Fatal Flaws of Inadequate Training

Last month, a family went to an amusement park in Colorado for a fun Labor Day weekend. When the ride was over, the young girl’s uncle looked over to ask what she thought of the Haunted Mine Drop ride – to his horror he saw her lifeless body 110 feet below, at the base of the ride’s mine shaft. Keep reading to learn about the fatal flaws that led to this tragedy.

An incident of this magnitude may seem taboo for some but, as a parent to three, and the youngest being my spunky 8-year daughter, the details of this investigation are so alarming I have to address it.

Throughout the accident investigation report, several safeguards were overlooked. In fact, it was one right after the other that left me shocked and in disbelief how this horrible accident could have occurred at all.

The Lawsuit

Unfortunately for innocent and unsuspecting victims like Wongel Estifanos, the people we “trust” ultimately make mistakes, and many times the mistakes are fatal. As a result, the family has filed a wrongful death suit for 6-year-old Wongel.

I can only fathom the immense terror the family experienced as they “screamed in horror and tried to get out of the ride to run to Wongel, the ride would not release them, and pulled them 110 feet back up to the top of the mine shaft,” as stated in the lawsuit.

2 Main Causes of Accidents

While I do not have an extensive background in human factors or root cause analysis, I do have plenty of knowledge in the importance of safety training.

For example, I regularly place in a person’s hands devices that propel objects by the ignition of strongly combustible materials. I do so by asking them to trust me, over their own limited knowledge and experience, and equip them with the skills and knowledge necessary to own and maintain their device.

I’m talking about instructing others on the safe handling and use of firearms and ammunition. I am relentless in my instruction methods to ensure my students know explicitly what to do, and not do, in all aspects of responsible firearm usage and ownership to prevent accidents. As such, the two main causes of firearms accidents are ignorance and carelessness.

• Ignorance is you simply do not know. No one told you, showed you, gave you a procedure to follow, or any formal, thorough instruction on what to do (and not to do).
• Carelessness means that you do know what is expected but you are cutting corners, in a hurry, overwhelmed, or simply negligent, when you do not care about the repercussions.

I can see from the accident investigation report that there were many flaws of inadequate training that led to this horrific event.

What Went Wrong

Built in 2017, the Haunted Mine at Glenwood Caverns Adventure Park passed a third-party inspection in June. As a result of the fatality, Glenwood Caverns Park Aventure provided all maintenance records, manufacturer drawings, inspection reports, including the required third-party inspections, training documentation, and accident reports over the past three years to be reviewed.

The State’s accident report says, “This fatal accident was the result of multiple operator errors, exacerbated by several factors detailed in this report.”

Wongel’s lap belt was not buckled.

The factors that led to the fatal accident include:

✦ Lack of proper procedures

✦ Inadequate training for ride operators

✦ Multiple operators taking responsibility for a ride during a cycle

✦ Restraint system involved

Inadequate Training

The problem stems from a lack of training of employees in the proper procedures, and the operating manual identifying the safety features, correlating errors, and how to properly correct them.

Fatal Flaw # 1 – Employees are to prepare for the next group of passengers by unbuckling the belts after each ride

• Wongle’s seat was not used by anyone prior to her entering the seating area
• She sat on top of the seat restraints, so they remained unused and underneath her instead of properly secured around her

Fatal Flaw # 2 – Employees are to ensure all belts are properly fastened prior to starting the ride

• Wongle’s uncle says the operator talked at length with her and did not pay attention to the lap belt
• The operating procedure specifically says to put the belt over each passenger and tighten the belt, in addition to visually checking that all passengers are belted

Fatal Flaw # 3 – A control system alarm warned the operators prior to starting the ride

• Two recent new hires were not properly trained on the purpose of the alarm
• One of the ride operators chose to reset the alarm, which allowed the ride to proceed

Fatal Flaw # 4 – The restraint system’s operation manual has inadequate instructions

• The belt manufacturer’s manual nor the operation manual adequately address safety errors and the causation.

The Denver Channel, a Denver news source, provides a full account of the incident and you can read the official Colorado Division of Oil & Public Safety Accident Investigation Report here. Additionally, internal incident reports from the employees operating the ride (redacted) are posted.

A History of Problems

The lawsuit alleges that the park failed to turn over complaints in 2018 and 2019 about passengers not being initially strapped into the ride. Digging a little deeper led to this email of a previous incident involving the Haunted Mine Drop ride.

The Estifanos’ attorney, Dan Caplis, says “Wongel’s parents are determined to do everything in their power to make sure that no one ever dies this way again. As part of this mission, they are asking witnesses to come forward, including folks who experienced problems with the Haunted Mine Drop before Wongel was killed on it.”

The Estifanos Family will Never be the Same

My sincere condolences go out to the family as they grieve over the tragic and sudden loss of young Wongel. If you are compelled to donate to the Estifanos, the family has a GoFundMe page. Please note that the Coroner’s Office has verified with the Go Fund Me organization and the Estifanos family that the linked Go Fund Me account is the only valid account in support of Wongel.

Find Out More About TapRooT® Root Cause Analysis

A key element of our mission is to change the way the world solves problems. The most valuable component of what we do is and will always be the people. Preventing accidents is achievable, but creating true workplace safety culture with no fatalities is why we do what we do.

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• A paper that describes how to use the TapRooT® Root Cause Analysis System – CLICK HERE
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