge
N/A
Manufacturer: IntaminLtd.
WhatoccUrredto causethe injury? SeeNarrative
Unsafeactsinvolved: SeeNarrative
Unsafeconditions(and/or)
CodeViolationsinvolved: SeeNarrative
Stepstakento eliminatethe hazard: SeeNarrative
':
Completethe reverseside of this form.
L
--
STATEOF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
~ Permanent
LJ Temporary
Page
6-
of
23
ACCIDENTINVESTIGATIONREPORTNARRATIVE
1
2
NOTIFICATION
1
OnFriday, September
21,2001, at approximately11:29PM, the Division of OccupationalSafetyand
2
3
Health,PermanentAmusementRide Unit, AnaheimDistrict Office ("The Division") receiveda telephone
3
4
messagevia the answeringservicefrom DonMaus, SafetyManagerof Knott's BerryFarm,reportingthat an
4
5
accidenthadoccurredthat day at approximately10:22PM, on an amusement
ride knownasthe ~erilous Plunge,
5
6
locatedat Knott's BerryFarm, 8039BeachBlvd., BuenaPark,California.
6
7
8
BRIEF SUMMARY OF ACCmENT
7
In brief summary,the circumstances
of the accidentwereasfollows: On Friday, September
21, 2001,at
8
9
approximately10:22P
10
BoatNo.1, Row 4 (numberedfrom frontto back),and tookthe seatclosestto the loadside of the dock. Shewas
11
accompaniedby herthreemembersof her family who wereseatedin variousotherseatsin BoatNo.1. Shethen 11
12
buckledher seatbelt andloweredher lapbar. The dispatchsignalwas givenand BoatNo.1 movedforward onto
12
13
the lift. The boatreachedthe top of the lift andmadea left turn approaching
the drop, following its designated
13
14
course. Oncethe boatwent overthe crownof the drop,the deceased
wasseparated
from her seat,moving in an
14
15
upwarddirection,thenfell pastthe backof the boat, strikingthe ride structureonthe way down,and landing in
15
16
the pool of waterlocatedat the baseof the attraction. At 10:56PM, approximately34 minutesaftershehad
16
17
enteredthe attraction,the deceased
waspronounceddead.
17
18
19
20
(the deceased)
enteredthe PerilousPlungeattraction,boarded
9
ATTRACTlONDESCRIPnON
10
18
ThePerilousPlunge,whosetradenameis "River Plunge",wasmanufacturedby IntaminLtd. It is a
19
high-speedwaterride reachinga maximumspeedof approximately55miles per hour with a cycletime of
~1_--~!,!,!~~~~l~ _1__~~u~:_3~
~~~~s.- ~e. ~~~~s~~f_~e~ttr~:-ti.:!!l_~~-~o~~~ ~~-~~-!~~~g~_e~ ~E-~~~
20
--~_1-
22
lift, downa dropinto a large splashpool, and thenbackinto the stationat its unloadingarea. The courseincludes 22
23
a 12I-foot tall DC-drive chainlift portionrising at an angleof 40 degrees,followed by a verticaldrop of liS feet
23
24
descendingat an angleof75 degrees.Thereare 865 feet of trackoverall. Brakingis providedby a pool of water
24
25
and"eddiecurrent"brakes.The waterflow consistsof one (1) 9000 GPM (gallonsper minute)show water
25
26
I_,~.
26
-",
STA TE OF CALIFORNIA
1:;( Permanent
DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
RELATIONS
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
[Temporary
Page
7
of
23
REPORT NARRATIV§
1
pumpand six (6) 6000GPM propulsionpumps,with threepropulsionpumpsalwaysoperatingatanyone time.
1
2
Thereis a crossoverbridge atthe end of the brakingareawhereguestscanview the attractionwhile in operation
2
3
(SeeAttachment1.)
3
4
5
4
The attractioncanaccommodate
upto threeboats,which are eachcapableof holding24passengersper
5
6
boat. The weight of the passenger-carrying
deviceor "boat" is 14,500poundsloaded.The dimensionsof the
6
7
boatare420 incheslong by 175incheswide. Eachindividual seatin a boatholdsonerider andhastwo restraint
7
8
devicesconsistingof a hydro lock T-Bar (lap bar)anda seatbelt (SeeAttachment2.)
8
9
9
10
The lapbar mechanismconsistsof a paddedT-bar with two hydro lock cylinders,accumulators,and24-
11
volt DC coils. The coils openvalvesthat allowthe cylindersto moveandthe lapbarto open. The function of the 11
12
accumulatorsis to raisethe lapbar oncethe coils areenergized.(SeeAttachment3.) The seatbelt system
12
13
consistsof two belts,one with a male lockingendandone with a femalelockingend. (SeeAttachment4.) The
13
14
seatbelts weredesignedand installedby lntaminLtd. atthe requestof Knott's BerryFarm. ThePerilousPlunge
14
15
attractionwas openedto the public on September
15,2000.
15
16
10
16
17
INVESllGATION NARRATIVE
17
18
At approximately11:45PM, Friday, September
21,2001, Al Tafazoli, AnaheimAmusementRide
18
19
District Manageradvisedme thatthe office hadreceiveda reportfrom Knott's BerryFarmthata seriousinjury
19
20
hadoccurredat its locationat 8039BeachBlvd., BuenaPar, on the PerilousPlungeattraction.(SeeAttachment
20
21
5.) At approximately11:55PM onthe sameevening,at Mr. Tafazoli's direction,I telephonedMr. Maus. At that
21
22
time, Mr. Mausgaveme his descriptionof the accidentandthe chainof eventsleadingupto it. I advisedMr.
