Ava-May Littleboy
PFD Report
All Responded
Ref: 2020-0085
All 3 responses received
· Deadline: 28 May 2020
Sent To
Response Status
Responses
3 of 1
56-Day Deadline
28 May 2020
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. Evidence was heard that it is required a device will be inspected by an independent third party and, provided it satisfies relevant requirements, it will be certified under the Amusement Device Inspection Procedures Scheme (ADIPS) (or Pertexa Inflatable Play Equipment (PIPA) or another testing scheme or method which demonstrates how such procedures equal or better the accepted best practice) as safe to operate and a Declaration of Operational Compliance (DOC) will be issued. If the device is not deemed fit to use, then the device is categorised according to the defect or concern raised which may
Responses
Response received
View full response
1
Head of Standards Governance BSI 389 Chiswick High Road London W4 4AL
Jacqueline Lake Senior Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN By Email 19 May 2020 Re: Ava-May Littleboy, deceased Coroner’s Report under para 7, Sch 5 to the Coroners and Justice Act 2009 and regs 28 and 29 of the Coroners (Investigations) Regulations 2013
I. Introduction
1. This letter constitutes the response of The British Standards Institution (BSI) to the Coroner’s Report dated 2 April 2020 (“the Report”), wherein BSI was requested to take action to prevent future deaths.
2. BSI would like to express at the outset its deepest sympathy and condolences for the family of Ava-May Littleboy, the child killed in the tragic accident which is the subject of the Report.
2
II. Executive Summary
3. BSI’s role as the National Standards Body (“NSB”) is to facilitate expert committees to achieve consensus on industry standards and best practice and to act as the publisher of standards and specifications. Its role is similar to that of the private standards company ADIPS, which is mentioned in the Report, albeit BSI has a broader remit.
4. BSI is not a regulatory body nor an enforcement authority. It is therefore unable to advise on regulatory matters, which are a matter for HM Government. Nor is it able to compel or monitor compliance with its standards, which are voluntary documents. As such, BSI is unfortunately not the right body to take action to prevent a reoccurrence of this tragic event. More detail on the role of BSI can be found below.
5. BSI does not consider that it is able to supplant the work of the Amusement Device Safety Council (ADSC), which functions in a similar fashion to BSI in the area of amusement park machinery. Instead, any question for increased control of devices such as that involved in the accident the subject of the Report is one for regulatory authorities and the Health and Safety Executive.
III. BSI expert committee feedback
6. In order to assist the Coroner, BSI referred the Report to the following expert committees, which it considered might have knowledge and expertise relevant to this matter:
a. SW/136/22/2 Trampoline parks
Under the direction of SW/136/22, this committee is responsible for the United Kingdom’s input into the European Committee CEN/TC 136/WG 17 Trampoline parks and tasked with establishing technical requirements for trampoline parks.
3
b. CEN/TC 136/WG 17
The task of the working group is to establish safety requirements for design, construction, inspection and maintenance of trampoline parks and their components. The task also includes specifying minimum operational requirements to ensure an appropriate level of safety and service when used for recreational, training, educational or therapeutic purposes.
c. CW/15 Safety of toys –
Under the direction of the Standards Policy and Strategy Committee, this committee is responsible for the development of standards within the field of safety of toys on activity toys, chemical properties, flammability, interpretations of standards, mechanical and physical properties, microbiology, phthalate plasticizers in toys, and the UK input into European standards through CEN/TC 52 (WG3, WG5, WG10, WG11, WG12 and WG13) and into International standards through ISO/TC 181 (WG1, WG6, WG7, WG8, WG9, WG10 and WG11).
7. The collective feedback of the above experts was as follows:
a. The standard BS EN ISO 25649-3:2017 (Floating leisure articles for use on and in the water. Additional specific safety requirements and test methods for Class A devices) might be extended to cover the device which caused the tragic accident the subject of the Coroner’s Report.
b. Even if it did fall within that standard, however, or if a separate 'air trampoline' BSI standard was developed, the concerns would still arise unless there was also a statutory requirement to report a 'breach'.
c. The other committees did not consider the equipment to fall within their scope.
d. Instead, the proper route to preventing future accidents is by regulation.
4
8. BSI concurs with the committees that the issue is one for regulation, not voluntary standards. The balance of this reply will expand further on that point.
IV. The role of BSI
9. BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents (available online):
a. BSI’s Royal Charter and Bye-laws 1981;
b. A Memorandum of Understanding (MoU) of 20 June 2002 between the United Kingdom government and BSI in respect of BSI’s activities as the United Kingdom’s NSB;
c. BS 0: 2016 ‘A standard for standards – Principles of standardization’ (BS 0)
10.Article 1.2 of the MoU provides that BSI’s role as the NSB should be interpreted to include the management, co-ordination and understanding of:
a) “British Standards” and “other standardization products”; b) participation by BSI in European and international standards bodies, and other international activity undertaken in the interests of BSI as the United Kingdom’s NSB; c) promotion, marketing, distribution and information activities concerned with British Standards, BSI’s other standardisation products, and standardisation generally; d) support any corporate infrastructure activities intended, wholly or in part, to enable paragraph 9(a) to (c) above. The Director of Standards has the primary responsibility for the activities set out in paragraph 9(a) to (d). BSI’s present Director of Standards is Dr
5
11.BSI develops and distributes standards in response to the needs of UK stakeholders, which include UK Government and business. Standards are technical documents representing good industry practice. They are voluntary documents drafted by independent experts.
V. Standards committee structure
12.Under Section V of the Bye-Laws, BSI has established a strategic policy committee, “SPSC” (Standards Policy and Strategy Committee) to advise on the preparation of standards.
13.The present composition of SPSC is set out on BSI’s website at
about-SPSCs-members/.
14.Each individual standard is the responsibility of one technical committee, under the overall authority of SPSC (cl 28 of the Bye-Laws). A technical committee may be responsible for more than one standard, and may establish subcommittees to deal with individual standards or other discreet areas of its work. The committees referred to in section III of this letter above are examples of technical and sub-committees under SPSC.
VI. Status of Standards
15.The defining characteristic of standards is that they are voluntary, agreed by industry experts and users, including manufacturers, health and safety representatives, regulators and consumer groups. They do not have the status of legislation or regulation (unless specifically referred to in a statute or regulatory instrument, which is extremely rare though not unknown), although they may be used as one means of demonstrating compliance in appropriate circumstances. They may also become privately enforceable between individual entities by being incorporated into a contract.
6
16.Paragraph 4.14 of BS 0 provides:
Voluntary status
British Standards are voluntary in that there is no obligation to apply them or comply with them, except in those few cases where their application is directly demanded by regulatory instruments. They are tools devised for the convenience of those who wish to use them. In certain circumstances the actions of third parties might have the effect of making the application of a standard a commercial necessity, e.g. in a contract, but BSI has no control over these actions and is not a party to them.
17.Paragraph 9.2 of BS 0 provides:
Relationship with the law Standards are always subordinate to the law. It is important that they are drafted so as to avoid any confusion between the provisions of a standard and requirements imposed by law. In general, it is not acceptable for standards to contain provisions that are already requirements imposed by law, nor to contain any statement recommending or requiring compliance with the law. It is also not advisable to quote legislation, and no attempt should be made to offer any interpretation of the law. Advice should be sought from BSI staff if circumstances arise where this appears to be necessary. Reference to particular legislation is permissible where it is relevant and potentially helpful in applying the standard. Lengthy lists of legislation should be avoided as there is a risk that the user might believe any such list to be definitive and exhaustive. The user’s attention should be drawn to the possibility that any reference to legislation might become out-of-date during the lifespan of the
7
standard, and no reliance should be placed on it as being a definitive statement of a user’s legal responsibilities or potential liabilities. Particularly for the purpose of preventing anticompetitive effects or impeding innovation [see 9.1f)], whenever possible, provisions are expressed in terms of performance rather than design or descriptive characteristics.
18. All BSI published standards include the following statement:
This publication does not purport to include all the necessary provisions of a contract. Users are responsible for its correct application. Compliance with a British Standard cannot confer immunity from legal obligations.
19.BSI is therefore not in a position to draft standards which would compel operators of machinery such as the trampoline in the Report.
20.Instead, it would effectively be duplicating the existing work of ADIPS. We note that ADIPS’ website (https://adips.co.uk/about/) describes its role in the following terms: The result is the Amusement Device Inspection Procedures Scheme (ADIPS) the national scheme for inspection and certification of fairground rides and amusement devices. ADIPS inspection is carried out by registered inspection bodies (IB’s) whose capability to perform competent and independent inspection is assessed and monitored on an ongoing basis. ADIPS certification is known as a Declaration of Operational Compliance (DOC). Look out for this; it’s your guarantee that a device has been certified as safe to operate by an independent and competent IB. ADIPS is managed and administered by the Amusement Device Safety Council (ADSC) which is made up of representatives from all
8
major industry trade associations. It is operated by ADIPS Ltd.; a not-for-profit company
21. The ADSC thus serves a similar role to BSI, in a narrower context.
22.According to the Report, the trampoline this case was inspected but a DOC was not awarded, because the device was considered to have a fundamental defect.
23.The Report then notes that the scheme operated by ADIPS is voluntary and not linked to regulatory control, either under HSE or by the Local Authority withholding planning consent for the running of the fairground. There was accordingly nothing stopping them claiming compliance separately and setting up the trampoline.
24.BSI reiterates that it would not be able to create a compulsory scheme to augment or replace that of ADIPS. On the contrary, any British Standard and accompanying certification/assurance scheme, either run by BSI’s own testing house (which is an entirely separate business to BSI’s work as the National Standards Body) or a third party testing house, would have the same status as ADIPS, namely it would be a voluntary scheme, and would not constitute the only means of compliance with H&S or local authority consent.
