Flaws in a manufacturer’s quality-control system and a mix-up in fixing components led to the supply of a faulty rope, which subsequently failed in safeguarding an outdoors-activities instructor as he carried out a simulated parachute landing.
Joshua Senior, 25, plunged nine metres to the ground at the Rock (UK) adventure centre in Carroty Wood, near Tonbridge, Kent, on 25 August 2010. The experienced instructor suffered a broken back and was paralysed from the waist down for some six months.
He slowly regained some use of his lower limbs but, as he was regaining movement, it became clear his ankle had been crushed and his right foot had to be amputated.
The rope used by Mr Senior to carry out his practice landing should have helped control his descent, but it simply unravelled as he stepped off the climbing-tower platform.
Southampton Magistrates’ Court heard that the rope supplier, Pfiefer Rope & Tackle Ltd, had supplied batches of ropes at the request of Rock (UK) to use in a ‘parafan’ device, which simulates parachute landings.
The rope leads from the person’s harness to the shaft of the parafan, which slows the person’s descent to that of a real parachute landing. Mr Senior fitted the first rope of the new batch and carried out all the tests prescribed by the parafan manufacturer. He then performed the final test, which involves using the parafan itself.
When making this batch of rope eye-end terminations, Pfiefer Rope & Tackle had used the wrong ferrules, small components that are used to crimp ropes. Consequently, when Mr Senior jumped from the climbing tower on which the parafan was fitted, the rope disconnected from his harness and he fell to the ground.
The court was told that although Pfiefer Rope & Tackle’s quality-control system was certified to ISO 9001, it had not operated effectively.
A short time before the supply of the faulty batch, the company had changed its supplier of ferrules and received smaller components than had previously been the case. This was not picked up by Pfiefer, which failed to carry out a simple measurement check on the eye-end terminations to confirm they had been fully crushed.
Although the outdoors-activities centre falls under local-authority jurisdiction, the matter was passed to the HSE to investigate what was thought could be a breach of s6 of the HSWA 1974, which covers general duties of manufacturers and suppliers.
Pfiefer Rope & Tackle Ltd was eventually charged under s3(1) of the 1974 Act, a breach of which it admitted. Sentenced on 15 August, the Southampton-based firm was fined £20,000 and ordered to pay £6348 in costs.
It also emerged that the company issued a certificate of thorough examination for the ropes under LOLER 1998, however, this should be done following installation of lifting equipment. In fact, the company should have supplied a certificate of conformity. This error also led Rock (UK) to understand that the ropes had been tested, the court heard.
“It is only a matter of chance that this was not a fatality,” commented HSE specialist inspector Steve Simmons-Jacobs after the hearing. “As it is, Mr Senior has suffered life-changing injuries and has now been fitted with a prosthetic foot.”
He continued: “Rope and sling manufacturers have a duty to their customers and others to ensure that the product is suitable for the designed loads, and that their quality-control systems are robust and effective at all times. Companies must realise that their systems may be critical to the health and safety of the people who use their products.”
The company has since made improvements to its quality-control system and no longer issues certificates of thorough examination.
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