Creative abandon

Following the conclusion in March of the Dreamspace trial, Pam Waldron explains the failures that led to the incident, the competence issue that this case highlighted, and the lessons for those involved in organising public events.

The trial of artist Maurice Agis — whose inflatable artwork, Dreamspace, broke free of its moorings while on display in Chester-le-Street with members of the public inside — attracted huge media coverage, with mobile phone and CCTV footage repeatedly shown on TV during the hearing (SHP May, In Court).

The incident, on 23 July 2006, occurred after the structure was lifted from the ground by strong winds. It travelled 30 metres before it snagged on a CCTV camera pole and deflated. Two people died and 27 suffered injury.

Agis eventually stood trial on a double count of manslaughter — on which a jury failed to reach a verdict — and a breach of section 3(2) of the HSWA, for which he was found guilty. There were also guilty pleas to health and safety charges brought against Brouhaha International, the promotions company run by Agis’ son, Giles, which assisted in erecting and exhibiting Dreamspace; and against Chester-le-Street District Council (CLSDC), which owned the park where the artwork was on display and helped organise the event.

So why were three parties convicted of health and safety offences, and what responsibilities and roles did they each have in the incident itself?

How was the structure designed?

Measuring 50 x 50 x 5 metres, Dreamspace was an interactive ‘experience’ through which visitors could walk and enjoy changes of space, light and colour, enhanced by a pre-recorded sound-track. It comprised numerous ovoid cells constructed of very thin, translucent PVC, arranged in different colour combinations. Internally, columns were formed where cells were glued together.

The structure was inflated by fans, such that it was supported by air under pressure, and it retained a relatively stable shape, having been fixed to the ground by a system of ropes and pegs. The ropes ran over the outside of the pods, down through the columns, and fed back to form loops. These loops were fixed, via a smaller loop of rope, to a peg, which was driven into the ground.

Events leading up to the incident

In 2005, CLSDC registered an interest in the new Dreamspace tour, which Agis was planning for the following summer. At the start of March 2006, the CLSDC arts officer asked Agis for the risk assessment and method statement relating to the structure and, in due course, documents were submitted.

The first document, headed Dreamspace Security Hazards and Control Measures, identified high winds and torrential rain as hazards, which were to be controlled by “40 stakes to secure structure to the ground; evacuation, closing and deflating; team of stewards”.

An accompanying document, entitled Further Information on Dreamspace, stated: “Cancellations may happen because of weather conditions. High and gust winds are dangerous to the public and the installation: Dreamspace remains closed and deflated [in such circumstances]. Constant moderate winds move the structure, [in which case] it may have to be repositioned.” This was the sum total of the safety information. Moreover, even though Agis specified the use of 40 pegs, this figure was not based on anything other than his experience. Later calculations showed that a minimum of 80 pegs, evenly distributed, was required with the type of ground anchor used.

The structure was first inflated at the venue on 21 July. Agis told a team of Brouhaha employees and agency workers where to put the ropes and pegs, but there was no plan to indicate how many there were and how they should be positioned. On 23 July, shortly after the structure had opened to the public, a Brouhaha employee noticed the wind passing underneath the structure and lifting the floor several feet in the air. He began to evacuate but Agis stopped him and told people to re-enter, before instructing two Brouhaha employees to attach some more ropes to pegs around the structure, which they duly did at the front and along one side. Later that afternoon, a gust of wind from the rear corner caused Dreamspace to break free from its moorings and rise into the sky.

Who could have prevented the incident?

Maurice Agis — Competence was needed to design, manufacture, erect and operate Dreamspace. Agis did not properly assess the risks, which meant he did not have suitable control measures to ensure the safety of persons inside. Fewer than 40 pegs were used, contrary even to his own inadequate risk assessment. The ropes were substantially weaker than required — Agis not only purchased extra rope rated for ‘general purpose and fastening’ from a local DIY store but used deteriorated ropes, whose breaking load was half of what would be expected for ropes of their size and type.

The rope strength was further reduced by the method of deployment, e.g. the tying of ropes with knots, which reduces the breaking strength by between 30 and 50 per cent. Significantly, despite knowing of the structure’s unsafe condition, he did not close the structure and reassess the anchorage system before reopening.