25.The use of such standards might be made compulsory by means such as the owner of the land on which the trampoline was installed including a condition requiring certification in a contract for the use of the land, local authorities making certification a condition for granting permission for the commercial activity which involved the trampoline, or by the Health and Safety Executive. However, BSI would not have any part in implementing or enforcing such requirements. This is a matter for HM Government and the HSE.
9
26.BSI believes that this letter and attachments constitutes a full reply to the Coroner’s Request. If, however, the Coroner has any further questions or requires clarification, BSI would be pleased to assist.
Head of Standards Governance BSI 389 Chiswick High Road London W4 4AL
Jacqueline Lake Senior Coroner for Norfolk Norfolk Coroner Service Carrow House 301 King Street Norwich NR1 2TN By Email 19 May 2020 Re: Ava-May Littleboy, deceased Coroner’s Report under para 7, Sch 5 to the Coroners and Justice Act 2009 and regs 28 and 29 of the Coroners (Investigations) Regulations 2013
I. Introduction
1. This letter constitutes the response of The British Standards Institution (BSI) to the Coroner’s Report dated 2 April 2020 (“the Report”), wherein BSI was requested to take action to prevent future deaths.
2. BSI would like to express at the outset its deepest sympathy and condolences for the family of Ava-May Littleboy, the child killed in the tragic accident which is the subject of the Report.
2
II. Executive Summary
3. BSI’s role as the National Standards Body (“NSB”) is to facilitate expert committees to achieve consensus on industry standards and best practice and to act as the publisher of standards and specifications. Its role is similar to that of the private standards company ADIPS, which is mentioned in the Report, albeit BSI has a broader remit.
4. BSI is not a regulatory body nor an enforcement authority. It is therefore unable to advise on regulatory matters, which are a matter for HM Government. Nor is it able to compel or monitor compliance with its standards, which are voluntary documents. As such, BSI is unfortunately not the right body to take action to prevent a reoccurrence of this tragic event. More detail on the role of BSI can be found below.
5. BSI does not consider that it is able to supplant the work of the Amusement Device Safety Council (ADSC), which functions in a similar fashion to BSI in the area of amusement park machinery. Instead, any question for increased control of devices such as that involved in the accident the subject of the Report is one for regulatory authorities and the Health and Safety Executive.
III. BSI expert committee feedback
6. In order to assist the Coroner, BSI referred the Report to the following expert committees, which it considered might have knowledge and expertise relevant to this matter:
a. SW/136/22/2 Trampoline parks
Under the direction of SW/136/22, this committee is responsible for the United Kingdom’s input into the European Committee CEN/TC 136/WG 17 Trampoline parks and tasked with establishing technical requirements for trampoline parks.
3
b. CEN/TC 136/WG 17
The task of the working group is to establish safety requirements for design, construction, inspection and maintenance of trampoline parks and their components. The task also includes specifying minimum operational requirements to ensure an appropriate level of safety and service when used for recreational, training, educational or therapeutic purposes.
c. CW/15 Safety of toys –
Under the direction of the Standards Policy and Strategy Committee, this committee is responsible for the development of standards within the field of safety of toys on activity toys, chemical properties, flammability, interpretations of standards, mechanical and physical properties, microbiology, phthalate plasticizers in toys, and the UK input into European standards through CEN/TC 52 (WG3, WG5, WG10, WG11, WG12 and WG13) and into International standards through ISO/TC 181 (WG1, WG6, WG7, WG8, WG9, WG10 and WG11).
7. The collective feedback of the above experts was as follows:
a. The standard BS EN ISO 25649-3:2017 (Floating leisure articles for use on and in the water. Additional specific safety requirements and test methods for Class A devices) might be extended to cover the device which caused the tragic accident the subject of the Coroner’s Report.
b. Even if it did fall within that standard, however, or if a separate 'air trampoline' BSI standard was developed, the concerns would still arise unless there was also a statutory requirement to report a 'breach'.
c. The other committees did not consider the equipment to fall within their scope.
d. Instead, the proper route to preventing future accidents is by regulation.
4
8. BSI concurs with the committees that the issue is one for regulation, not voluntary standards. The balance of this reply will expand further on that point.
IV. The role of BSI
9. BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents (available online):
a. BSI’s Royal Charter and Bye-laws 1981;
b. A Memorandum of Understanding (MoU) of 20 June 2002 between the United Kingdom government and BSI in respect of BSI’s activities as the United Kingdom’s NSB;
c. BS 0: 2016 ‘A standard for standards – Principles of standardization’ (BS 0)
10.Article 1.2 of the MoU provides that BSI’s role as the NSB should be interpreted to include the management, co-ordination and understanding of:
a) “British Standards” and “other standardization products”; b) participation by BSI in European and international standards bodies, and other international activity undertaken in the interests of BSI as the United Kingdom’s NSB; c) promotion, marketing, distribution and information activities concerned with British Standards, BSI’s other standardisation products, and standardisation generally; d) support any corporate infrastructure activities intended, wholly or in part, to enable paragraph 9(a) to (c) above. The Director of Standards has the primary responsibility for the activities set out in paragraph 9(a) to (d). BSI’s present Director of Standards is Dr
5
11.BSI develops and distributes standards in response to the needs of UK stakeholders, which include UK Government and business. Standards are technical documents representing good industry practice. They are voluntary documents drafted by independent experts.
V. Standards committee structure
12.Under Section V of the Bye-Laws, BSI has established a strategic policy committee, “SPSC” (Standards Policy and Strategy Committee) to advise on the preparation of standards.
13.The present composition of SPSC is set out on BSI’s website at
about-SPSCs-members/.
14.Each individual standard is the responsibility of one technical committee, under the overall authority of SPSC (cl 28 of the Bye-Laws). A technical committee may be responsible for more than one standard, and may establish subcommittees to deal with individual standards or other discreet areas of its work. The committees referred to in section III of this letter above are examples of technical and sub-committees under SPSC.
VI. Status of Standards
15.The defining characteristic of standards is that they are voluntary, agreed by industry experts and users, including manufacturers, health and safety representatives, regulators and consumer groups. They do not have the status of legislation or regulation (unless specifically referred to in a statute or regulatory instrument, which is extremely rare though not unknown), although they may be used as one means of demonstrating compliance in appropriate circumstances. They may also become privately enforceable between individual entities by being incorporated into a contract.
6
16.Paragraph 4.14 of BS 0 provides:
Voluntary status
British Standards are voluntary in that there is no obligation to apply them or comply with them, except in those few cases where their application is directly demanded by regulatory instruments. They are tools devised for the convenience of those who wish to use them. In certain circumstances the actions of third parties might have the effect of making the application of a standard a commercial necessity, e.g. in a contract, but BSI has no control over these actions and is not a party to them.
17.Paragraph 9.2 of BS 0 provides:
Relationship with the law Standards are always subordinate to the law. It is important that they are drafted so as to avoid any confusion between the provisions of a standard and requirements imposed by law. In general, it is not acceptable for standards to contain provisions that are already requirements imposed by law, nor to contain any statement recommending or requiring compliance with the law. It is also not advisable to quote legislation, and no attempt should be made to offer any interpretation of the law. Advice should be sought from BSI staff if circumstances arise where this appears to be necessary. Reference to particular legislation is permissible where it is relevant and potentially helpful in applying the standard. Lengthy lists of legislation should be avoided as there is a risk that the user might believe any such list to be definitive and exhaustive. The user’s attention should be drawn to the possibility that any reference to legislation might become out-of-date during the lifespan of the
7
standard, and no reliance should be placed on it as being a definitive statement of a user’s legal responsibilities or potential liabilities. Particularly for the purpose of preventing anticompetitive effects or impeding innovation [see 9.1f)], whenever possible, provisions are expressed in terms of performance rather than design or descriptive characteristics.
18. All BSI published standards include the following statement:
This publication does not purport to include all the necessary provisions of a contract. Users are responsible for its correct application. Compliance with a British Standard cannot confer immunity from legal obligations.
19.BSI is therefore not in a position to draft standards which would compel operators of machinery such as the trampoline in the Report.
20.Instead, it would effectively be duplicating the existing work of ADIPS. We note that ADIPS’ website (https://adips.co.uk/about/) describes its role in the following terms: The result is the Amusement Device Inspection Procedures Scheme (ADIPS) the national scheme for inspection and certification of fairground rides and amusement devices. ADIPS inspection is carried out by registered inspection bodies (IB’s) whose capability to perform competent and independent inspection is assessed and monitored on an ongoing basis. ADIPS certification is known as a Declaration of Operational Compliance (DOC). Look out for this; it’s your guarantee that a device has been certified as safe to operate by an independent and competent IB. ADIPS is managed and administered by the Amusement Device Safety Council (ADSC) which is made up of representatives from all
8
major industry trade associations. It is operated by ADIPS Ltd.; a not-for-profit company
21. The ADSC thus serves a similar role to BSI, in a narrower context.
22.According to the Report, the trampoline this case was inspected but a DOC was not awarded, because the device was considered to have a fundamental defect.
23.The Report then notes that the scheme operated by ADIPS is voluntary and not linked to regulatory control, either under HSE or by the Local Authority withholding planning consent for the running of the fairground. There was accordingly nothing stopping them claiming compliance separately and setting up the trampoline.
24.BSI reiterates that it would not be able to create a compulsory scheme to augment or replace that of ADIPS. On the contrary, any British Standard and accompanying certification/assurance scheme, either run by BSI’s own testing house (which is an entirely separate business to BSI’s work as the National Standards Body) or a third party testing house, would have the same status as ADIPS, namely it would be a voluntary scheme, and would not constitute the only means of compliance with H&S or local authority consent.
25.The use of such standards might be made compulsory by means such as the owner of the land on which the trampoline was installed including a condition requiring certification in a contract for the use of the land, local authorities making certification a condition for granting permission for the commercial activity which involved the trampoline, or by the Health and Safety Executive. However, BSI would not have any part in implementing or enforcing such requirements. This is a matter for HM Government and the HSE.
9
26.BSI believes that this letter and attachments constitutes a full reply to the Coroner’s Request. If, however, the Coroner has any further questions or requires clarification, BSI would be pleased to assist.
