Or is it a failure of the system if it’s possible for that to be the result of somebody making a mistake? They say they are changing the system, which seems like an admission that it wasn’t just a human failure. I smell scapegoating.

http://www.bbc.co.uk/news/uk-england-34911943

I don’t buy it as human error, yes the human pressed the button but surely there should be a system where a human cant override it if a safety warning is detected?

Seems reasonable. There will be safety systems and interlocks that have been found to have some dangerous settings. An Organic component fiddles and sets them to danger and that’s when you have issues.

Take those seetings away and the thing becomes safer.

I would have thought there would be a rule that should cars collide, no human limbs would be in the pinch zone. Wouldn’t be hard to do, and would make all rides like these safer

I can’t remember if it was the Smiler, but a colleague was telling me he nearly made it onto a ride at Alton Towers, when the operator suddenly realised this incredibly tall chap had breached the upper height limit. I never knew they existed but it makes perfect sense.

I can remember I was so excited in the mid 80’s, being just tall enough to ride the Corkscrew!

no human limbs would be in the pinch zone. Wouldn’t be hard to do, and would make all rides like these safer

But also more boring.

Rollercoaster collisions are not exactly a common source of injury.

Every safety system can be over ruled by lateral thinking

Hi
There’s a difference between human error (which suggests a mistake) and over riding a safety system which is a conscious and deliberate act.
I would have thought that the “system” should fail to safety but that didn’t happen suggesting that the “system” was flawed.
Cheers
Steve

Sure, but it’s a question of how difficult you make it. If it only requires a couple of seconds thought, then people will over-ride it with only a couple of seconds thought. If you make it so it takes a bit longer then the fallible bits have more time to consider whether it’s really a glitch or they should check properly.

Also, if the shutting down of safety-critical systems is happening against the background of commercial pressures to get the ride back open, you have to take a hard look at the safety culture and oversight under which the engineers are working.

I’d hope they don’t just say – ‘a man cocked up’ – and brush away the rest.

Damage limitation exercise. Trying to cloud the issue before the HSE verdict. This as has already been stated should be a fail to safe system. A mistake proof level 3 which would need conscious human intervention to override it. I can’t see the HSE verdict concurring.

Blaming human error makes their rides sound safer, they can then wash their hands of the situation to an extent. Joe Public will then feel more like turning up which will help return the lost takings…
#scapegoat

Im always a bit skeptical of the human error explanation. Its usually the cheapest fix that minimises downtime too.

Wasn’t me, honest….

Which is exactly what this looks like to me. Having a safety system which can be over-ridden that easily smacks of commercial pressures.

But also more boring.

Rollercoaster collisions are not exactly a common source of injury.

You reckon?

I’m really not too sure why this:
would have been any less fun with a few hundred mm of impact protection. It looks dull to me anyway, with that big barge area up front.

If it had been this one:
Then sure I could see the argument.

Overriding interlocks is not human error, I’m sure the HSE will state something similar.

IMO the ride design is flawed as a collision between 2 carriages is always going to be a possibility yet the carriages do not have fully rated buffers on them.

I’ve operated theme park rides before and think have a pretty good idea of what will have probbaly occcured so will be interested to read the HSE report when it comes out

Hi again
A safety system that can easily be over ridden is not a safe system by definition imo.
I accept there will be commercial pressures but the implications of not operating this equipment properly can not be understated, as we have seen unfortunately!
I will be interested to see (if or) how the report details the design of the ride and how the so called safety system was implemented.
I just don’t see how it could be “signed off” as being safe by design and there must also be implications for the designer/manufacturer in the HSE investigation.
We shall see
Cheers
Steve

I will abseil 400ft cliffs on a single rope but I would never go on a roller coaster as I am not in control.

In all cases it will be “Human error”. It could be the operator pressing the wrong button, or the human who designed the system failing to put sufficient safety interlocks or processes into place!

For now, all that “human error” means is that there was not a direct mechanical (or electircal) failure that caused the accident (ie, welds breaking, or a wire shorting out or whatever)

All systems will have methods in place to override the normal processes, necessary for test, or emergency usages. However, anyone who has the authority to circumvent the normal process needs to be trained to understand exactly what they might be doing. Unfortunately, with complex modern systems, the chain of events to the eventual failure can be complex and very difficult for a non expert to predict. And the chances are, the person tasked to run this ride was a none expert, even if they had a basic level of training.

It’s what i call the security guard conundrum. IE the ideal security guard is a person who can sit through literally years of absolute boredom and inaction (the normal state of the job), and yet, in a split second, react rapidly, decisively and with absolute accuracy (the abnormal part). And, yup, you simply don’t get a human that has both those atributes……..

I just don’t see how it could be “signed off” as being safe by design and there must also be implications for the designer/manufacturer in the HSE investigation.

I agree (sort of). My background is in H&S although thankfully out of it now. There are significant differences between what is acceptable in design in different countries, and we are not talking about Chinese type differences.