22
23
Mausthat he shouldpreservethe accidentsceneandinformedhim thatthe Division would arrive at Knott's Berry 23
24
Farm at 8:00Am the nextmorning,Saturday,September
22,2001, to startthe Division's investigation.Oncethat 24
25
conversationwascompleted,I telephonedMr. Tafazolito advisehim of my conversationwith Mr. Maus.
26
25
26
'.
.STATE
OF CALIFORNIA
.DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
~
RELATIONS
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
1
Page -L-
Permanent
Temporary
of
23
REPORT NARRATIVE
On Saturday,September
22,2001, at approximately8:00AM, I arrivedat Knott's Berry F8ml to startthe
1
2
Division's investigation.I was met by severalmenidentifiedto me as Mark Schuller,Vice Presidentof
2
3
Ma_intenance;
BradNes1and,Directorof RideMaintenance;Kevin Norris, Directorof Operations;JackFalfas,
3
4
Vice President/General
Managerof West CoastOperations,CedarFairL.P.; andMr. Maus,ail of whom stated
4
5
thatthey wereemployedby Knott's BerryFarm. Also presentwasBoyd Jensen,who indicatedthathe was
5
6
Knott's BerryFarm's attorney.
6
7
7
8
At this time I held an openingconference,duringwhichthe above-mentioned
Knott's Berry Faml
8
9
personnelprovidedme with a basicaccountof the eventsthat took placein regardto the accidentonthe Perilous
9
10
Plungeattractionon September
21,2001. Duringthe openingconferenceI requestedthatthe following
10
11
documentation
be providedby Knott's BerryFarmManagement:manufacturer'smaintenance
and operation
11
12
manuals,Knott's Berry Farmmaintenanceandoperationsmanual,daily maintenancechecklist of 9/21/01, l
12
13
openingslip for 9/21/01,maintenance
andoperationstrainingdocumentation,
copiesof employeeand witness
13
14
statements,
andthe daily maintenance
recordsfor the two weeksimmediatelyprecedingthe accident.The above
14
15
mentionedKnott's BerryFarm personnelinformedme thatthe accidentscenehad beenpreservedand that there
15
16
were securitypersonnelpresentto keepthe areasecured.Priorto goingto the accidentscene,I reviewedall of
16
17
the employeeandwitnessstatements
thathadjust beengivento me. (SeeAttachment6.)
17
18
18
19
At this time, Mr. Mark Schuller,Mr. NeslandandI walkedto the PerilousPlungeattraction. Mark
19
20
Haywood,RideMaintenanceManagerfor Knott's BerryFarm,metusthere. I visually inspectedthe boatandthe
20
21
seatwherethe deceased
wasreportedto havebeensittingprior to beingseparatedfrom the boat,and I took
21
ZZ -pfiotogr-apns.-(See
Attac-mnent
71 roDserv-ed-tfiaftfiefe"-weretWo"DoafS
"iii-tfie
sra-tion-area.-
;~-~..;~' --2--
23
24
23
The first boat(referredto for the purposesof this reportas "Boat No.1") wasin.theunloadposition,
24
25
while the secondboatwas in the secondaryloadposition. I wastold at thattime thatthe deceased
was in the seat 25
26
26
,r
.' ,
STATEOF CALIFORNIA
~
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
ACCIDENT INVESTIGATION
Permanent
'UTemporary
Page
9
of
23
REPORT NARRATIVE
1
thatwas onthe far left (facingthe directionof travel) of Row 4 of BoatNo.1 atthe time of the accident. I
1
2
inspectedthe lapbar and seatbelt of that seat(which, for the purposesof this report,will be referredto as "the
2
3
subjectseat"). I observedthatthe seatbelt was fully extendedand properlylocked,andthatthe lapbar was
3
4
partially in the downposition,approximatelyfourteenandone half inchesbelowthe positionit occupieswhen
4
5
raisedto its maximumheight. I measuredthe distancefromthe backof the seatonthefar left (in the direction of
5
6
travel) of Row 3 to the centerof the lapbar in the subjectseat. (SeeAttachment3.)
6
7
7
8
A maintenancedepartmentemployeethenremovedseverallapbar mechanismcoversso that I could
8
9
visually inspectthe mechanismof the lapbar in question.(SeeAttachment8.) I took photographsof the seatand 9
10
the lapbar of BoatNo.1, the generalride, and safetysignagefor the ride. (SeeAttachment9.) I observedthatthe
11
safetysignage(i.e., signagewith safetyadvicefor passengers
of the attraction)wasdisplayedin various locations 11
12
throughoutthe queue-lineof the attraction,but was notplacedso asto be clearlyvisible to patronsoncethey have 12
13
occupieda seat. I conducteda walking visual inspectionof the ride track, anddrop,as well asthe paths of ingress 13
14
to andegressfrom the PerilousPlungeattraction. I observedthattherewereno loadinggatesandno exit gateto
14
15
preventpatronsfrom gainingunauthorizedaccessto the ride envelope.I alsoobservedthata sectionof the
15
16
existingqueue-linedid not complywith ASTM F 115914.1.2,dueto the fact thatthe queue-linehad openings
16
17
largerthan 4 inchesby 4 inches. I theninspectedthe portionof the ride track that is in the wateras well asthe
17
18
body of waterwhereI wastold the deceased
hadlandedaftershewasseparatedfrom her seat. (SeeAttachment
18
19
10.)