Response received
View full response
Dear Ms Lake Inquest concerning the death of Ava-May Littleboy 1represent John H Rundle Limited ("Rundles") and this letter is sent in response to your communication dated 26 March 2020 addressed to the company's MD who is Preamble The reason Finch Consulting has been asked to respond on behalf of Rundles is not just because I am a solicitor experienced in Health & Safety Law, but also because one of my colleagues at Finch Consulting, was formerly one of HM's Inspectors for the HSE. Between 2009 and 2017
- was HSE's operational policy lead for fairgrounds and theme park safety, where he specialised in fairground accidents, led the HSE's investigation into the death of Summer Grant in 2016 on an inflatable which blew away at a fair in Harlow, and was largely responsible for writing the third edition of the HSE's Guidance on Safe Practice in Fairgrounds and Amusement Parks (HSG 175). Rundles' Managing Directorllllllllllllltvas also on the committee fonnulating that Guidance (and its previous versions). is in a unique position to help explain the HSE's approach to the Guidance and explain the roles of and expectations from those involved in fairground equipment from supply to operation and to maintenance.
- has had some input to this letter, to help in explaining why the concern raised by your letter is, with respect, both misdirected and misconceived. Your letter First of all, I would like to understand please, the proper status of your letter. The letter reads in some respects as a PFD Report. Like a PFD report your letter has been copied to a number of others (presumably the Interested Persons). It does not however follow the Chief Coroner's recommended template for a PFD report and towards the end of the letter you suggest that it does not Finch Legal Services is a trading name of Finch Consulting Ltd and is authorised and regulated by the Solicitors Regulation Authority. A list of legal staff names and their professional qualification can be found on our website www.finch-consulting.com. Finch Consulting Limited is a company registered in England and Wales under No: 02774164. The registered office is at Ivanhoe Business Park Ashby de la Zouch, Leicestershire, LE65 2AB
0 Finch Consulting have PFD status because you reserve the right to make a report under Regulation 28 of the 2013 Regulations ifyou are not satisfied that your concerns have been addressed. The consequence of your letter appears to be that you seek to carry out your regulation 28 duty through it by raising a concern that you seek to have addressed, but because the letter is not a PFD report you deny our client their right to fuller information 1 about why you have a concern based on evidence to which they are not privy and which they have been given no opportunity to consider or challenge. As I have no idea what information and evidence led to the concern raised, and you assert that Rundles should address it through action on their part (or else ... ), the company has been put by you in the invidious position of needing to respond to a concern based on evidence it has been unable to consider or challenge. Notwithstanding my ambivalence regarding the nature of your letter, Rundles is, and has always been, happy to assist in any way that it can with the investigation into the circumstances of Ava-May's tragic accident. This letter therefore explains in some detail why the concern you have raised appears to be misconceived and inappropriately directed. Should there be any queries remaining at the end ofthis letter, please do come back to me and we will endeavour to assist. My apologies if any of the following detail has already been presented to you. The fact you suggest you have an ongoing concern which you feel Rundles may be able to address however, suggests to me that it may not have been made available to you previously. HSG 175 The HSE Guidance (HSG 175) entitled "Fairgrounds and Amusement Parks: Guidance on safe Practice" applies to inflatable devices and other fairground equipment and devices. The guidance is available on line at no cost, at: hse.gov.uk/pubns/priced/hsg175.pdf. Whilst HSE Guidance is not mandated (meaning that safe practice can be demonstrated by other means), the foreword to the Guidance makes clear that in the fairground and leisure park industry it sets out: "appropriate measures for those in the industry to reduce risks, work safely and comply with the law" 1 You have not set out the full factual basis for your concerns (as required for a PFD report per R -v- Shrewsbury Coroner's Court exp British Parachute Association (1988) 152 JP 123.) You have also chosen not to fully set out the evidence or information on which your concern is based. 2
0 Finch Consulting As it comes from the principal specialist H&S regulator for enforcement of the law, it carries considerable weight. On page 5/6 of the Guidance the roles of the various duty holders are described: Controllers ...own or otherwise have control of an attraction and have a duty to operate and maintain it in a safe condition ( emphasis added). Operators are in immediate charge of an attraction and have a dutv to operate it safely (emphasis added) Inspection Bodies ... provide inspection and testing services. Rundles' role in relation to the fairs at Great Yarmouth and Gorleston was as an Inspection Body ("18") for a large inflatable slide at Gorleston CUthe slide"), and swing boats at Great Yarmouth ("the swing boats"). In Section A of the HSE's Guidance (entitled "The System for Safety of Attractions") a table identifies what checks are recommended for amusement devices and fairground equipment and by whom those checks are to be carried out. This is important because if you interfere with that Guidance by requiring one 18 (Rundles) to take on duties beyond what is suggested by the HSE's Guidance, this actually has the serious potential of creating additional health and safety risks by suggesting that duty holders can depend on others to perform roles reserved to them. That I am sure, would not be your intention. The Guidance makes clear that attractions require that among other things: Operation is carried out "by competent persons, suitably trained ... " (This is not the IBs). Ongoing device integrity is maintained by a series ofchecks, maintenance, and inspection. These include daily checks before the device is opened for use, and periodic checks, both by competent persons (normally the operator), and in service annual Inspections by competent and independent IBs. To comply with the Guidance, inspections for Inflatable devices must include2: Initial test (to check the device conforms to the standards in BS EN 14960 "Inflatable Play Equipment. Safety Requirements and Test Methods") - this is to check that the device can be operated safely in accordance with the design specification and instructions in the operations manual and should be carried out by or on behalf of the manufacturer, supplier importer and 2 See pages 8-9 ofHSG 175 3
0 Finch Consulting witnessed by an inspection body. The test is only carried out when the device is used for the first time or after safety critical modifications. In service Annual inspection (carried out by an 18 to decide whether an amusement device may continue to be operated for a specified period of time). These requirements cross refer to Section D ofthe Guidance which is entitled "Inspecting an Am usement Device". In relation to in service annual inspections (with emphasis added}: "144 In-service annual inspection .. .is for independent and competent IBs to check on the fitness of an amusement device for further use during its operational life. It is also a check on the safety-critical components of an amusement device to make sure that they have not deteriorated to an extent liable to cause danger. 145 In-service annual inspection will verify whether a device is fit to be used for a specified period. ft does not remove the duty on the controller of a device to ensure that the device is adequately maintained, nor does it duplicate the pre-use inspection procedure." The HSE makes clear that anchorage is a controller/operator (and not an IB) duty at para 227 of the Guidance within Section F which provides "Guidance for Controllers" says, "Take account of any manufacturers' instructions relating to operating conditions such as wind speed and make sure that adequate anchoring points have been used." Further advice from the HSE specifically on inflatables3 adds, under the heading "Before anyone Uses it" at bullet point two, "Have a good look at the inflatable when it is blown up and before use. You should check ... if the anchor points have been pulled out during inflation." The advice also confirms the obligation on owners of the equipment to have an initial test on new equipment and annual inspections (as are set out in more detail in the ADIP scheme to which it cross refers). The reason Rundles visited Great Yarmouth and Gorleston on 26th June 2018 was because
had asked them as an ADIPS4 approved inspection body to carry out the in-service annual inspection of the swing boats and slide. They had inspected those devices previously and had been given the information necessary to complete those inspections. When Rundles arrived at Great Yarmouth, sked that Rundles also inspect a number of other devices, specifically other inflatable rides that he was operating. This was not possible as Rundles 3 Bouncy Castles and Other Play Inflatables: Safety Advice hse.gov.uk/eotertainrnent/fairgrounds/inflatables.htm 4 Amusement Device Inspection Procedures Scheme 4
0 Finch Consulting had not been given the information they needed to do this including previous inspection information, manufacturer instructions, operations manual and maintenance information. As a result, in relation to those rides, they were able to have a look to see what would be involved in an inspection and took some photographs, but they did not inspect them and it would have been necessary to return to do this on another day. For completeness I should perhaps draw attention to the fact that HSG 175 does say: "any person to whom this guidance is directed who finds a generic or serious fault on a device, which could have wider safety implications for that or other similar devices" should "inform their trade association and the National Association for Leisure Industry Certification ... ". This obligation applies (among others) to Rundles when carrying out an ADIPS inspection. Faults and defects, however, do not include failures in set up and operating procedures and although the Guidance could have required any noted issues in those areas to be drawn to the attention ofthe operator, it does not. This was a point examined very closely following both the Summer Grant accident in Harlow on 26th March 2016 and an earlier accident on ?1h May 2013 involving a zipline in North Wales which led to the death of Bailey Sumner. In both cases the HSE made clear that the inspection bodies are there to comment on the safety of the equipment if used correctly and not to comment on how it has been and may be used going forwards. ADIP scheme Inspections I am unsure what familiarity you have with the Amusement Device Inspection Procedures Scheme ("ADIPS"). ADIPS Limited administers the ADIPS and is owned by The Amusement Devices Safety Council which consists of all the major trade organisations involved in the UK fairground industry and the HSE which attends and advises. The HSE publicly supports the ADIP scheme. The purpose of the ADIP scheme is: "to ensure that each and every fairground and amusement park ride or device is certified as safe for use". 5
