Victoria Balch and Leah Washington had their legs amputated after the crash on 2 June, when the Smiler ride hit an empty carriage in front of it.
An investigation by the park has confirmed that staff misunderstood a shutdown message and wrongly restarted the ride. No technical or mechanical issues were found with the ride itself.
The ride, which has been closed since the crash, will reopen next year with improved safety measures.
“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.”
A total of 16 people were injured when the carriage they were in collided with an empty one that had come to a halt ahead of them.
Merlin Entertainment, which owns Alton Towers, previously said all 16 would receive compensation.
The Health and Safety Executive said its own investigation was “still ongoing”.
Alton Towers said it had followed “standard HR procedures and taken the appropriate action” when dealing with the staff whose errors caused the crash.
A spokeswoman said: “The outcome of this however remains a private matter between us and any individual concerned.”
“We are confident that lessons have been learned and that appropriate action has been taken to address all the issues raised by our investigation.”
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I sincerely hope that more lessons have been learnt from this accident than are apparently being reported. Unfortunately, it appears to be yet another high profile accident where underlying lessons do not seem to have been learnt. To attribute this accident to human error is a classic example of attaching the cause to the last triggering action in what will have been a long line of root causes.
Once again, the Human lands up in the firing line. Systems should be designed to be error intolerant. If a human is capable of making the error in the first place, the system is usually at fault. In all the accident investigations that I have conducted over the years, I have only found one case of an actual, deliberate violation causing the incident. Every other incident or accident can be tracked back to systemic and management failures in the organisation or design flaws in the equipment or plant.
‘Human Error’ should be the start of the investigation, not the end resulting in ‘HR actions…’
I hope that the HSE Investigation delves deeper and that Alton Towers get given a lesson in Human Factors and Human Error. Heck, I might send them one of James Reason’s or Sydney Dekker’s books myself…
I totally agree with Richard – human error is the beginning no the end of the investigation. By stating this the company shows a lack of knowledge around system safety. As some of the other respondents have said a system needs to be designed in a way that does not allow a manual override to take place without other controls in place – both technical and human
It should not be possible for the operator to override the control system it should be fool proof, was an override key left in control panel or override code given to the operator of the ride? Stop blaming the operator and find the real reason why this accident occurred! This is clearly a management or design flaw in the safety system of the equipment and let’s hope the HSE investigation identifies the real root cause of the accident.
Of course they’ve followed (their own) “standard HR procedures and taken the appropriate action”. Let’s put the blame on the low paid, untrained staff why don’t we. My son worked there while at Uni. Alton Towers undertake a huge push at the beginning of the term to recruit inexperienced students to work part time. Furthermore, they limit the time that individual can work and are prevented from returning next season. Presumably this is for employment / financial reasons. Surely it makes more sense to employ experienced (competent) staff even if it is only casual work. If his experience is anything to go by, the HSE need to keep looking very hard at how Merlin Entertainment operate.
I just hope that those poor kids don’t accept a measly compensation offer and more importantly, manage to overcome their physical and mental injuries.
It seems that the operators are lacking in the skills to investigate and have an old fashioned “blame culture”. It is very worrying that the comments from Alton Towers says everybody will get compensation and action has been taken for the individual responsible. My first question would be how did the empty carriage become stranded in the middle of the ride in the first place? to say there is no equipment error is clearly apportioning blame;. as for training you have 3 options, retrain to the same standard that has already failed, accept the person is responsible and say that it will not happen again he has learnt his lesson or sack the individual. Any of the options will not address the issues in a blame culture. I certainly believe HSE will conduct a proper thorough investigation and expose failings in safe working practices and procedures.Historically management is often a contributor to accidents to some degree.either through poor quality procedures or failing to implement.Human error certainly, who’s error ????? .
I hope that the HSE investigation will uncover:
– why it was necessary to override the control system to restart the ride? (design error)
– whether, as usually proves to be the case, it had become accepted practice to override the control system? (management system failure)
I very much doubt that it was a one-off occurrence of human error!
Well said I agree completely with your comments
I worked there for a season 20 years ago, and i once had to call over the CB “HIT THE EMERGENCY STOP!”. The response was “Why?”
So i am not surprised.
Very sad that this can happen in the health and safety mad society we live in and i feel deeply for those affected. Seems there needs to be a little more automation in the emergency procedures.
I am glad my thoughts have already been echoed above.
Funny how HUMAN ERROR is the apparent cause yet, improved safety measures are being delayed “The ride, which has been closed since the crash, will reopen next year with improved safety measures.”
“An investigation of the park has confirmed that staff misunderstood a shutdown message and wrongly restarted the ride. No technical or mechanical issues were found with the ride itself.” – This is a poorly designed system, the HUMAN ERROR lies with the design and control fault, not with the operator.
safety measures are being *deployed*
An appalling conclusion. Merlin Entertainment have leaned nothing from the previous misdemeanours, and with this kind of announcement the HSE will hopefully be looking conduct a proper root cause analysis that will include management systems, responsibilities and aspects of machine safety. It should not have been too difficult to install robust systems to ensure this could not have happened. Hang your heads in shame Merlin!
The conclusion drawn here is preposterous (in my opinion). I would be interested to know which root cause analysis method was employed for this incident and who is accountable for letting this statement be publicised. To simply blame the Operator and not even give a ‘reason why’ they came to this conclusion, is bordering on arrogance; as clearly mentioned numerous times already, “It should not be possible for the operator to override the control system”!
I work with manufacturing systems with far less potential for injury in case of a malfunction than these rides, but even so, there is no way that an operative would be able to simply override safety protocols by restarting a piece of equipment. If there can be multiple redundancies and soft and hard guarding on our machinery preventing this sort of issue, why the hell can it not be implemented on machines like these attractions, the design and structure of which thousands of people a year entrust their lives to?
Well done Merlin entertainment,Blame human error when safeguarding processes to prevent a manual override were obviously not in place at the time of the accident.
Oh dear! I look forward to the outcome of the HSE’s investigation which will identify the true cause and then perhaps real lessons can be learnt!
Human error is not the cause, there will be a reason why this failed and without wanting to preempt the outcome from the HSE, a lack of management controls, design fault and suitable training would be high on my list.
If the operators understood the requirements, control measures and most importantly risks then they wouldn’t have overridden the system, the design of the ride should include sufficient controls to be ‘fool’ proof and if management controls had been stronger then as a minimum double checking would have been part of their procedure before overridding.
I dread to think what HR actions have already been taken if this is their conclusion, perhaps one action still to be taken is to hire a competent H&S advisor!
I agree with the comments above, its yet another PR stunt by a large corporation to protect its reputation and income. Imagine the effect on visitor numbers if it stated “accident down to our poorly designed system because we failed to include human factors in our hazard identification and risk reduction strategy”. The HSE report may still be 12 months away by which time visitor numbers will be maintained in 2016 as they have an easy scapegoat e.g. a low paid, overworked individual who more than likely was influenced by supervisors and managers to keep the ride going and ques short. Seen it all before, will see it all again.
Well I shall not be going to Alton Towers anytime soon!