19
20
21
10
20
I returnedto Knott's BerryFarm onMonday, September
24, 2001,to continuemy investigationof the
21
22
PerilousPlungeattraction. I wasmet by Mr. Schu11~andMr. Nesland,who escortedme to the ride, and onthe
22
23
waywe metMr. Haywoodanda manidentifiedto me asRichardH. Brown,Ph.D., of RHB, Inc. At this time I
23
24
conducteda visual inspectionof BoatNo.1, looking atthe following: generalconditionof the interior and
24
25
exteriorof the boat,the undersideof the boat,the roadwheels,upstopwheelsguidewheels,and wheelcarriers,as 25
26
26
""',."',"_._,
~
'",,
"",-
..".
..
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
ACCIDENT INVESTIGATION
1
~ Permanent
1] Temporary
Page
10
of
23
REPORT NARRATIVE
well astile chaindogand anti-rollbackmechanism.(SeeAttachment11.)
1
2
2
3
I notedtilat tile seatbelt of tile subjectseatconsistedof one belt thatmeasured11 incheslong with a
3
4
female lockingunit attachedto tile belt,anda longerbelt thatmeasured39 incheswith a male locking unit
4
5
attachedto the belt. It appearedto me thatthe belts and lockingmechanism
were in goodoperatingconditionand
5
6
free of anyvisible defects. I measured
the width of the seatbackandfound it to be 15 inchesfrom side to side.
6
7
(SeeAttachment4.)
7
8
8
9
At this time I beganan inspectionof the dropto determinewhethertherewere anyvisible defectsin the
9
10
tracks. Forthis purposeI wasraisedaboveground level by a man-lift operatedby Larry Vance,a Knott's Berry
10
11
Fann employee.However,I could not getan adequateview of the tracksatthe upperportion of the drop,
11
12
becauseof the heightlimitationsof the man-lift. Accordingly,I requestedthatKnott's BerryFann have the drop
12
13
completelyinspectedwith adequateequipmentand reportall findingsto the Division.
13
14
14
15
While I wasthere,I observedDr. Brown performinga dynamicaccelerationevaluationonthe subject
15
16
seat. The datawas collectedin accordance
with the mostrecenteditionto ASTM (AmericanSocietyfor Testing
16
17
andMaterials)F-2137-01,"Standardfor the Measurementof the DynamicCharacteristics
of Amusementllides
17
18
andDevices". The ride vehiclewasloadedfor testingto a passenger
weightof 150poundsper seat. The results
18
19
of this testshowed,amongotherthings,that, atthe top of the dropportionof the course,the subjectseatwas at a
19
20
maximumof negative"0.9+" g for 1100milliseconds. In lay terms,this meansthata passenger
in the seatwould
20
21
22
be subjectedto a negativeor upward-directed
force equalto slightlymorethan9/10the force of gravity (g) for a
period of 1.1 seconds.While the above-referenced
1.1 secondtestresultrepresents
the period of greatest
21
22
'
23
intensityof negativeg force,the entireperiod duringwhichtherewould be someamountof negativeg force
23
24
exertedonthe passenger
would be longerthan 1.1 seconds.(SeeAttachment12.)
24
25
25
26
26
.
".
'C'_-"'.""""""~'~."""'.,c"".,~_.c.",._-
STATE OF CALIFORNIA
~
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
ACCIDENT INVESTIGATION
1
Permanent
'D Temporary
Page
11
of
23
REPORT NARRATIVE
OnTuesday,September
25, 2001,I arrivedatKnott's BerryFarmandwas met by Mr. SchullerandMr.
1
2
Nesland. I wasescortedto the office of Mr. Maus,whereI conductedan interviewwith a personwho was
2
3
identified to me as CaseyPerez,a Shift Leaderemployedby Knott's BerryFarm. Ms. Perezstatedtllat shewas
3
4
working the unloadpositiononthe PerilousPlungeattractionat the time of the accident.Ms. Perezalso stated
4
5
that shedid not seethe accidentoccur. Shefurtherstatedthat shehad beentrainedby Knott's BerryFarm to
5
6
performandcarry outthe dutiesandresponsibilitiesof her assignedposition. Duringthe interviewI askeda
6
7
numberof queStionsregardingthe trainingof employeesandthe operationalproceduresfor thePerilousPlunge
7
8
attraction. Ms. Perezstatedthatshedid not recallif all seatbeltsand lapbarswere in their properposition when
8
9
BoatNo. I departedonthe run thatleadto the accident.(SeeAttachment13.)
9
10
10
11
After the conclusionof my interview,I proceededto the PerilousPlungeattractionwhereI was met by
11
12
Mr. Schuller;Mr. Nesland;Mr. Haywood;anda manidentifiedto me as SandorKemacs,Presidentof Intamin
12
13
Ltd. Mr. Kemacsinformedme thatthe seatbeltsweremanufacturedandinstalledby lntaminLtd. atthe request
13
14
of Knott's BerryFarm. He alsostatedthathe personallyprovidedtrainingto Knott's BerryFarmpersonnelon
14
15
the maintenanceand operationof the PerilousPlungeattraction,andthatthe contentof the traininghe provided
15
16
coveredthe issueof whatto do whena "large" guestrequestedto ride the attraction. He statedthathe told
16
17
Knott's BerryFarmpersonnelasa part of this trainingthat if the lapbar "came downto the belly" or "a fatty
17
18
portion of the guest'sbody", anddid not "rest onthelap, hips, or a fInD part of the guest'sbody," the guestmust
18
19
be refusedentryto the attraction. I askedMr. Kemacsfor corroborationof this in the form of documentationof
19
20
the training contentanddetailsaboutwho specificallyhe trained in themanner. Mr. Kemacsrepliedthat he did
20
21
not recall who he trainedandhe did not havedocumentationof the contentof the trainingheprovided. He also
21
22-
---TJ:
23
amusement
parksasdescribedaboveonthe handlingof largeguests.I lateraskedKnott's BerryFarm
23
24
management
whethertheyrecalledtrainingbeingprovidedby Mr. Kemacs. Theystatedthathe did provide
24
25
training, butthe contentdid not includeinstructionsfor handlinglargeguestsbeyondwhatis statedin the
25
26
26
"
.