0 Finch Consulting The certification provided by the ADIPS is not and cannot be for the purpose of ensuring each ride is set up or used correctly. ADIPS certification, like an MOT for a motor vehicle, will only confirm that !f equipment is set up and operated in accordance with manufacturer instructions and operating procedures, then the ride will be safe for use for a specified period. Under the ADIP scheme, annual inspections (suggested by HSG 175) should be carried out by Independent registered 18s whose ability to perform competent and independent inspection is assessed and monitored by ADIPS Ltd on an ongoing basis. Rundles is an established, reputable, registered ADIPS approved IB. Once an ADIP scheme 1B has completed inspection of any amusement device and been paid for their services, the 1B is required to record inspection details on the central ADIPS database of amusement devices and ADIPS Limited then will provide the owner/operator of the device a Declaration of Compliance ("DOC") which confirms the device has been registered on the ADIPS database and is certified safe to operate for the time specified in the period covered by the DOC. The owner/operators of fairground/amusement park rides or devices have the obligation to ensure that annual inspections on their equipment are arranged, and that at all times they hold a current DOC issued by an approved 1B for each ride/device that they operate. There are a number of IBs, and it is not unusual for different IBs to carry out inspections on the same device over the years. Which 1B is used will often turn on availability and location as many of the rides will move around the country. There is no obligation on an 1B to accept an instruction, to provide their services ex gratis, or to remind operators that a DOC they have previously issued needs renewal. The owner/operators need to provide the inspecting 1B with information about each ride before its inspection, particularly: manufacturer's information (for any equipment with which the 1B was unfamiliar) to ensure testing can be carried out within the parameters in which the ride or device is to operate and it is clear what safety features exist which must be checked as part of an inspection. operating and maintenance information the last DOC (for devices which are not new). If Rundles had carried out the previous inspection they would have this information already. That applied to the swing boats and the slide. 6
0 Finch Consulting Insurers of the equipment will normally require proof of current DOCs as a condition of policy coverage and renewal. Those who make pitches available for the rides (I presume Great Yarmouth Borough Council in this case) will also typically check that all equipment to be used holds a current DOC and, for new equipment like the inflatable trampoline, had had its initial test as recommended by HSG 175, overseen by an 18. Visit on 26th June 2018 When Rundles visited the sites at Great Yarmouth and Gorleston on 26th June it was at the request of for and with the intention of carrying out annual inspections required by HSG 175, under the ADIP scheme, on the swing boats and the slide both of which were owned by On arrival at Great Yarmouth, asked that other equipment he owned was also inspected. explained that was not possible because he did not have the necessary information about that other equipment. - did have a look at the other equipment while there, to assess what the equipment was, and to take photos, so that he could return to perform the inspections on a later date when the necessary information had been sent through. The need for information pre inspection would have come as no surprise to He had provided it for the two inspections previously arranged ( on the swing boats and slide) and in fact a similar absence of infomiation had previously led to our clients refusing to inspect one of roundabouts and a rodeo ride. When the slide was inspected it was not in use. It was deflated and re-inflated as part of its testing. In those circumstances, before reuse (after the inspection) an operator should check (as they are responsible for its safety) that nothing has become loose in the inspection process o has been moved or placed during the inspection such that the unit would not be safe for use. This is the same as their daily inspection before the ride is opened. On re-inflation a tie can come undone or get caught. It was not part of Rundles' role post-inspection to oversee the setting up ofthe ride and to check that itwas subsequently operating safely - only to check that if set up and operated in accordance with manufacturer recommendations, that it would be safe to use. Although inspected, no DOC was ever issued in relation to the slide, or the swing boats. failed to pay for the inspections and in accordance with Rundles' terms of business (and in line with the industry norm), the DOC or report of issues preventing a DOC, was therefore never issued. 7
0 Finch Consulting It may be helpful to add that is not possible to inspect when a ride is in use as inspection includes, for example, examination of the condition of the tie downs which usually cannot be properly completed without releasing them. With inflatables, part of the inspection would involve a test on the functioning of the air blowers which involves deflation and reinflation. When Rundles arrived on site hoped that inspections and testing would proceed on all equipment. Since inspections cannot be done when the equipment is in use, none of the equipment was in use by the public when Rundles was having a look at it on 26th June. Rundles is not in a position and does not seek to suggest that tie downs had been undone in preparation for their visit, but many inspections take place when no ties are in use at all because the equipment is not in use at the time and indeed may even be indoors for inspection. My point is that whether or not tie downs are in use is simply not part of what is inspected by an IB. They check the number of tie downs and their physical integrity only. To suggest that the IB should have an obligation to comment on operational use would be like taking your car for an MOT and expecting the mechanics to include a critique of your driving in their observations. It simply is not the purpose of an ADIPS inspection. And in this case, as explained, such an inspection did not in any event proceed on the inflatables ( other than the slide) because of the lack of documentation. The check of whether equipment has been safely installed and is being safely operated is part of set up and daily checks required by HSG 175 to be made by the operator as referenced above. Rundles "Report•• dated 2nd July What seems to have been relied upon by you as some sort of inspection report from Rundles is not and was never intended to be such. Although it is titled "Report of Findings for to elevate it to the status of a formal report perversely misinterprets the facts. The purpose of Rundles' visit as I have explained, was to inspect, test and if appropriate to issue a DOC on the swing boats and slide in accordance with the HSG 175 and ADIPS requirements. If testing revealed defects such that the unit was not safe for use, then Rundles would have identified those issues and required a further inspection to verify they had been dealt with before issuing a DOC. Rundles was asked on the day to inspect other equipment but refused as necessary information to complete those inspections had not been made available. They did however have a look at the other equipment so that they knew what to expect on return. 8
0 Finch Consulting Following Ava-May's tragic accident a few days later, - contacted Rundles and asked for any information that they had about their visit on 26th June which might help. The information sent to assist in response to that request is the report. This is no more than an informal summary of notes made regarding the swing boats and slide inspected, and observations about the rides that could not be inspected on the day. It summarised the issues in relation to the inspected slide and swing boats which needed rectification, and it provided a copy of photographs taken on the day. Although there was no duty or obligation to mention that not all tie downs were seen as being in use, this was included to assist in giving a picture of what was observed as it may have been relevant to an accident investigation. The observatior:i in his notes to about some tie downs not apparently being used at Great Yarmouth was imparted to - on the day of his visit by This was before his visit to Gorleston. I understand that this was evidence to the Inquest. It would not be an observation included in a DOC. The use of the word "Report" in Rundles' summary of its visit might be regarded as unfortunate with the benefit of hindsight, but no one has been misled by it. It is clearly not a formal report or intended to be relied on as an 1B inspection report. It was as I have said, a summary of notes in response to a request for any information they had, following a fatal accident. iPad You suggest that the fact that an iPad brought by Rundles to the sites was not charged is a matter for concern and that if the situation were to arise again future deaths may occur. The use of tablets on inspections was at the time and remains under trial by ADIPS. Rundles has been appointed as one of the registered IBs to trial their use. The reason for the trial arises from an HSE concern that some IBs might be tempted in some circumstances to sign off certificates for equipment which they had not gone out to see and test or that IBs might come under pressure to backdate DOCs. The iPads have tracking devices in them which enable checks to be made (should questions arise) to confirm whether the iPad was in the area of the inspected device on the date shown on the certificate and can confirm how long that inspection took. They also facilitate immediate online registration DOC's that are issued. The iPad undoubtedly did lose its charge on the day, after the visit to Great Yarmouth. However, that was not the reason that the inspections (other than for the slide and swing boats) did not proceed. That was 9
0 Finch Consulting due to the fact Rundles had not been asked to do other inspections before they arrived on site, and the relevant documentation needed to proceed was not made available on the day. The lack of the iPad did not compromise the planned inspections on the swing boats or slide which were completed in paper format which was and still is the principal way in which the 18 ADIPS inspections are recorded. The iPad does not have the functionality to carry out any tests or determine pass/fail criteria. The use of tablets for ADIPS inspections is still under trial. Pen and paper alternatives for recording results of inspections remain a commonly used alternative under the ADIP scheme and were used on the day. Your suggestion that lack of an iPad might lead to further deaths seems to misunderstand the position to a degree that I do not feel I can usefully comment further. Additional Points HSG 175 is clear about who has responsibility for what in relation to inflatables and other fairground equipment for good reason. Clarity of role is a very important aspect of health and safety management and avoids reliance by operators on others to ensure that they set up and operate their own equipment safely. It is not reasonable and is potentially dangerous, to ask that Rundles commit to meeting additional obligations that are not required ofall the other IBs in the UK, by HSE and industry guidance. with any operators he appointed, had responsibility for ensuring that the tie downs on his inflatable devices were used. If you seek to divert that responsibility to IBs by seeking from Rundles an assurance that they will draw attention to operator issues, you may actually increase the risk of injury and death by inherently encouraging an owner or operator to rely on someone visiting or inspecting to pick up on their incompetence in operating their equipment. That cannot optimise safety. Our client, and any IB in their position, has no legal obligation, nor it is suggested by HSG 175 or the ADIP scheme, that they should draw attention to any issues they may observe regarding use of equipment on an inspection, never mind on a pre inspection visit. This is NOT within their area of responsibility and goes beyond their remit.
- agrees with this and has advised he would expect an IB to note the number of and condition of tie downs on an inspection but due to varying circumstances, not necessarily to see them staked down as that is entirely an operational issue and failures in operation are not defects. 10
0 Finch Consulting If you have an issue with the law and guidance then it would be more appropriate to take that up with the HSE and with The Amusement Devices Safety Council. Please let me know if you have any further questions or need clarification on any of the points covered. Please also confirm that this letter deals to your satisfaction with the concern you have raised as far as Rundles is concerned.
- was HSE's operational policy lead for fairgrounds and theme park safety, where he specialised in fairground accidents, led the HSE's investigation into the death of Summer Grant in 2016 on an inflatable which blew away at a fair in Harlow, and was largely responsible for writing the third edition of the HSE's Guidance on Safe Practice in Fairgrounds and Amusement Parks (HSG 175). Rundles' Managing Directorllllllllllllltvas also on the committee fonnulating that Guidance (and its previous versions). is in a unique position to help explain the HSE's approach to the Guidance and explain the roles of and expectations from those involved in fairground equipment from supply to operation and to maintenance.
