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July 27, 2011

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Banana-boat tragedy highlights need for specialist risk knowledge

A watersports club contracted a consultancy to help it set up safety management systems, despite the company having no experience of assisting water-ski parks in managing the risks from their activities, a report into the death of a child in a banana-boat incident has found.

Eleven-year-old Mari-Simon Cronje died on 11 September last year from severe leg and perineal injuries after she fell off a banana boat into a lake and came into contact with the propeller of the ski boat that was towing the inflatable.

The driver of the ski boat was not aware that she had fallen into the water, and did not see her as he continued on a tight circular route.

An independent investigation report, issued last week by the Marine Accident Investigation Branch (MAIB), concluded that the incident at Princes Club, Middlesex, was, in part, a direct result of the organisation’s flawed process for completing risk assessments, as well as the failure of the specific banana-boat risk assessment to identify the hazard of a fallen rider not being spotted by the driver.

The lack of external oversight of towed inflatable rides meant that Princes Club’s safety procedures went unchecked. Nevertheless, investigators also heavily criticised the club over the implementation of its safety management system, which they described as “flawed at every level”.

Although the club had contracted MHL Support Ltd in 2008 to establish health and safety management procedures, the consultancy “had no prior experience of assisting water-ski parks and had no record of taking specialist advice on the subject before, or during the contract”.

MHL’s initial survey of 31 May 2008 made 14 safety observations, but none of these related to the core activities on the site – namely, water skiing, cable skiing, or rides on the banana boat. An annual inspection by the consultancy in May 2010 made seven observations, but the club was not required to report back to MHL when these actions had been completed, and had no internal procedures to follow up the points raised.

Furthermore, despite many staff members having considerable experience of water sports, Princes Club chose to appoint its events coordinator as its health and safety liaison officer. She took on the role in 2009 only after she raised concerns about her lack of experience, at which point the club made arrangements for her to attend a four-day IOSH course.

Having completed the training, she carried out a full site inspection, identifying 49 safety observations and raising serious concerns about the “lax attitude” to health and safety on site.

The MAIB report noted the numerical difference between the 21 safety observations that MHL made over two visits, compared with the 49 identified by the inexperienced health and safety liaison officer in a single inspection.

It said: “This difference demonstrates that while MHL might have fulfilled the basic obligations of its contract with Princes Club, it had a limited ability to conduct a worthwhile health and safety inspection of a 120-acre site in the space of a few hours – particularly given its lack of experience in the sports involved. Similarly, Princes Club had an unrealistic expectation of the service that MHL was providing.”

The issue of accredited consultants providing advice in very specialist areas where their knowledge, or experience is limited was raised as a concern by some SHP readers during the development of the Occupational Safety & Health Consultants Register (OSHCR).

The MAIB report recommends that MHL (now Bibby Consulting and Support) review its service “to ensure that the limitations of any inspections carried out by its consultants are made clear to the client and, in particular, that the inspection may not necessarily reflect the standard of the entire operation”. It also recommends that either proper, technical advice is sought when assessing specialised activities, or that the limitations of the service are made clear to the client.

The company has already engaged specialist lawyers to assist in reviewing its health and safety systems and procedures to ensure that they provide a workable framework for clients to comply with statutory health and safety duties.

Riding on towed inflatables has never been included in the list of activities that are required to be assessed and licensed by the Adventure Activities Licensing Authority (AALA). The HSE is currently consulting on the closure of the AALA and replacing the licensing regime with a code of practice.

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Audrey

HSE guidance on RA, says it’s ‘straight forward’ and can / should be done by the ‘person with the problem’. HSE also reminds clients that using a consultant does not transfer their responsibility. As already said, no-one would be “an expert” in this kind of activity, except the provider, I would have thought.
This outcome reinforces the flawed view that only “experts” and “safety folk” can possibly “know” all safety risks, and now they seem to be taking the rap, wrongly, in my view.

Ray

To be perfectly honest these type of activities are unusaul and most consultancies would not have been exposed to this type of undertaking. Only with proper assistance from the Princes Club could a consultant have understood all the issues. Moreover, how many consultants would have overlooked a person falling from a banana boat and being hit by the boat towing it?