STATE OF CALIFORNIA
Rf Permanent
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
n
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
Page
12
Temporary
of
23
REPORT NARRATIVE
1
manufacturer manual. The instruction in the manual is the same as the instruction Mr. Kemacs has stated he gave
1
2
to Raffi Kaprelyan, Managerof Ride Operation at the time of installation of the Perilous Plunge attraction, which
2
3
is that "larger people" should not sit in the last two rows of a boat, but can ride in other parts of the attraction as
3
4
long as they fit in the restraint system. (See Attachment 14.)
4
5
5
6
On Wednesday, September26, 2001, I arrived at Knott's Berry Farm and was escortedto the Perilous
6
7
Plunge attraction, where I was met by Mr. Schuller, Mr. Nesland, and Mr. Haywood. I requestedthat the lap bar
8
mechanism of the subject seatbe removed for inspection. Once the lap bar mechanismwas removed and inStalled 8
9
on a bench, I performed a pull test on the lap bar mechanism, and completely disassembledand inspected it. I
9
10
observed no defects in the lap bar mechanismand it appearedto function properly. (See Attachment 15 and 16.)
10
11
I then inspectedthe electrical terminal box for the subject seatand observed that it was in good working
11
12
condition. (See Attachment 17.)
12
13
7
13
14
At this time I was escortedto Mr. Schuller's office to conduct individual interviews with three men who I
14
15
was told were maintenanceemployeeswho had arrived at the Perilous Plunge attraction shortly after the
15
16
happened. I allowed Mr. Schuller to be present for the interviews becauseeach of the witnessesrequested his
16
17
presence. The three men were identified to me as Knott's Berry Farm employees: Mike Michalka, Maintenance
17
18
Technician; John Goetz, Duty Electrician; and Aigoeerto Velarde, Ride Maintenance Assistant. All three stated
18
19
that they did not seethe deceasedboarding the boat prior to its dispatch and did not seethe accident, However,
19
20
they Statedthat they did seethe immediate aftermath of the accident when the arrived to assistin the evacuation
20
21
of the deceasedfrom the pool of water that surroundsthe Perilous Plunge attraction. (See Attachment 13.)
21
22-23
~
22I then proceededto Mr. Maus' office to conduct an interview with a man identified to me as Alex
23
24
Medina, employed by Knott's Berry Farm in the Ride Operation department,who stated that he was working at
24
25
the dispatch position on the Perilous Plunge attraction at the time of the accident. Mr. Medina Statedthat he had
25
26
26
"
,"'"-"'",,-
STATE OF CALIFORNIA
~
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
ACCIDENT INVESTIGATION
Permanent
U Temporary
Page
13
of
23
REPORT NARRATIVE
1
received training in the duties and responsibilities of his assignedposition. He also infonned me that, prior to the
1
2
boat leaving the station, he visually verified that all lap bars were in the down position on both the load and
2
3
Unload sides. Mr. Medina further statedthat, once he heard what had happened,he depressedthe emergency stop 3
4
button (E-Stop). (See Attachment 13.)
5
6
4
5
On Thursday, September27,2001, I arrived back at Mr. Maus' office at Knott's Berry Fann to conduct
6
7
an interview with a man identified to me as Brian Frohreich, employed by Knott's Berry Fann in the Ride
7
8
Operation department,who stated that he was working at the load position on the Perilous Plunge attraction at the
8
9
time of the accident. Mr. Frohreich stated that he did not seethe accidentoccur. He also stated that he checked
9
10
all seatbeltsand lap bars on the load side, prior to giving the clear to dispatch. Mr. Frohreich further stated that he
10
11
had beentrained by Knott's Berry Farm to perfonn and carry out the duties and responsibilities of his assigned
11
12
position. (See Attachment 13.) I was then escortedto a conference room where I reviewed the maintenance and
12
13
operational manuals with a woman identified to me as SuzanneBilodeau CIH, REHS, Sr. Safety Specialist
13
14
employed by Knott's Berry Farm. I observedwile reviewing this documentation that the manual from the
14
15
manufacturer was designed for various Intamin attractions, and that the manual had not infonnation in regard to
15
16
the maintenance or operation of the seatbelts. (See Attachment 18.)
16
17
18
17
I arrived back at Knott's Berry Farm on Monday, October 1,2001, and was met by Mr. Schuller, Mr.
18
19
Nesland, Mr. Haywood, and Dr. Brown. Dr. Brown perfonned dynamic acceleration evaluations on Boat No. 1,
19
20
Rows 1, 2, 3, 5 and 6. I was infonned that this datawas collected in accordancewith the most recent edition to
20
21
ASTM (American Society for Testing and Materials) F-2137-01 Standardfor Measurement of Dynamic
21
22-
22
23
amountsand duration of the periods of maximum negative g force for Rows 1 through 3 were less than the values
23
24
obtained earlier for Row 4. The results for Rows 5 and 6 showed that the peak g forces were higher than for Row
24
25
4, but the duration of the maximum g-force periods were shorter. (See Attachment 12.)
25
26
26
STATE OF CALIFORNIA
DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
RELATIONS
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
1
Page
14
~
Permanent
1]
Temporary
of
23
REPORT NARRATIVE
On Tuesday, October 2,2001, Mr. Nesland and Mr. Haywood escortedme back to the Perilous Plunge
inches.
