(1) The ride had been staffed with one attendant, one operator and a trainee operator The ride operator tasks included stopping and starting the lift to space boats in order to assist the attendant with loading, unloading and turning empty boats. Additionally on this the operator had training responsibilities. Consequently it was not possible to monitor the CCTV adequately: The operator training in respect of monitoring the CCTV was limited to told to watch it the the day day being

(2) No safety warnings were given to guests loading onto the boats. The attendant was not trained to give safety warnings and it was not covered in the Code of Safe Working Practice: In any event even if safety warnings had been given guests might not have been able to hear them because of background noise. The attendant's ability to give safety warnings was limited due to working as a sole attendant which required him to load and unload boats with the emphasis placed on unloading: (3) Warning signs paced around the ride advised guest to remain seated and hold the centre rail but did not spell out the consequences of failing to stay seated (the risk of falling out and drowning), Signage in the boats was worn and in part illegible (4) Staff had not been trained in water rescue and there was no water rescue equipment available_ (5) Ride operators had no clear understanding of the emergency procedure to be followed if a guest fell into the water: (6) Management staff did not accept that guest safety measures (CCTV, safety instructions and signage) had failed The ride at Drayton Manor Park was decommissioned following the accident and will not be recommissioned without the approval of HSE. assurances were given at the inquest that if the ride is to be reopened it will only be after considerable improvements have been made Following the death of Evha Health and Safety Executive issued the following 'Information Note on Safety at water rides' which is applicable to all theme parks. HSE Information Note Safety at water rides People can into difficulties on fairground rides for a variety of reasons; this is foreseeable, well documented and the risk of serious harm is heightened if the ride experience includes deep andlor moving water: Ride controllers have duties to take reasonably practicable steps to ensure the safety of people on their rides. On water rides HSE expects that: given that incidents can happen anywhere on a ride, operators are both able to, and do actively monitor the whole of the ride at all times, either by direct sight or via effective CCTV and similar operators should give clear; unambiguous advice and instructions about safety on the ride before riders boardlduring boarding operators should be able to identify individual boats and quickly address any emerging problems, firstly through PA systems or similar if a person enters the water, the operator should raise the alarm immediately and staff should be deployed without to the correct part of the ride to effect rescue operators will have identified and taken action to eliminate, control or manage any additional hazards which may increase the risk of drowning or impede rescue in the event of a rider entering into the water any theming or participatory items such a as water cannons or similar items whether on the boat or the bank, should not encourage riders to adopt unsafe positions suitable and sufficient equipment is readily available along the ride so that rescue can be effected. 16 May 2017 It is appropriate that Drayton Manor Theme Park manager should respond in detail to the matters raised at the inquest and that all other theme park managers should respond in respect of the HSE Safety Notice. being the Some the get delay