- has had some input to this letter, to help in explaining why the concern raised by your letter is, with respect, both misdirected and misconceived. Your letter First of all, I would like to understand please, the proper status of your letter. The letter reads in some respects as a PFD Report. Like a PFD report your letter has been copied to a number of others (presumably the Interested Persons). It does not however follow the Chief Coroner's recommended template for a PFD report and towards the end of the letter you suggest that it does not Finch Legal Services is a trading name of Finch Consulting Ltd and is authorised and regulated by the Solicitors Regulation Authority. A list of legal staff names and their professional qualification can be found on our website www.finch-consulting.com. Finch Consulting Limited is a company registered in England and Wales under No: 02774164. The registered office is at Ivanhoe Business Park Ashby de la Zouch, Leicestershire, LE65 2AB
0 Finch Consulting have PFD status because you reserve the right to make a report under Regulation 28 of the 2013 Regulations ifyou are not satisfied that your concerns have been addressed. The consequence of your letter appears to be that you seek to carry out your regulation 28 duty through it by raising a concern that you seek to have addressed, but because the letter is not a PFD report you deny our client their right to fuller information 1 about why you have a concern based on evidence to which they are not privy and which they have been given no opportunity to consider or challenge. As I have no idea what information and evidence led to the concern raised, and you assert that Rundles should address it through action on their part (or else ... ), the company has been put by you in the invidious position of needing to respond to a concern based on evidence it has been unable to consider or challenge. Notwithstanding my ambivalence regarding the nature of your letter, Rundles is, and has always been, happy to assist in any way that it can with the investigation into the circumstances of Ava-May's tragic accident. This letter therefore explains in some detail why the concern you have raised appears to be misconceived and inappropriately directed. Should there be any queries remaining at the end ofthis letter, please do come back to me and we will endeavour to assist. My apologies if any of the following detail has already been presented to you. The fact you suggest you have an ongoing concern which you feel Rundles may be able to address however, suggests to me that it may not have been made available to you previously. HSG 175 The HSE Guidance (HSG 175) entitled "Fairgrounds and Amusement Parks: Guidance on safe Practice" applies to inflatable devices and other fairground equipment and devices. The guidance is available on line at no cost, at: hse.gov.uk/pubns/priced/hsg175.pdf. Whilst HSE Guidance is not mandated (meaning that safe practice can be demonstrated by other means), the foreword to the Guidance makes clear that in the fairground and leisure park industry it sets out: "appropriate measures for those in the industry to reduce risks, work safely and comply with the law" 1 You have not set out the full factual basis for your concerns (as required for a PFD report per R -v- Shrewsbury Coroner's Court exp British Parachute Association (1988) 152 JP 123.) You have also chosen not to fully set out the evidence or information on which your concern is based. 2
0 Finch Consulting As it comes from the principal specialist H&S regulator for enforcement of the law, it carries considerable weight. On page 5/6 of the Guidance the roles of the various duty holders are described: Controllers ...own or otherwise have control of an attraction and have a duty to operate and maintain it in a safe condition ( emphasis added). Operators are in immediate charge of an attraction and have a dutv to operate it safely (emphasis added) Inspection Bodies ... provide inspection and testing services. Rundles' role in relation to the fairs at Great Yarmouth and Gorleston was as an Inspection Body ("18") for a large inflatable slide at Gorleston CUthe slide"), and swing boats at Great Yarmouth ("the swing boats"). In Section A of the HSE's Guidance (entitled "The System for Safety of Attractions") a table identifies what checks are recommended for amusement devices and fairground equipment and by whom those checks are to be carried out. This is important because if you interfere with that Guidance by requiring one 18 (Rundles) to take on duties beyond what is suggested by the HSE's Guidance, this actually has the serious potential of creating additional health and safety risks by suggesting that duty holders can depend on others to perform roles reserved to them. That I am sure, would not be your intention. The Guidance makes clear that attractions require that among other things: Operation is carried out "by competent persons, suitably trained ... " (This is not the IBs). Ongoing device integrity is maintained by a series ofchecks, maintenance, and inspection. These include daily checks before the device is opened for use, and periodic checks, both by competent persons (normally the operator), and in service annual Inspections by competent and independent IBs. To comply with the Guidance, inspections for Inflatable devices must include2: Initial test (to check the device conforms to the standards in BS EN 14960 "Inflatable Play Equipment. Safety Requirements and Test Methods") - this is to check that the device can be operated safely in accordance with the design specification and instructions in the operations manual and should be carried out by or on behalf of the manufacturer, supplier importer and 2 See pages 8-9 ofHSG 175 3
0 Finch Consulting witnessed by an inspection body. The test is only carried out when the device is used for the first time or after safety critical modifications. In service Annual inspection (carried out by an 18 to decide whether an amusement device may continue to be operated for a specified period of time). These requirements cross refer to Section D ofthe Guidance which is entitled "Inspecting an Am usement Device". In relation to in service annual inspections (with emphasis added}: "144 In-service annual inspection .. .is for independent and competent IBs to check on the fitness of an amusement device for further use during its operational life. It is also a check on the safety-critical components of an amusement device to make sure that they have not deteriorated to an extent liable to cause danger. 145 In-service annual inspection will verify whether a device is fit to be used for a specified period. ft does not remove the duty on the controller of a device to ensure that the device is adequately maintained, nor does it duplicate the pre-use inspection procedure." The HSE makes clear that anchorage is a controller/operator (and not an IB) duty at para 227 of the Guidance within Section F which provides "Guidance for Controllers" says, "Take account of any manufacturers' instructions relating to operating conditions such as wind speed and make sure that adequate anchoring points have been used." Further advice from the HSE specifically on inflatables3 adds, under the heading "Before anyone Uses it" at bullet point two, "Have a good look at the inflatable when it is blown up and before use. You should check ... if the anchor points have been pulled out during inflation." The advice also confirms the obligation on owners of the equipment to have an initial test on new equipment and annual inspections (as are set out in more detail in the ADIP scheme to which it cross refers). The reason Rundles visited Great Yarmouth and Gorleston on 26th June 2018 was because
had asked them as an ADIPS4 approved inspection body to carry out the in-service annual inspection of the swing boats and slide. They had inspected those devices previously and had been given the information necessary to complete those inspections. When Rundles arrived at Great Yarmouth, sked that Rundles also inspect a number of other devices, specifically other inflatable rides that he was operating. This was not possible as Rundles 3 Bouncy Castles and Other Play Inflatables: Safety Advice hse.gov.uk/eotertainrnent/fairgrounds/inflatables.htm 4 Amusement Device Inspection Procedures Scheme 4
0 Finch Consulting had not been given the information they needed to do this including previous inspection information, manufacturer instructions, operations manual and maintenance information. As a result, in relation to those rides, they were able to have a look to see what would be involved in an inspection and took some photographs, but they did not inspect them and it would have been necessary to return to do this on another day. For completeness I should perhaps draw attention to the fact that HSG 175 does say: "any person to whom this guidance is directed who finds a generic or serious fault on a device, which could have wider safety implications for that or other similar devices" should "inform their trade association and the National Association for Leisure Industry Certification ... ". This obligation applies (among others) to Rundles when carrying out an ADIPS inspection. Faults and defects, however, do not include failures in set up and operating procedures and although the Guidance could have required any noted issues in those areas to be drawn to the attention ofthe operator, it does not. This was a point examined very closely following both the Summer Grant accident in Harlow on 26th March 2016 and an earlier accident on ?1h May 2013 involving a zipline in North Wales which led to the death of Bailey Sumner. In both cases the HSE made clear that the inspection bodies are there to comment on the safety of the equipment if used correctly and not to comment on how it has been and may be used going forwards. ADIP scheme Inspections I am unsure what familiarity you have with the Amusement Device Inspection Procedures Scheme ("ADIPS"). ADIPS Limited administers the ADIPS and is owned by The Amusement Devices Safety Council which consists of all the major trade organisations involved in the UK fairground industry and the HSE which attends and advises. The HSE publicly supports the ADIP scheme. The purpose of the ADIP scheme is: "to ensure that each and every fairground and amusement park ride or device is certified as safe for use". 5
0 Finch Consulting The certification provided by the ADIPS is not and cannot be for the purpose of ensuring each ride is set up or used correctly. ADIPS certification, like an MOT for a motor vehicle, will only confirm that !f equipment is set up and operated in accordance with manufacturer instructions and operating procedures, then the ride will be safe for use for a specified period. Under the ADIP scheme, annual inspections (suggested by HSG 175) should be carried out by Independent registered 18s whose ability to perform competent and independent inspection is assessed and monitored by ADIPS Ltd on an ongoing basis. Rundles is an established, reputable, registered ADIPS approved IB. Once an ADIP scheme 1B has completed inspection of any amusement device and been paid for their services, the 1B is required to record inspection details on the central ADIPS database of amusement devices and ADIPS Limited then will provide the owner/operator of the device a Declaration of Compliance ("DOC") which confirms the device has been registered on the ADIPS database and is certified safe to operate for the time specified in the period covered by the DOC. The owner/operators of fairground/amusement park rides or devices have the obligation to ensure that annual inspections on their equipment are arranged, and that at all times they hold a current DOC issued by an approved 1B for each ride/device that they operate. There are a number of IBs, and it is not unusual for different IBs to carry out inspections on the same device over the years. Which 1B is used will often turn on availability and location as many of the rides will move around the country. There is no obligation on an 1B to accept an instruction, to provide their services ex gratis, or to remind operators that a DOC they have previously issued needs renewal. The owner/operators need to provide the inspecting 1B with information about each ride before its inspection, particularly: manufacturer's information (for any equipment with which the 1B was unfamiliar) to ensure testing can be carried out within the parameters in which the ride or device is to operate and it is clear what safety features exist which must be checked as part of an inspection. operating and maintenance information the last DOC (for devices which are not new). If Rundles had carried out the previous inspection they would have this information already. That applied to the swing boats and the slide. 6