1
2
attraction where we assembleda manikin to simulate a person with a waist measurementoffifiy-eight
3
The manikin was placed in the subject seat,the seatbeltwas buckled around it, and the lap bar was lowered to the
3
4
point of touching the manikin. I observedthat, with the manikin in the seat,the lap bar and seatbelt were in the
4
5
same approximate position as they were when I fIrst saw them after the accident.
5
6
7
2
6
I then conducted an electrical inspection of Boat No.1, Row 4, including the 24 volt DC coils and wires
7
8
back to the temlinal boxes. All appe~ed to me to be in good working condition. (See Attachment 17.) I was then
8
9
taken to Mr. Maus' office to conduct an interview with Mr. Maus and Mr. Pratte. Both stated that they did not
9
10
seethe accident occur, but did seethe evacuation of the deceasedfrom the pool of water surrounding the Perilous
10
11
Plunge attraction. Both infomled me that they saw assistancefrom Knott's Berry Farm being given to the
11
12
deceased. (See Attachment 13.)
12
13
14
13
On Thursday, October 4, 2001, I arrived back at Knott's Berry Farm and was met by Ms. Bilodeau. At
14
15
that time she provided me with a document she identified as the purchase agreementfor the Perilous Plunge
15
16
attraction. I noted that, according to this document,Intamin, Ltd. built the Perilous Plunge attraction in
16
17
accordancewith the DIN (DeutschesInstitute ofNormung) Standard.
17
18
19
18
I then proceededto interview a man identified as Joey Mohammed, a Knott's Berry Farm employee. He
19
20
stated that he did not seethe accident, but was present for and assistedwith the evacuation of the deceased from
20
21
the body of water that surroundsthe Perilous Plunge attraction. (See Attachment 13.)
21
22
23
22On Friday, October 5,2001, in the DOSH Anaheim District Office, I interviewed a man who identified
23
24
himself as Richard Loya. Mr. Loya stated that he was a patron who was in Boat No.1 at the time of the accident.
24
25
Mr. Loya stated that he witnessed the accident,and he was occupying the seaton the far right (facing the
25
26
26
~, ..,
STATE OF CALIFORNIA
'fX Permanent
DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
RELATIONS
SAFETY AND HEALTH
UTemporary
AMUSEMENT RIDE UNIT
Page
ACCIDENT INVESTIGATION
15
of
23
REPORT NARRA TIV§
1
direction of travel) of Row 5. Mr. Loya stated that a female ride operator "checked" his seatbeltand lap bar, but
1
2
he did not seeanyone check the seatbeltsand lap bars on the seatsto his left. :Mr. Loya also stated that he saw the
2
3
deceasedseparatefrom her seatasthe boat went over the top of the drop. He also stated that he did not see any
3
4
safety signage on the Perilous Plunge attraction. (See Attachment 13.)
4
5
6
5
On Tuesday, October 9, 2001, at approximately 6:00 PM, I arrived at
6
7
California, which I was informed was the home of a female minor, age 13, identified to me as
I
8
conducted an interview of Ms. Wells, with a man presentwho identified himself to me as Mr. Wells, her father.
8
9
Ms. Wells statedthat, while shewas on the crossoverbridge watching the Perilous Plunge attraction, she saw the
9
10
deceasedbeing separatedfrom the boat as it proceededover the top of the drop, and then sawthe deceasedhit the
10
11
structure of the drop prior to her landing in the body of water that surroundsthe attraction. (See Attachment 13.)
11
12
13
7
12
Following this interview, I interviewed four additional female minors identified to me as
14
13
The interviews
Also presentwere three females identified to me as their mothers. At
14
15
took place at the home of
15
16
the request of their mothers, I agreedto interview the four minors as a group. They stated that they were on Boat
16
17
No.1 at the time of the accident and were occupying the four seatsin Row 6. They all appearedto be in
17
18
agreementin making the following statements:that the ride operator "checked" their seatbeltsand lap bars, that
18
19
as their boat went down the drop, that they saw something go over their heads, and that they did not recall seeing
19
20
any safety signage. (See Attachment 13.)
20
21
21
~
22
23
Nesland, Mr. Mark, and Dr. Brown to perform a dynamic acceleration evaluation using specifications provided by
23
24
Intamin, Ltd., through Mr. Kernacs. This test was performed by Dr. Brown with Boat No. 1 loaded and unloaded,
24
25
and datawere taken for eachrow. The results of this test showed that the design specifications (See Attachments
25
26
26
,,""'
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,""U
.
STATEOF CALIFORNIA
DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
t;{ Permanent
RELATIONS
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
fJ
Page
16
Temporary
of
23
REPORT NARRATIVE
1
19and20) werehigherthanthe resultsof this test. It wasalsonotedthatthe durationof the maximum g force in
1
2
Row 4 duringthis testwas longerthanthe designspecificationsfor Row4. (SeeAttachment21.) Testswere also 2
3
performedby operatingthe ride througha completecycle withoutpassengers
and with the lap barsin various
3
4
positionsatthestart of the cycleto seeif the lapbarswould automaticallylower if subjectedto downwardg-
4
5
forcessuchasthoseaswould be causedby the attraction.-Ifoundthatthe lap barswould movetowardsthe down 5
6
positionapproximatelyoneto threeinches,no matterhow highwas their original positionatthe ~
7
This finding contradictsStatements
madeby the manufacturer
thatthe actionof the lapbarswould be to travel all
7
8
the way to the downpositionfrom anystartingposition.