A few years ago I was with an HSE inspector on a site visit. It was to a pie making factory with a brand new pie making machine – basically you get the flour, meat etc and shovel it in one end and a pie comes out the other end. The owner was very proud of this machine, it was made in Germany and was all CE marked etc and good quality.

The HSE inspector looked at it and immediately put a prohibition notice on it as there were a couple of small “doors” which could be opened, hands inserted and turned into pie! There were just signs on the doors which had the appropriate danger symbol and a note saying not to open the doors when the machine was running.

The owner immediately called the German manufacturer and told him the problem. The designer was shocked that it could be an issue. He said in Germany if there was a sign saying not to open the door then no-one would open the door. The HSE inspector had to explain that in Britain this wasn’t acceptable and the typical operator would open the door BECAUSE there was a sign saying not to, just to see what would happen.

I’ve seen light guards on guillotines defeated by complex periscope type mirror arrangements and bolts wedged in interlocks.

Anyway, the purpose of this is to say that just because it was signed off as safe somewhere doesn’t mean it should have been signed off in the UK, and given a chance ANY safety system can be defeated.

The interesting thing is in the staff training and whether there was any commercial pressure to run “at any cost”. Bottom line is it is managements fault. They either failed to train, supervise or implement a suitable safe system of work.

An accident investigation which correctly blames the person at the bottom is in my experience very rare. I probably investigated 200+ accidents and in maybe one case could I say the root cause was with an individual at the bottom of the tree.

Sounds like a look for a scapegoat to me, or at least to minimise damages if they can share the blame with a normal person who doesn’t have lots of money or legal insurance.

What’s the point of having a safety system if any operator who didn’t understand the risks couldn’t simply override it to keep the queues moving.

What’s the point of having a safety system if any operator who didn’t understand the risks couldn’t simply override it to keep the queues moving

This will definitely not be the case, it will have been done by a senior operator/engineer, and it won’t be just a case of pressing a single button to get the ride going again. High level system logons and/or authorisation keys will be required as a minimum.

The control systems on rides like this have to go through independent assessment by a UK company, and will therefore be solid. This assessment will cover ‘idiotic’ or ‘accidental’ actions by operators.

However maintenance/manual modes and system overrides are always included as part of a control system such as that will be installed here, as under certain situations they are required (usually maintenance but sometimes in a emergency). The use of these system should be very closely controlled and documented, and this is what looks to have gone wrong here.

In the case of a ride like this I would have expected every system override to have a defined procedure which requires carrying out and signing off by at least two people (both must be authorised for the operation also). This procedure would ensure that the override will not create a dangerous situation. In the case of this incident it should cover things like visually checking the track is clear. This procedure will also be linked to the detailed operations manual which should exist for the ride.

It is very unlikely a single person will be scapegoated for this horrible incident. Ultimately a single person may have carried out the override and set the ride going again but a whole load of other things must have failed for situation to arise in the first place, and this will come back to the company.

The bit that I find intriguing and will be interested what the HSE cover on the matter, is why the cartridges don’t have bumpers/buffers that can withstand a crash at full speed fully loaded. In the photo above right under the smiler logo you can see the main backbone of the chassis protruding surly it’s ‘reasonably practicable’ to fit bumpers/buffers that would stop people getting crushed in a crash did happen?
Under the hierarchy of control you shouldn’t relay on a safety system when the situation (crushing) can be removed by mechanical design.

“A ride shutdown message was misunderstood by staff at the ride,” an Alton Towers spokeswoman said.
“This led to a decision to manually restart the ride, overriding the control system without appropriate safety protocols being followed correctly.”

Manual overrides exist is most automated and safe systems, the system to get out of a fault condition should include all the checks and safety measures to do so safely – like checking what the fault is and working out the implications of doing the manual recovery.
If as stated they didn’t follow the process then that comes down to human error.

Ultimately a single person may have carried out the override and set the ride going again but a whole load of other things must have failed for situation to arise in the first place, and this will come back to the company.

This is also very true.

It sounds as though these things are too complicated for fairground operators to be in charge of.

is why the cartridges don’t have bumpers/buffers that can withstand a crash at full speed fully loaded. In the photo above right under the smiler logo you can see the main backbone of the chassis protruding surly it’s ‘reasonably practicable’ to fit bumpers/buffers that would stop people getting crushed in a crash did happen?

I can understand from an aesthetic point of view, no bumpers on the front of a carriage train, but if you have multiple trains on the track with the potential for collision, then a buffer added to the rear of each train should be the crumple zone instead . . . which was have no affect on the forward facing passenger enjoyment.

I think the human error will pan out as being a scapegoat type of thing . . . the company will try and blame a person whilst the bulk of the media focus is on the issue, but that media focus will go after a while, and the HSE report could blame the company procedure, but by that time the media will have moved their interest on.