0 Finch Consulting Insurers of the equipment will normally require proof of current DOCs as a condition of policy coverage and renewal. Those who make pitches available for the rides (I presume Great Yarmouth Borough Council in this case) will also typically check that all equipment to be used holds a current DOC and, for new equipment like the inflatable trampoline, had had its initial test as recommended by HSG 175, overseen by an 18. Visit on 26th June 2018 When Rundles visited the sites at Great Yarmouth and Gorleston on 26th June it was at the request of for and with the intention of carrying out annual inspections required by HSG 175, under the ADIP scheme, on the swing boats and the slide both of which were owned by On arrival at Great Yarmouth, asked that other equipment he owned was also inspected. explained that was not possible because he did not have the necessary information about that other equipment. - did have a look at the other equipment while there, to assess what the equipment was, and to take photos, so that he could return to perform the inspections on a later date when the necessary information had been sent through. The need for information pre inspection would have come as no surprise to He had provided it for the two inspections previously arranged ( on the swing boats and slide) and in fact a similar absence of infomiation had previously led to our clients refusing to inspect one of roundabouts and a rodeo ride. When the slide was inspected it was not in use. It was deflated and re-inflated as part of its testing. In those circumstances, before reuse (after the inspection) an operator should check (as they are responsible for its safety) that nothing has become loose in the inspection process o has been moved or placed during the inspection such that the unit would not be safe for use. This is the same as their daily inspection before the ride is opened. On re-inflation a tie can come undone or get caught. It was not part of Rundles' role post-inspection to oversee the setting up ofthe ride and to check that itwas subsequently operating safely - only to check that if set up and operated in accordance with manufacturer recommendations, that it would be safe to use. Although inspected, no DOC was ever issued in relation to the slide, or the swing boats. failed to pay for the inspections and in accordance with Rundles' terms of business (and in line with the industry norm), the DOC or report of issues preventing a DOC, was therefore never issued. 7
0 Finch Consulting It may be helpful to add that is not possible to inspect when a ride is in use as inspection includes, for example, examination of the condition of the tie downs which usually cannot be properly completed without releasing them. With inflatables, part of the inspection would involve a test on the functioning of the air blowers which involves deflation and reinflation. When Rundles arrived on site hoped that inspections and testing would proceed on all equipment. Since inspections cannot be done when the equipment is in use, none of the equipment was in use by the public when Rundles was having a look at it on 26th June. Rundles is not in a position and does not seek to suggest that tie downs had been undone in preparation for their visit, but many inspections take place when no ties are in use at all because the equipment is not in use at the time and indeed may even be indoors for inspection. My point is that whether or not tie downs are in use is simply not part of what is inspected by an IB. They check the number of tie downs and their physical integrity only. To suggest that the IB should have an obligation to comment on operational use would be like taking your car for an MOT and expecting the mechanics to include a critique of your driving in their observations. It simply is not the purpose of an ADIPS inspection. And in this case, as explained, such an inspection did not in any event proceed on the inflatables ( other than the slide) because of the lack of documentation. The check of whether equipment has been safely installed and is being safely operated is part of set up and daily checks required by HSG 175 to be made by the operator as referenced above. Rundles "Report•• dated 2nd July What seems to have been relied upon by you as some sort of inspection report from Rundles is not and was never intended to be such. Although it is titled "Report of Findings for to elevate it to the status of a formal report perversely misinterprets the facts. The purpose of Rundles' visit as I have explained, was to inspect, test and if appropriate to issue a DOC on the swing boats and slide in accordance with the HSG 175 and ADIPS requirements. If testing revealed defects such that the unit was not safe for use, then Rundles would have identified those issues and required a further inspection to verify they had been dealt with before issuing a DOC. Rundles was asked on the day to inspect other equipment but refused as necessary information to complete those inspections had not been made available. They did however have a look at the other equipment so that they knew what to expect on return. 8
0 Finch Consulting Following Ava-May's tragic accident a few days later, - contacted Rundles and asked for any information that they had about their visit on 26th June which might help. The information sent to assist in response to that request is the report. This is no more than an informal summary of notes made regarding the swing boats and slide inspected, and observations about the rides that could not be inspected on the day. It summarised the issues in relation to the inspected slide and swing boats which needed rectification, and it provided a copy of photographs taken on the day. Although there was no duty or obligation to mention that not all tie downs were seen as being in use, this was included to assist in giving a picture of what was observed as it may have been relevant to an accident investigation. The observatior:i in his notes to about some tie downs not apparently being used at Great Yarmouth was imparted to - on the day of his visit by This was before his visit to Gorleston. I understand that this was evidence to the Inquest. It would not be an observation included in a DOC. The use of the word "Report" in Rundles' summary of its visit might be regarded as unfortunate with the benefit of hindsight, but no one has been misled by it. It is clearly not a formal report or intended to be relied on as an 1B inspection report. It was as I have said, a summary of notes in response to a request for any information they had, following a fatal accident. iPad You suggest that the fact that an iPad brought by Rundles to the sites was not charged is a matter for concern and that if the situation were to arise again future deaths may occur. The use of tablets on inspections was at the time and remains under trial by ADIPS. Rundles has been appointed as one of the registered IBs to trial their use. The reason for the trial arises from an HSE concern that some IBs might be tempted in some circumstances to sign off certificates for equipment which they had not gone out to see and test or that IBs might come under pressure to backdate DOCs. The iPads have tracking devices in them which enable checks to be made (should questions arise) to confirm whether the iPad was in the area of the inspected device on the date shown on the certificate and can confirm how long that inspection took. They also facilitate immediate online registration DOC's that are issued. The iPad undoubtedly did lose its charge on the day, after the visit to Great Yarmouth. However, that was not the reason that the inspections (other than for the slide and swing boats) did not proceed. That was 9
0 Finch Consulting due to the fact Rundles had not been asked to do other inspections before they arrived on site, and the relevant documentation needed to proceed was not made available on the day. The lack of the iPad did not compromise the planned inspections on the swing boats or slide which were completed in paper format which was and still is the principal way in which the 18 ADIPS inspections are recorded. The iPad does not have the functionality to carry out any tests or determine pass/fail criteria. The use of tablets for ADIPS inspections is still under trial. Pen and paper alternatives for recording results of inspections remain a commonly used alternative under the ADIP scheme and were used on the day. Your suggestion that lack of an iPad might lead to further deaths seems to misunderstand the position to a degree that I do not feel I can usefully comment further. Additional Points HSG 175 is clear about who has responsibility for what in relation to inflatables and other fairground equipment for good reason. Clarity of role is a very important aspect of health and safety management and avoids reliance by operators on others to ensure that they set up and operate their own equipment safely. It is not reasonable and is potentially dangerous, to ask that Rundles commit to meeting additional obligations that are not required ofall the other IBs in the UK, by HSE and industry guidance. with any operators he appointed, had responsibility for ensuring that the tie downs on his inflatable devices were used. If you seek to divert that responsibility to IBs by seeking from Rundles an assurance that they will draw attention to operator issues, you may actually increase the risk of injury and death by inherently encouraging an owner or operator to rely on someone visiting or inspecting to pick up on their incompetence in operating their equipment. That cannot optimise safety. Our client, and any IB in their position, has no legal obligation, nor it is suggested by HSG 175 or the ADIP scheme, that they should draw attention to any issues they may observe regarding use of equipment on an inspection, never mind on a pre inspection visit. This is NOT within their area of responsibility and goes beyond their remit.
- agrees with this and has advised he would expect an IB to note the number of and condition of tie downs on an inspection but due to varying circumstances, not necessarily to see them staked down as that is entirely an operational issue and failures in operation are not defects. 10
0 Finch Consulting If you have an issue with the law and guidance then it would be more appropriate to take that up with the HSE and with The Amusement Devices Safety Council. Please let me know if you have any further questions or need clarification on any of the points covered. Please also confirm that this letter deals to your satisfaction with the concern you have raised as far as Rundles is concerned.
Response received
View full response
Dear Jes
Re: Ava-May Littleboy
1. This letter constitutes the response of the Health and Safety Executive (HSE) to the Coroner’s Report dated 2 April 2020, sent to HSE on 15th July 2020. The Coroner has asked whether there is any action that HSE is able to take that may assist in the prevention of future deaths.
2. HSE would like to express at the outset its deepest sympathy and condolences for the family of Ava-May Littleboy, the child killed in the tragic accident which is the subject of the Report.
Background
3. HSE holds the national policy lead for health and safety law which applies to the fairground industry including the supply, hire and use of inflatable play equipment for commercial purposes, although it does not apply to private, domestic buyers and users.
4. Enforcement allocation is split between the Health and Safety Executive (HSE) and Local Authorities and is dependent upon the type of amusement equipment in use. HSE is the regulator for fairground rides and associated equipment used on fairgrounds and theme parks whilst Local Authorities enforce sites with equipment such as coin-operated children’s rides outside shops, bouncy castles at pubs, hotels and other LA-enforced premises.
2
5. HSE has a dedicated team (the National Fairground Inspection Team – NFIT) whose responsibilities include proactive inspection of fairgrounds as well as reactive investigation
e.g. of concerns and serious accidents. In common with HSE’s overall strategic approach to regulation, proactive inspection of the fairground industry is based on targeting areas of highest risk.
Legal Framework
6. Sections 2 and 3 of the Health and Safety at Work etc. Act 1974 respectively place duties on (i) those operating fairground equipment (including inflatable devices) to ensure, so far as is reasonably practicable, the health, safety and welfare of their employees and (ii) that members of the public are not, so far as is reasonably practicable, exposed to risks to their health and safety.
7. Section 6 of the 1974 Act places a duty on designers, manufacturers, importers and suppliers of fairground amusement equipment to ensure that, so far as is reasonably practicable, it is safe and without risk to health, when used in connection with entertaining the public.
8. The Provision and Use of Work Equipment Regulations 1998 require that fairground equipment is maintained in an efficient state, in efficient working order and in good repair, and subject to inspection at suitable intervals to ensure its continued safe operation.
HS(G) 175 - Fairgrounds and amusement parks: Guidance on safe practice
9. The operation of fairground amusement devices is generally considered to be a high hazard activity. That is to say that an untoward event arising from operation of amusement devices, including inflatables, could have serious consequences, involving serious multiple injuries or fatalities.