8
of the cycle. 6
9
9
10
Onthe sameday,Wednesday,October10,2001,I aIrivedbackatthe DOSHAnaheimDistrict Office to
10
11
conductan interviewwith a womanidentifiedto me asAnne Sheehan,
a patronwho was presentatthe Perilous
11
12
Plungeattractionatthe time of the accident.Ms. Sheehanstatedthat shesawthe deceased
asshewas separated
12
13
from her seatonthe boatwhenthe boatstartedto comedownthe drop,and sawherland in the body of water
13
14
surroundingthe PerilousPlungeattraction.Ms. Sheehanstatedthatshedid not seethe deceased
boardthe boat
14
15
prior to the boatleavingthe station. Shefurtherstatedthatshethoughtthe responsetime for gettinghelp to the
15
16
deceased
was"slow", However,shedid notprovide anydetailsin regardto herconclusion.(SeeAttachment13.) 16
17
17
18
19
OnThursday,October11,2001,I wentto the OrangeCountySheriff CoronerDepartmentlocatedat
2700 SouthBristol Street.SantaAna, California,to reviewthe Coroner'sdocumentation.
20
18
19
20
21
22
-_0
On Wednesday,October16,2001,I wentto Knott's Berry Farmto observean inspectionthat I was
informedhadbeenrequestedby attorneysrepresenting
the family of the deceased.WhenI aIrived I was met by
21
22
23
peoplewho were identifiedto me as StephenMancini,Attorney;Mark Feldman,Attorney; KenMartin, Ride
23
24
Consultant;and Tom Owens,Investigator,as well asMr. Schuller,Mr. Nesland,Mr. Haywood,andMr. Jensen.
24
25
The requestedinspectionwas conductedin my presence.
25
26
26
..'
",.,
'.
"'"
~
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
1
2
3
-
Page -1~
Temporary
Permanent
of
23
REPORT NARRA TIV~
On Friday, October17,2001,I arrivedatthe homeof the deceased'sfamily at
Duarte,California,to conductinterviewsseparately
with
o,sonof the deceased;
an
1
daughterof the deceased;
Frankie
nieceof the deceased.Mr. Feldmanwas presentfor the
2
3
4
interviews. All three of thesefamily membersstatedthatthe deceased'sseatbeltwasbuckledand her lap bar was
4
5
downprior to BoatNo. 1 beingdispatched.Theyalsostatedthatno onecheckedeithertheir or the deceased's
5
6
seatbeltsor lapbars. DarleneLarenzwas occupyingRow4, secondseatfrom the loadside in BoatNo.1, Frankie 6
7
owas occupyingRow2, third seatfrom the load sidein BoatNo.1, and
8
Row 2, secondseatfromthe loadside in BoatNo.1. (SeeAttachments13and 22)
nwas occupying
9
10
7
8
9
OnFriday, November2, 2001,Mr. Neslandcontactedme atthe AnaheimDaSH office to request
10
11
pemlissionto move BoatNo.1, statingthatthe purposefor doingthis wasto drainthe watersurroundingthe
11
12
PerilousPlungeattraction. Permissionwasgranted.(SeeAttachment23.)
12
13
13
14
Knott's Berry Farmadvisedthe Division of its discoveryof crackindicationsin the I-Beamthat supports 14
15
the up-stopplate of the PerilousPlungeattraction.I wastold thatthesecrackindicationswerefound duringthe
15
16
follow-up inspectionof the dropI hadrequestedon September
24, the daywhenI was unableto completean
16
17
inspectionof the dropbecauseof the heightlimitationsof the man~lift. I was informedthat Kelly Roberts,Ride
17
18
MaintenanceTechnicianfor Knott's BerryFarm,performedthis inspectionby meansof rappelling downthe drop 18
19
of PerilousPlunge.
20
21
19
20
On Friday, November9,2001, I arrivedatKnott's BerryFarmandwas met by Mr. Nesland.Via a man-
22-
21
22---
23
concludedthatthesecrackindicationsweretoo smallto havehad anyeffect onthe accidentonthe Perilous
23
24
Plungeattraction.
24
25
25
26
26
.;:
"'.
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
1
Page --1!L-
~
Temporary
Permanent
of
23
REPORT NARRATIVE
I reviewedthe SecurityDepartmentDaily Log andfound that Station23 (Fire Department)was at the
1
2
attraction8minutesafterthe call wasreceivedby dispatchthat an accidenthadtakenplace. In addition, I
2
3
detenninedthatthe Knott's Berry FarmEMT was atthe attractionwithin 2 or 3 minutesafterthe c:allwas
3
4
receivedby dispatch.(SeeAttachment24.)
4
5
5
6
CONCLUSIONS
7
6
The Division hascompletedits investigationof the PerilousPlungeattraction,whichwasconductedas
7
8
describedaboveandincludeda review of the following documentation:Trainingrecords,trainingmanuals,(See
8
9
Attachment27.), mechanicalspecifications,maintenanceand operationmanuals,witnessstatements,security
9
10
departmentdaily log, drawingsof the boat,BuenaParkpolice reportCR: 01-8104,(SeeAttachment25.) Orange
10
11
County Sheriff-CoronerreportCaseNumber01-06035-0N,(SeeAttachment26.)photodocumentation,
11
12
maintenanceopeningprocedures,daily maintenancelog, purchaseagreement,
technicalinformationfrom Intamin 12
13
Ltd., and dynamicacceleration
evaluations.As a resultof its investigationthe Division has drawnthe following
13
14
conclusions:
14
15
15
16
1.
17
beingseparatedfrom the seatonthe far left (facingthe directionof travel)of Row 4 of BoatNo. 1, of an
17
18
attractionknownasthe PerilousPlunge. The deceased
was lifted in anupwarddirectionfrom her seatat the top
18
19
of the "drop" as BoatNo.1 went overthe crownportion of the attraction. After separatingfrom her seat,shefell
19
20
pastthe backside of the boat,Struckthe ride structureonthe way down,andlandedin the bodyof water
20
21
surroundingthe attraction.