I read it as the operator over-rode the safety system so went out of process. Its not unusual for a ‘system’ to include a human and as long as that human observes the training they received everything should be perfectly safe. However if the human deviates from the procedure and their training then things can go wrong. It is usually the job of the design team to design out any possibility of the system failing even if human operators do something they shouldn’t do, but it’s not always possible to completely design that out, not at a sensible cost anyway, and you do rely on humans being trained and complying with procedures. Look at a Passenger planes – we rely on trained pilots carrying out their job within the defined procedures all the time, and as a result all air crashes these days are due to human error – i.e. pilots not working to procedures, rather than a failure of the aircraft itself.

So if the operator went out of process and the accident resulted, then it’s human error. If the operator was working within the process and their training then it is a system failure.

Either way we’re told additional safety measures have been put in place so I assume that means they’ve closed the loop on this particular failure mechanism – doesn’t mean there are not others.

It doesn’t matter how idiot proof you make a system, there will always be a better idiot coming along soon……..

“A shutdown message was misunderstood by staff”
“This led to a decision to manually restart, overriding the control system without appropriate safety protocols being followed correctly.”

I work in industrial insurance, and this reason is behind a huge amount of losses. Expand it to general “human error” – lack of maintenance, failure to follow procedures in place, lefty loosy/righty tighty errors, and that’s pretty much everything bar outside events – arson, natural catastrophes

Usually a combination of lots of unlikely conditions all occuring at once, that if you proposed it beforehand as a possible cause of loss to the site manager “what if, what if, what if”, you’d get laughed at as a doom-merchant.

t all air crashes these days are due to human error – i.e. pilots not working to procedures, rather than a failure of the aircraft itself.

…apart from the ones that get blown up. Or shot down. Or a pilot commits suicide. Or birdstrike, etc.

But anyway, on with the Alton Towers tale of the recovering Merlin plc share price…

I will abseil 400ft cliffs on a single rope but I would never go on a roller coaster as I am not in control.

So you walk everywhere, never drive or get on public transport or even take your bike on the road. You must live nice and close to those cliffs. 🙂

would have been any less fun with a few hundred mm of impact protection. It looks dull to me anyway, with that big barge area up front.

It doesn’t have to be in front of the riders; it can be out of sight on the track below or above.

I think ‘boring’ is better than having a pair of socks last twice as long…

The legendary Trevor Kletz’ classic quote:

“For a long time, people were saying that most accidents were due to human error and this is true in a sense but it’s not very helpful. It’s a bit like saying that falls are due to gravity.”

coffeeking – Member
would have been any less fun with a few hundred mm of impact protection. It looks dull to me anyway, with that big barge area up front.

You could have train buffers on the back of each coach and not affect the aesthetics too much.

You’d never be able to absorb the impact at all (at the end of the day it’s going 23 meters per second and weighs several tonnes) but might just save people’s legs.

There will not be a single fault or failing that caused this accident it will be like in every other instance a sequence of events that will have gone wrong, only one of which will be the operator. In this sequence the omission of one of the steps would have meant the accident didn’t happen. If you really want to scare yourself though, ask yourself this, how many times has this accident almost occurred where one of those sequence of events didn’t happen?

This

The interesting thing is in the staff training and whether there was any commercial pressure to run “at any cost”. Bottom line is it is managements fault

is so true of many situations and the disturbing thing is that even when commercial pressure has been removed, getting people to change their behaviour in a way that will protect them is a lot more difficult that you’d imagine.

I will abseil 400ft cliffs on a single rope but I would never go on a roller coaster as I am not in control.

This just shows that you have very poor judgement of risk, in common with nearly everybody else.

whether there was any commercial pressure to run “at any cost”

There has been a lot of speculation about “commercial pressure” on this thread.

It’s probably worth remembering that you pay an entrance fee at Alton Towers. There isn’t a fee for the individual rides.

So while there may be some pressure to keep the rides running so customers are happy, I suspect it’s not nearly as bad as pay-per-ride fairs where they are losing money every second a ride is shut down.

This just shows that you have very poor judgement of risk, in common with nearly everybody else.

😀

This just shows that you have very poor judgement of risk, in common with nearly everybody else.

well it kinda depends doesn’t it. I hate “fairground” rides but I’m ok with bouncing downhills on a push bike (which I’ve cackhandedly built myself) at silly speeds.
I know I’m much, much safer on a well maintained alton towers ride but I’m more at ease choosing my own highly dubious lines.

I’d argue my risk assessment isn’t too bad but for some reason I’m compelled to ignore it.

So while there may be some pressure to keep the rides running so customers are happy, I suspect it’s not nearly as bad as pay-per-ride fairs where they are losing money every second a ride is shut down.

People queuing for longer for a reduced of rides (due to closure of certain ones) aren’t spending money in the cafes or such like. Or have gone home early etc.

People queuing for longer for a reduced of rides (due to closure of certain ones) aren’t spending money in the cafes or such like. Or have gone home early etc.

True but I’ve been to Alton Towers since the Smiler incident, when a lot of the Sector X rides were shut, and it was still absolutely mobbed.

So yeah, what I’m saying is there may be some commercial pressure to keep rides open, but I don’t think it’s some manager screaming “We’re losing money. Override the safeties and get this f&*%&* ride open now.”