10. In such situations, it is important that the risk, or likelihood, of such an event occurring is reduced to the lowest degree reasonably practicable, with a higher level of precautions taken than would generally be expected in situations of low hazard, i.e. where any harm which materialised would be minor.
11. In recognition of this, HSE has worked with the industry to produce detailed guidance on the precautions to be taken. HSE publication HS(G)175, ‘Fairgrounds and Amusement Parks: Guidance on safe practice’ focuses on the safety of employers, employees and the general public using fairgrounds and amusement parks and gives advice on measures to control risk. It provides advice on issues relating to attractions, including design, manufacture, inspection, operation, maintenance, repair, and modification and is free to download from the HSE website.
12. Although the Coroner’s report dated 2 April 2020, records that the Inquest heard evidence in relation to the content of HS(G) 175 ‘Fairgrounds and Amusement Parks: Guidance on safe practice’, it may be of assistance to set out the specific requirements applicable to the matters set out in the Coroner’s report.
3
13. Specifically, HS(G)175 sets out the roles of the designer, manufacturer, importers and suppliers who have a duty to ensure that the attractions are safe for use when first supplied and to provide their customers with appropriate information to allow safe use. It also details how people undertaking each of these roles can discharge their duties under Section 6 of the Health and Safety at Work etc Act 1974.
14. HS(G)175 also sets out the ‘System for safety of attractions’, which consist of a series of ‘steps’ and ‘checks’ intended to ensure safety of an amusement device from design, through to operation and maintenance of the ride.
15. This can be found in tabular form (table 1) on page 8 of HS(G)175. The requirement for ‘checks’ is intended to avoid a situation where defects, faults and errors could go undetected and is consistent with the usual goal of a Safety Engineer, which is the avoidance of conditions where a single failure (whether a ‘hardware’ failure or a human behavioural failure) could lead directly to a high hazard situation without opportunity for corrective action.
16. The approach by HS(G)175 of requiring steps and checks can be illustrated with the example of ride design. The requirement (or ‘step’) in table 1 is for design “by competent designers with knowledge of the relevant standards”. The additional requirement is for an independent check on the soundness of the overall design concept, by the process known as ‘Design Review’, which forms part of the pre-use inspection process.
17. The other aspects of the pre-use inspection process relate to the manufacture of the device and include the requirement to complete an assessment of conformity to design (ACD) which confirms that the device is manufactured and constructed to the reviewed design specification.
18. The process is then concluded by the completion of the “initial test”, which is a series of tests to check that the device operates safely in accordance with the reviewed design specification and the instructions in the operations manual.
19. The first step when considering HS(G) 175 is to identify in Table 2, the type of device that is under consideration. The table sets out the recommended action for various types of attraction, confirming the need for a design review, assessment to conformity to design, initial test and in-service inspection or an alternative.
20. HSE have considered the devices listed in table 2 of HS(G) 175 and can confirm that the device involved in the incident under investigation is not specifically listed.
21. Although there is reference to “inflatable (bouncy)” the recommendations stipulated in table 2 would not be applicable, as the device did not fall within the scope of BS EN 14960: 2019 or its predecessor BS EN 14960: 2013.
22. The scope of BS EN 14960 is limited to inflatable play equipment defined as “a structure relying on a continuous supply of air to maintain its shape, on or in which users may play, bounce”, and as the incident device was a “sealed air unit” the standard would not have been applicable.
23. Therefore, the incident device could not have been inspected under the Pertexa Inflatable Play Accreditation (PIPA) scheme, which specifically limits the devices that can be inspected under its scheme to those that fall within the scope of BS EN 14960.
4
24. Furthermore, HSE do not consider that the device should be categorised as “other inflatable (not used for bouncing or sliding)”. as the incident device was being used primarily for bouncing.
25. There is a further reference to a “pneumatic or air supported structure” in table 2, but HSE do not consider the incident device to be a pneumatic or air supported structure HSE understand that this reference applies to inflatable structures such as “inflatable start/finish race arches” and other similar structures.
26. Although the incident device is not specifically listed within table 2 of HS(G) 175, this is an indicative list of amusement devices which are used within the UK, rather than an exhaustive list. HSE would expect that the principles set out in HS(G) 175 would be applied to all types of amusement device imported and used in the UK, including the incident device.
27. Section C of HS(G) 175 details how a designer, manufacturer, importer and supplier of an attraction can discharge their duties under Section 6 of the Health and Safety at Work etc Act 1974.
28. In relation to fairground amusement devices, section 6 of the HSW Act states that “it shall be the duty of any person who designs, manufactures, imports or supplies any article of fairground equipment:
o to ensure, so far as is reasonably practicable, that the article is so designed and constructed that it will be safe and without risks to health at all times when it is being used for or in connection with the entertainment of members of the public;
o to carry out or arrange for the carrying out of such testing and examination as may be necessary for the performance of the duty imposed on him by the preceding paragraph;
o to take such steps as are necessary to secure that persons supplied by that person with the article are provided with adequate information about the use for which the article is designed or has been tested and about any conditions necessary to ensure that it will be safe and without risks to health at all times when it is being used for or in connection with the entertainment of members of the public; and
o to take such steps as are necessary to secure, so far as is reasonably practicable, that persons so supplied are provided with all such revisions of information provided to them by virtue of the preceding paragraph as are necessary by reason of its becoming known that anything gives rise to a serious risk to health or safety”.
29. Section C defines the roles of an importer and supplier and sets out what actions they need to complete in order to discharge their relevant legal duties under Section 6 as follows:
30. “Importers…You are an importer if you bring a device into the country either temporarily or permanently. If you buy a foreign device through an agent who is permanently resident
5 in Great Britain, the agent is normally the importer are responsible for ensuring that the pre-use inspections (design review, ACD and initial test) are carried out and that the designer and manufacturer have followed the information in this guidance. You can do this by checking that the operations manual contains the necessary reports on the pre-use inspections.
31. The device should not be used unless these pre-use inspections have been carried out and a suitable documentation and certification has been issued.
32. It is recommended that in purchase contracts for new devices you should request that designers, manufacturers and importers follow the appropriate guidance in this book and in Safety of amusement devices: Design.
33. You should take care to check that the documentation you receive follows the requirements of the pre-use inspections in this guidance. Differences in methodology, practice, procedures and certification requirements between countries can lead to different interpretations of what is required, for example:
o use of design criteria inappropriate for Great Britain, e.g. wind loading;
o incomplete review, e.g. with no, or inadequate, attention to control systems or passenger-containment systems;
o false assumptions, e.g. that a component or a safety-control system will never fail or that it will fail safe.
34. Suppliers…You become a supplier if you sell (or hire out) any device, new or second- hand. Make sure you do everything possible to check that the designer, manufacturer and importer, as appropriate, have complied with their legal requirements and have followed the advice in this guidance.
35. You should do this by checking that the operations manual contains the necessary reports on the pre-use inspections: design review, ACD and initial test. If these have not been done, you should take steps to have these completed before the device is first used.
36. You must provide the controller with all the information and instruction necessary for safe use before the device is first used. You should include the reports of pre-use inspections and any modifications stemming from them. Written information provided should be in English (and in the language of the controller if different).
37. If you hire out a device, you should confirm that there are documents demonstrating that the device has been subjected to pre-use and in-service annual inspection by competent persons”.
38. The guidance set out in HS(G) 175 is well established guidance and is well known and understood within the UK fairground industry. Furthermore, HSE would suggest that if a person was unable to discharge any of the requirements set out for either the importer or supplier, that there would be adequate provision of competent organisations and individuals that could provide the necessary assistance on their behalf.
39. Primarily, in such circumstances HSE would expect any importer or supplier unable to meet the requirements set out in paragraphs 72-80 of HS(G) 175 on their own, to engage
6 the services of an Inspection Body (IB) registered with the Amusement Device Inspection Procedures Scheme (ADIPS).
40. The scheme is currently administered by ADIPS Ltd on behalf of the Amusement Device Safety Council and is based on the system for the safety of attractions set out in HS(G)
175.
41. ADIPS Ltd acts as registration body for the competence assessment, registration and administrative control of IBs.
42. Furthermore, the ADIPs scheme is currently supported by HSE, and by all the major ride- owning trade associations who recommend it to their members for the pre-use inspection, in-service annual inspection and certification of all amusement devices.
43. HSE would consider that ADIPs have registered within their scheme suitably qualified and experienced IBs who could have completed the necessary pre-use inspection work in relation to the incident device.
Pre use inspection process
44. In addition, to the guidance in Section C of HS(G) 175 which addresses the roles and responsibilities of the designer, manufacturer, importer and supplier, the guidance clearly defines the various stages of the pre-use inspection process in Section D.
45. At paragraph 100 of Section D it states that “The controller of an amusement device is responsible for ensuring that the three pre-use inspections are satisfactorily carried out before it is put into operation with the public, either for the first time following its manufacture or import, or after any safety-critical modification”.
46. In circumstances where the “controller” does not have the necessary knowledge or understanding to ensure that the necessary pre-use inspection has been completed, then it would be reasonably practicable to engage the services of an Inspection Body (IB) registered with the Amusement Device Inspection Procedures Scheme (ADIPS).
47. In addition, the guidance states that “The controller may appoint an IB to take overall responsibility for arranging the work, confirming the completion of the pre-use process and issuing the DOC, although the final responsibility for the adequate completion of the pre- use inspection process rests with the controller”.
48. The requirements set out in HS(G) 175 in relation to the “controller” are very well defined and HSE would suggest that it is reasonably practicable for the person fulfilling this role to discharge their duty by confirming that the necessary pre-use inspection work has been completed and that the device is in fact safe for use.
49. HSE consider that the pre-use inspection process set out in HS(G) 175 provides a suitably robust framework for ensuring that fairground amusement devices are in fact safe before they it is brought into use for the first time.