21
22
The deceased
was fatally injured on September
21, 2001,whenshefell approximately120feet after
16
22
::
23
2.
The deceased
was not securedto the seatin a mannerthatwas sufficientto keepher in place,giventhe
24
intensityand durationof the negativeg force exertedon her body atthe time of separation.The separationmost
24
25
likely occurredbecauseof a combinationof factorsincludingthepositionsandmotions of BoatNo. I, the
25
26
23
261
,",-,
","_.~,~"'"
i
,
..'.,
STATE OF CALIFORNIA
DEPARTMENT
DIVISION
OF INDUSTRIAL
OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
RELATIONS
SAFETY
~
AND HEALTH
ACCIDENT INVESTIGATION
Page -1~
Temporary
Permanent
of
23
REPORT NARRATIVE
1
resultingdynamicforcesactingontheride componentsandthe deceased's
body,the force of gravity,the
1
2
positioningof the restrainingdevices,andthe physicalattributesof the deceased.Beyondconcludingthat the
2
3
durationand intensityof the maximumg forceoccurringatthe top of the dropwas sufficientto separatethe
3
4
deceasedfrom her seat,the Division is unableto determineatthis time the relativecontributionof eachof these
4
5
factorsto the accident,but all mustbe givenconsideration.It is unknownwhetherthe deceased
was holding onto
5
6
the GrabHandleatthe time shewasseparated.
6
7
7
8
3.
The deceased'sseatbeltwasbuckledandthe lap bar was downand in contactwith the deceasedwhen
9
BoatNo.1 was dispatched.The seatbeltremainedattachedthroughoutthe courseof the accident,and the lapbar
9
10
remainedin a downposition. It is possiblethatthe lap bar was not tightly securedonthe deceased
when she
10
11
buckledher seatbelt and loweredthe lapbar aftertaking her seat,althoughit appearsthat it did make contact
11
12
with herbelly. It is highly unlikely thatthe lap bar couldhavemovedupwardat anytime after it was lowered
12
13
ontothe deceased.The mechanismof the lapbar is biasedtowarda downwarddrift, so that somedownward
13
14
shifting ofthe lap bar couldhaveoccurredduringthe course ofthe ride upto thetime ofthe accident. While the
14
15
possibility cannotbe excludedthatmoreoptimalplacementor adjustmentof the seatbelt and/orlapbar could
15
16
havebeenachievedso asto havepreventedthe accidentor mitigatedits outcome,the designof the restraint
16
17
systemwas clearlynot adequateto protectagainstthe type of eventthat resultedin the deceased'sseparation
17
18
from her seat.
18
19
8
19
20
4.
At the time ofthe accident,neitherIntaminLtd., nor Knott's BerryFarmhaddevelopeddocumentation
21
with sufficientlydetailedinstructionsto ride operatorsfor the handlingof passengers
whosephysical
20
21
22 ~aiacterIsticscoU1djeopardiZe-ilieir-iafe;tyonthe ride. This documentation
wasinadequateand insufficient in its 22
23
descriptionof the passenger
characteristics
thatwarrantedrestrictionor specialprocedures,as well as in its
23
24
descriptionof the specialprocedures
to befollowed.
24
25
25
26
26
-".~
,.,,
, ,
,
""..~.'-~'"--"-,,".~",
., .,,
.
STATEOF CALIFORNIA
DEPARTMENT
DIVISION
OF
OF
INDUSTRIAL
OCCUPATIONAL
~ Permanent
RELATIONS
SAFETY
'D'Temporary
AND
HEALTH
AMUSEMENT RIDE UNIT
Page ~~
ACCIDENT INVESTIGATION
of
23
REPORT NARRA TIV§
1
5.
TheKnott's Berry Farmtrainingmanualstatesthat lapbar restraintsareto be checkedby "pushingdown, 1
2
thenup". Ride operatorsare furtherinstructedto "Visually checkthe seatbelt." It appearsthat,before
2
3
dispatchingthe ride, the ride operatorschecked,in the mannerspecifiedby the Knott's BerryFarmtraining
3
4
manual,the seatbeltsandthe lapbarsonthe right side of BoatNo. 1. However,it appearsthatthe ride operators
4
5
may not havefully compliedwith Knott's BerryFarmprocedurefor checkinglapbarsfor passengers
on the left
5
6
side of BoatNo. 1. It is unknownwhethera more thoroughcheckof the left side of BoatNo.1 would have
6
7
resultedin anychangein the adjustmentof the lapbar usedby the deceased.However,sincethe deceased'slap
7
8
bar had beenloweredto the point of contactwith herbody, it is unlikely that pushingdownonthe bar by a ride
8
9
attendantwould haveresultedin a significantalterationof the positionof the lapbar. Althoughthe procedure
9
10
describedin the Knott's Berry Farm trainingmanualfor checkingseatbeltsand lap barsis inadequatedueto its
10
11
vaguenessand lack of detail, it is unlikely thatthis inadequacyis causallyrelatedto the accident.
11
12
12
13
6.
Themaintenanceand operationsmanualprovidedby the manufacturerof the PerilousPlungeattraction
14
and in the possession
of Knott's BerryFarmisa genericmanual,with applicabilityto severalrides besidesthe
14
15
PerilousPlunge. The manualdoesnot includeinstructiononthe operationor maintenanceof the seatbelts.
15
16
13
16
17
7.
