How process safety can apply outside the process industries - Taming the wild river rapids Trish Kerin Director, IChemE Safety Centre Hazards 29 May 2019, Birmingham Thunder River Rapids Ride, Dreamworld, Gold Coast. Source: abc.net.au What is the IChemE Safety Centre? Current Operating and Industry Partners Current supporting partners and collaborators The Incident 25th Following Raft with Empty October Water raft with people raft 2016 level 6 people flips, became pump dropped collides fatally stuck failure with it injuring 4 Incident details Graphics from HeraldSun A model for process safety • Lack of training for operators –Informal at best, lasted 90 minutes –“showedHow effective me the and front comprehensive page of the manual is your andfacility just flipped through it. I hadtraining? to go through it myself. She saidDo yourjust signoperators off on fullyit when understand you are happy”how to safely operate the facility? • Not trainedDo they on understand emergency the hazards stop of the – “don’t worry about equipment?it, you don’t need to use it” Do they know what to do in the event of an – “would have waited for the senior operator to tell her emergency? to hit the e stop” • Six clear areas to explore –Timber slats –The pump –Low water –Emergency stop –Maintenance –Seatbelts • Timber slats Photo: Thunder River Rapids ride after the incident showing large gaps between slats. Source: abc.net.au Photo: Infinity Falls Orlando, showing correct slats. Source: Intamin • The pump –Pumps had tripped out 3 times in days leading up to the incident and twice that day –Cause of tripping not investigated, just reset –Lack of indication that pumps had tripped • Low water –Known hazard –Water dropped when pumps tripped –No indication of water level other than scum line –Safety rated detection and shut down system would have cost approx. USD2,200 Photo: Thunder River Rapids ride showing water line. Source: en.Wikipedia.org • Emergency stop –Recommendation to simplify E-stop rejected based on risk being acceptable –Poor location –Function unknown – senior operator “surprised” to know one existed Photo: Sample control panel Source: www.themeparkreview.com • Maintenance –All maintenance spending was cut 7 months prior –Maintainer stated he performed regular checks –Regulator stated ride was in “generally poor condition” –Ride shut annually for overhaul, but maintenance planner said he never Photo: Thunder River Rapids saw an engineer inspect it on 9 ride after the incident. occasions he witnessed shutdown Source: abc.net.au • Seatbelts –In May 2017 a fatality occurred at Drayton Manor due to no seat belts being installed –Thunder River Rapids had Velcro seatbelts that were very worn and did not hold –Other rides have mechanical buckles Photo: Coventry Telegraph of Drayton Manor Splash Canyon ride How robust is your MoC process? How reliable is your equipment? Do your operators have the correct instrumentation? Do they understand how to safely shut the plant down? Do you have the right maintenance regimes and competent maintainers? Do you have suitable PPE? • Similar incident in 2001 where empty raft flipped • Investigation determined chance of repeatHow thorough with arepassengers your incident investigations?in “is nil” Is your system resilient to procedural deviation? • SeniorDo you engineer have regular believed emergency thedrills 2016and incidentevaluate was their effectivenesscaused by for operators learnings? not following procedures • No emergency drills conducted before or since incident • Many third party audits and inspections • Three years earlier recommended simplifyingHow thorough to are one your Eaudits-stop and – inspections?not done • In 2016How are ride recommendations given extension managed as and could addressed? notAre find required a competent regulatory audits person or inspections to inspect • Inspector carriedapproved out as required?ride weeks before incident without completing required checks • Confusing control panel and emergency stop set up – Two different stops available and no one appeared to understandHow much how theyload worked is being placed on your • 36 checks per minuteoperators? to be performed by operator, from safety Areto customer your procedures service simple to follow? • LackDo of you understanding have engineered of human safety factors systems or are you relying on administrative controls only? – “In my view if procedures are followed the system is a safe system, you may as well not open the park. Procedures are there to be followed, if we don't follow procedures in everyday life, things happen” • New rides prioritised over maintenance of existing rides • Culture of fear among operators How much focus is ageing plant getting versus • Lack of learningnew from plant? incidents Do people feel safe to report issues? • No effectiveHow are learnings incident captured tracking and shared? system • RegardingWho is accountable safety for “everyone safety in your thought facility? it was someone else’s responsibility” Questions Photo: Floral tributes at Dreamworld entrance. Source: abc.net.au Contact details Trish Kerin, CEng, FIChemE, FIEAust, Professional Process Safety Engineer, Director IChemE Safety Centre –Email [email protected] –Phone +61 408 925 536 –www.ichemesafetycentre.org –Twitter @TkerinTrish & @SafetyIChemE –LinkedIn https://www.linkedin.com/in/trishkerin https://www.bit.ly/ISCLinkedIn.