It appears to me the Club’s safety management was seriously flawed in many different aspects. No mention of a prosecution…

Ray

David, I know this is a popular mantra by those who are pro consultants register, however there is little evidence that there are unqualified h&s consultants operating in industry. There has only been a handful of prosecutions for consultants providing inappropriate advice – hardly an epidemic!

One of the purposes of the register was to ensure h&s advice was commensurate with the risks and not OTT. The irony being the above article illustrates that not enough advice was given.

Ray

A very complex case. The difficulty for consultants is twofold, first companies do not want to pay large amounts of money for h&s services, so working to a fixed price can be incongruous a good and complete service. Second, clients often make little effort to assist the consutant, adopting a here’s the documentation – get on with it attitude. Hence things can easily get overlooked.

The duty for providing a safe undertaking lies with the organisation – not the consultancy.

Pragmaticrisksolutions
Pragmaticrisksolutions

Red tape, lack of ‘common sense’ / lack of common knowledge, call it what you want – Speedboat has spinning propeller – Inflatable banana must be inherently unstable – No appointed observer as generally required during serious waterskiing. It’s not difficult! If we’re not careful we’ll have NEBOSH developing a qualification in Waterborne Activities.

Pragmaticrisksolutions
Pragmaticrisksolutions

Towing individuals on inflatable bananas behind a speed boat is not a water sport; it’s yet another unregulated use of high speed waterborne equipment, unfortunately these dreadful accidents are inevitable. I’ve sailed for many years and have looked on in amazement at this so called form of water sport and others such as jet skiing. Indeed I once had to rescue a jet skier far out to sea, when the hull of his craft delaminated. Unfortunately HSE intervention always appears to be retrospective.

Paul

As a boat owner, I have approx 20 inflatables. I Never-ever-ever allow anybody on a toy without fully briefing them on the basic signals and without a “spotter” next to me.

I warn that anybody breaching these basics will be returned to land immediately. I just cannot fathom how you would not know a rider has come off a toy.

Absolutely shocking that an amateur / pleasure owner such as myself would, it appears, have a more robust procedure in place than a commercial enterprise.

Neil

I’d probably take issue with “An annual inspection by the consultancy in May 2010 made seven observations, but the club was not required to report back to MHL when these actions had been completed,” . A consultant providing advice typically would not expect the organisation to report back to them (this will often be outside of the scope of their engagement). Also what is the MAIB’s competence to examine organisational H&S factors (as opposed to Marine safety issues)?

Michael

In answer to Neil’s question I believe MAIB has siginificant experience in organisational H&S factors. Their inspectors go through a rigourous training programme and they support this by using outside consultants where necessary – you only have to look at the reports on their website to see this. I have been to a few conferences where their former Chief Inspector presented and I can assure you they are a reputable group. The quote he questions is simply stating a fact, not drawing a conclusion

Jkirby

MAIB mentions AALA. This activity not in scope, but in future no advent act for young people (mountaineering, canoeing etc) will be covered, but subject to code of practice. We have no idea how robust this will be and is causing great concerns within the outdoor ed industry. AALA was a robust system with annual/bienniel inspections.AALA practice was instrumental in North Yorks successful defence v. HSE last year. How we regulate such activites in future is part of consultation.

David

The problem is with Consultancy firms having non professionally qualified consultants carrying out professional audits/inspections, etc. It should be mandatory for only consultants on the HSE register of professional consultants to be employed to give professional advice.

Chris

Doesn’t this illustrate one of the major flaws in the consultants register. As a specialist in one particular aspect of health and safety I do not qualify to be on the register, but frequently find that those with the relevant qualifications have inadequate knowledge in my field and have taken inappropriate action. So what value can one place on the register?

Safeteenet

Surely this incident illustrates two problems that are are very common in the use of external consultants, and I am one of those. The employer failed to appoint a fully competent adviser, which the Register should make easier to identify but more importantly the organisation acting as adviser did not understand that the most important part of competency is knowing where it ends and specialist knowledge is needed. I believe the ‘paperwork exercise’ attitude to H&S is, as usual, the root cause.