It appearsthat, whenthe PerilousPlungeattractionoperateswithout anywait in the queue-line,the
18
currentplacementof the safetysignagemaynotafford patronswho boardthe ride during suchperiods sufficient
1.8
19
time to readandunderstandthe advicecontainedonthe signage.
19
20
21
17
20
8.
It appearsthat the emergencyresponseof the employeesafterthe accidentoccurredwasproper, and
21
22 ---assistance
occurredassoonaspossibie. -.22
23
23
24
24
25
25
26
26
,,"
,,--
_."""~".~"""~
1
.
STATE
~
OF CALIFORNIA
DEPARTMENT
OF INDUSTRIAL
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
RELATIONS
SAFETY AND HEALTH
ACCIDENT
Permanent
Temporary
Page -.J~
INVESTIGATION
REPORT
of
23
NARRA TIV§
1
1
2
CORRECTIVE ACTION SPECIFICATIONS
3
As part of its process of implementing these corrective actions, the Owner/Operator shall obtain ,,'hatever
3
4
relevant infonnation and advice is available from the manufacturer of the Perilous Plunge attraction. This
4
5
information and advice may be utilized to the extent either or both serveto further compliance. The following are
5
6
the corrective actions that shall be taken before the Perilous Plunge attraction is placed back into public operation:
6
7
7
8
A.
The Perilous Plunge attraction, as well as its existing restraint system, shall be evaluated and modified as
8
9
necessaryto protect passengersfrom being separatedfrom the ride. The evaluation shall (1) Consider all motions
9
10
and forces produced by the ride; (2) Assume that the passengeris unable to contribute to keeping his or her body
10
11
in place by holding or gripping with the hands or by exerting force with the feet; and (3) Give full consideration
11
12
to the range of body dimensions and weights encounteredin the human population. If the modifications are based 12
13
on assumptionsregarding limitations in height, weight, or body shape,these limitations shall be stated
13
14
specifically and clearly so they can be communicatedas instructions to ride operators for the purpose of ensuring
14
15
that safety will be compromised by a passenger'splacement on the ride. The evaluation and the resulting
15
16
modifications shall be certified by a licensed engineer.
16
17
17
18
B.
The Owner/Operator shall develop detailed documentation to conform to the specifications of Sections
19
4.2 and 4.2.1 of ASTM F 770-93 (Reapproved 2000). This documentation shall incorporate any and all passenger 19
20
limitations arising out of measurestaken to comply with the Corrective Action Specifications of ParagraphA.
18
20
21
21
22 "C.- ---The-ownerTOperatOrShal-ilmplementa"iraWng program which shall be designed to ensure that all
22
23
operatorsand attendantswho are or will be assignedto the Perilous Plunge attraction are thoroughly familiar with
23
24
the restraint systems to be used on the Perilous Plunge after it has been evaluated and modified as required by
24
25
ParagraphA. The training program shall additionally ensure that all trainees demonstratecompetence in all
25
26
--"
r-
2
26
_.~~,
,..,"~
,
".","...,-""-",
.'.,
..
~
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL
AMUSEMENT RIDE UNIT
SAFETY AND HEALTH
ACCIDENT INVESTIGATION
Page ~~
Temporary
Permanent
of
23
REPORT NARRATIVE
1
procedurestheyareto perfonn in connectionwith seatingpassengers,
engagingand checkingrestraintsystems,
1
2
and following the instructionscontainedin the documentation
requiredby the CorrectiveAction Specificationsof
2
3
Paragraph
B. This training shallbe providedto the employeebeforebeingallowedto serveasan attendantor
3
4
operatorof the PerilousPlungewith passengers
on board.
4
5
5
6
D.
The Owner/Operatorshall implementa methodto ensurethatthe attractionwill not operateif a guestis
7
not properlysecuredin the passenger-carrying
device.
8
6
7
8
9
E.
The Owner/Operatorshall install safetysignagein the passenger-carrying
device,which shallbe
10
consistentwith the documentation
requiredby Paragraph
B.
11
9
10
11
12
F.
The Owner/Operatorshall install safetygatesatthe load dockand exit rampfor the purposeof preventing 12
13
unauthorizedpatronaccessto the ride envelopeof the PerilousPlungeattraction.
14
13
14
15
G.
The Owner/Operatorshall complywith AS'IM F 115914.1through14.1.6,6fueditionwith respectto all
16
gatesandfencesaroundthe PerilousPlungeattraction.
17
15
16
17
18
H.
Any and all modifications.made
to theI-beamthat supportsthe up-stopplate shallbe certified by a
19
licensedengineer.Considerationshallbe givento, but not be limited to, the dynamicforcesgeneratedby the ride
19
20
andthe load of the boatonthe I-beamandup-stop.
20
21
21
22 "I.
23
18
The owner/Operatorshalluprlaieall documentation
that reflectsch-anges
in the maintenanceand
operationof the PerilousPlungeattraction.
22
23
24
24
25
25
26
26
'.:
.' "
STATE
OF CALIFORNIA
'f;lJ Permanent
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE UNIT
ACCIDENT INVESTIGATION
0 Temporary
Page ~L-
of
23
REPORT NARRATIVE
1
J.
The Owner/Operator
shallreviewthe trainingmanualto makesureit has sufficientdetailsrelated to the
2
specificsof the PerilousPlunge. The manualshallbe revisedto includeinstructionsfor seatbelt operationand
2
3
maintenanceandto includeanyotherdetailsfoundto benecessaryasa resultof the review.
3
4
1
4
5
K.
ThePerilousPlungeattractionshallnot be reopenedto the public until the Division hasconductedan
6
inspectionto verify compliancewith thesecorrectiveactionspecifications.
5
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22 --~
23
23
24
24
25
25
26
26
I
co
'"
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",wc-'