His previous experience of being in control of structures that had broken free from their anchorages — in Glasgow and Germany — should have made him well aware of the risks, particularly in relation to the effects of wind. However, over the years the structure had increased in size, while the number of anchors used to fix it in place had remained unchanged. Hence, the control measures became less and less effective.

Brouhaha International — Managing director Giles Agis was well aware of the scale of Dreamspace. He relied on his father to ensure that it was safe to exhibit and a safe place in which to work, given his father’s considerable experience of exhibiting similar structures. But it is difficult to see how he could think that Maurice Agis would have the technical expertise to design, manufacture and install Dreamspace safely. Brouhaha had seen the documents provided to CLSDC, including the unsuitable and insufficient risk assessment document. It failed to take any further steps to ensure the safety of its employees.

Chester-le-Street Advisory Group (SAG) — The event application was considered by the SAG, a body with no statutory responsibilities. Its membership includes individuals from CLSDC, the emergency services, and other relevant organisations involved in the assessment of public events. In broad terms, its aim is to offer advice and guidance to those concerned in the planning, organising and promotion of events, so that such events can take place safely.

Significantly, no one with any health and safety expertise attended the meeting where the application was approved. Questions were raised regarding fire safety, which was subsequently dealt with by correspondence.

At the same meeting, an application for Uncle Sam’s American Circus was considered. The information provided by that applicant was significantly more robust and included various documents relating to structural calculations, tests and examinations. Even a cursory examination and comparison of the safety-critical information for each event should have raised concerns about the Dreamspace documentation among those present. SAGs clearly require the competence necessary to discharge their function, i.e. the approval of event applications.

CLSDC — The council assisted Agis with his event application and presented it to the Safety Advisory Group (SAG) on his behalf. CLDSC accepted the documentation Agis supplied and sought no advice from its own health and safety department. Simple questions would have swiftly revealed massive failings and should have raised alarm bells about the absence of any competent input.

But CLSDC failed to review and amend its internal procedures for dealing with event applications when the SAG was set up. The result was that individuals were unclear as to how to proceed now that the SAG approved applications rather than the council. Existing procedures fell by the wayside. As an unintended but inevitable consequence of the introduction of the SAG, CLSDC had effectively delegated its legal responsibility to a body that had no statutory duties. This should have been obvious to the council’s director of development, who was also the SAG chair.  

The lessons to be learnt

1    Structures should be safely designed by a competent person. For a structure the size of Dreamspace, structural engineering advice was required. The rule of thumb is: the more unusual the structure the greater the degree of scrutiny required.

2    Even for structures like Dreamspace there are relevant standards and guidance. In the absence of relevant standards, a competent person will work from first principles. There should be design documentation, stating who the designer is and what standards have been used, together with calculations to support the design. Safety critical features should be specified and there should also be informative drawings.

3    Safe operating parameters should be specified and there should be evidence of arrangements to ensure safe operation (including monitoring of weather forecasts and measurement of wind speed, if appropriate), as well as training of staff and emergency procedures.

4    Evidence of independent review, or third-party verification is good practice with large high-risk structures.

5    Those who have to review and approve applications, e.g. local authorities and SAGs, should ensure that the documentation is appropriate, with relevant calculations and independent verification. If inspections are carried out they should check to see that documented control measures are in place.

Local authority responsibilities

This case has caused some concern among local authorities, who will be aware of their duties under sections 3 and 4 of the Health & Safety at Work, etc. Act 1974. The extent of those duties will very much depend on their involvement in the planning, organisation and operation of the event. The responsibilities of event organisers and others involved in ensuring the health and safety of employees and the public should be clearly identified when events are being planned.  

Further reading

1    HSE (1999): The Event Safety Guide: A guide to health, safety and welfare at music and similar events, HSG 195, ISBN 9780717624539

2    Football Licensing Authority (2008): Guide to Safety at Sports Grounds, Fifth ed., The Stationery Office, ISBN 0 11 300095 2 (particularly chapter 14: ‘Spectator accommodation — Temporary demountable structures’)

3    The Institution of Structural Engineers (2006): Temporary Demountable Structures, Third ed

Pam Waldron is head of field operations for HSE in the North East.