50. The individual aspects of the pre-use inspection process are detailed in Section D of HS(G) 175 which can be found in Appendix 1 to this letter.
7
Legal Duties
51. As detailed HSE have published guidance in HS(G)175, which sets out how the owner/operator of an amusement device can discharge their legal duties.
52. Within the guidance HSE recognise and support three industry schemes for the Inspection and testing of amusement devices, including the Amusement Device Inspection Procedures Scheme (ADIPS), which HSE consider would have been an appropriate body to engage to complete the necessary inspection of the device to ensure that it was in fact safe.
53. However, it should be noted that HS(G)175 is guidance and there is no legal requirement for the owner/operator to use the ADIPS scheme and they are free to engage the services of any competent body to carry out the necessary work to discharge their legal duties.
54. Additionally, it should be noted that there is no legal requirement imposed on an inspection body including ADIPS registered bodies, to report to the relevant Enforcing Authority (HSE or Local Authority) the details of any amusement device that has either not been subject to a suitable inspection or has in fact failed an inspection.
55. The duty remains with the owner/operator to ensure that the amusement device is in fact safe as required under sections 2 and 3 of Health and Safety at Work etc. Act 1974.
56. Finally, HS(G)175 states that “any person to whom this guidance is directed who finds a generic or serious fault on a device, which could have wider safety implications for that or other similar devices, should inform their trade association and the National Association for Leisure Industry Certification (NAFLIC). Trade associations may decide to distribute the relevant information to their members or others in the interests of safety on fairgrounds”.
57. HSE can confirm that ADIPS inspection bodies routinely provide safety critical information to NAFLIC Technical Committee, who use this information to produce regular technical bulletins for their membership, which details the safety critical defects with amusement devices along with the remedial action required to address these issues.
58. It is also worth noting that NAFLIC maintain a digital library of these technical bulletins on their website, which can be freely accessed by their members and other parties.
Future work
59. HSE continue to work with industry stakeholders in the entertainment and leisure sector through the Amusement Safety Device Council, to improve the safety of amusement devices and following the incident at Gorleston has written to them to remind them of their obligations and signposted them to the relevant information.
8
60. Additionally, HSE has reviewed the scope of its existing guidance and intends to publish additional guidance on the design, operation and inspection of sealed inflatable devices, which is currently being drafted in consultation with representatives of the amusement industry.
61. Finally, the safe operation of amusement devices remains a priority for HSE and Local Authorities and forms an integral part of the annual inspection programme delivered by the designated team of inspectors who make up the HSE’s National Fairground Inspection Team and the Local Authorities Health and Safety Officers.
62. I hope this reply is helpful in addressing the issues raised in your Coroner’s report dated 2 April 2020. If, however, the Coroner has any further questions or requires clarification, HSE would be pleased to assist.
Re: Ava-May Littleboy
1. This letter constitutes the response of the Health and Safety Executive (HSE) to the Coroner’s Report dated 2 April 2020, sent to HSE on 15th July 2020. The Coroner has asked whether there is any action that HSE is able to take that may assist in the prevention of future deaths.
2. HSE would like to express at the outset its deepest sympathy and condolences for the family of Ava-May Littleboy, the child killed in the tragic accident which is the subject of the Report.
Background
3. HSE holds the national policy lead for health and safety law which applies to the fairground industry including the supply, hire and use of inflatable play equipment for commercial purposes, although it does not apply to private, domestic buyers and users.
4. Enforcement allocation is split between the Health and Safety Executive (HSE) and Local Authorities and is dependent upon the type of amusement equipment in use. HSE is the regulator for fairground rides and associated equipment used on fairgrounds and theme parks whilst Local Authorities enforce sites with equipment such as coin-operated children’s rides outside shops, bouncy castles at pubs, hotels and other LA-enforced premises.
2
5. HSE has a dedicated team (the National Fairground Inspection Team – NFIT) whose responsibilities include proactive inspection of fairgrounds as well as reactive investigation
e.g. of concerns and serious accidents. In common with HSE’s overall strategic approach to regulation, proactive inspection of the fairground industry is based on targeting areas of highest risk.
Legal Framework
6. Sections 2 and 3 of the Health and Safety at Work etc. Act 1974 respectively place duties on (i) those operating fairground equipment (including inflatable devices) to ensure, so far as is reasonably practicable, the health, safety and welfare of their employees and (ii) that members of the public are not, so far as is reasonably practicable, exposed to risks to their health and safety.
7. Section 6 of the 1974 Act places a duty on designers, manufacturers, importers and suppliers of fairground amusement equipment to ensure that, so far as is reasonably practicable, it is safe and without risk to health, when used in connection with entertaining the public.
8. The Provision and Use of Work Equipment Regulations 1998 require that fairground equipment is maintained in an efficient state, in efficient working order and in good repair, and subject to inspection at suitable intervals to ensure its continued safe operation.
HS(G) 175 - Fairgrounds and amusement parks: Guidance on safe practice
9. The operation of fairground amusement devices is generally considered to be a high hazard activity. That is to say that an untoward event arising from operation of amusement devices, including inflatables, could have serious consequences, involving serious multiple injuries or fatalities.
10. In such situations, it is important that the risk, or likelihood, of such an event occurring is reduced to the lowest degree reasonably practicable, with a higher level of precautions taken than would generally be expected in situations of low hazard, i.e. where any harm which materialised would be minor.
11. In recognition of this, HSE has worked with the industry to produce detailed guidance on the precautions to be taken. HSE publication HS(G)175, ‘Fairgrounds and Amusement Parks: Guidance on safe practice’ focuses on the safety of employers, employees and the general public using fairgrounds and amusement parks and gives advice on measures to control risk. It provides advice on issues relating to attractions, including design, manufacture, inspection, operation, maintenance, repair, and modification and is free to download from the HSE website.
12. Although the Coroner’s report dated 2 April 2020, records that the Inquest heard evidence in relation to the content of HS(G) 175 ‘Fairgrounds and Amusement Parks: Guidance on safe practice’, it may be of assistance to set out the specific requirements applicable to the matters set out in the Coroner’s report.
3
13. Specifically, HS(G)175 sets out the roles of the designer, manufacturer, importers and suppliers who have a duty to ensure that the attractions are safe for use when first supplied and to provide their customers with appropriate information to allow safe use. It also details how people undertaking each of these roles can discharge their duties under Section 6 of the Health and Safety at Work etc Act 1974.
14. HS(G)175 also sets out the ‘System for safety of attractions’, which consist of a series of ‘steps’ and ‘checks’ intended to ensure safety of an amusement device from design, through to operation and maintenance of the ride.
15. This can be found in tabular form (table 1) on page 8 of HS(G)175. The requirement for ‘checks’ is intended to avoid a situation where defects, faults and errors could go undetected and is consistent with the usual goal of a Safety Engineer, which is the avoidance of conditions where a single failure (whether a ‘hardware’ failure or a human behavioural failure) could lead directly to a high hazard situation without opportunity for corrective action.
16. The approach by HS(G)175 of requiring steps and checks can be illustrated with the example of ride design. The requirement (or ‘step’) in table 1 is for design “by competent designers with knowledge of the relevant standards”. The additional requirement is for an independent check on the soundness of the overall design concept, by the process known as ‘Design Review’, which forms part of the pre-use inspection process.
17. The other aspects of the pre-use inspection process relate to the manufacture of the device and include the requirement to complete an assessment of conformity to design (ACD) which confirms that the device is manufactured and constructed to the reviewed design specification.
18. The process is then concluded by the completion of the “initial test”, which is a series of tests to check that the device operates safely in accordance with the reviewed design specification and the instructions in the operations manual.
19. The first step when considering HS(G) 175 is to identify in Table 2, the type of device that is under consideration. The table sets out the recommended action for various types of attraction, confirming the need for a design review, assessment to conformity to design, initial test and in-service inspection or an alternative.
20. HSE have considered the devices listed in table 2 of HS(G) 175 and can confirm that the device involved in the incident under investigation is not specifically listed.
21. Although there is reference to “inflatable (bouncy)” the recommendations stipulated in table 2 would not be applicable, as the device did not fall within the scope of BS EN 14960: 2019 or its predecessor BS EN 14960: 2013.
22. The scope of BS EN 14960 is limited to inflatable play equipment defined as “a structure relying on a continuous supply of air to maintain its shape, on or in which users may play, bounce”, and as the incident device was a “sealed air unit” the standard would not have been applicable.
23. Therefore, the incident device could not have been inspected under the Pertexa Inflatable Play Accreditation (PIPA) scheme, which specifically limits the devices that can be inspected under its scheme to those that fall within the scope of BS EN 14960.
4
24. Furthermore, HSE do not consider that the device should be categorised as “other inflatable (not used for bouncing or sliding)”. as the incident device was being used primarily for bouncing.
25. There is a further reference to a “pneumatic or air supported structure” in table 2, but HSE do not consider the incident device to be a pneumatic or air supported structure HSE understand that this reference applies to inflatable structures such as “inflatable start/finish race arches” and other similar structures.
26. Although the incident device is not specifically listed within table 2 of HS(G) 175, this is an indicative list of amusement devices which are used within the UK, rather than an exhaustive list. HSE would expect that the principles set out in HS(G) 175 would be applied to all types of amusement device imported and used in the UK, including the incident device.
27. Section C of HS(G) 175 details how a designer, manufacturer, importer and supplier of an attraction can discharge their duties under Section 6 of the Health and Safety at Work etc Act 1974.
28. In relation to fairground amusement devices, section 6 of the HSW Act states that “it shall be the duty of any person who designs, manufactures, imports or supplies any article of fairground equipment:
o to ensure, so far as is reasonably practicable, that the article is so designed and constructed that it will be safe and without risks to health at all times when it is being used for or in connection with the entertainment of members of the public;
o to carry out or arrange for the carrying out of such testing and examination as may be necessary for the performance of the duty imposed on him by the preceding paragraph;
o to take such steps as are necessary to secure that persons supplied by that person with the article are provided with adequate information about the use for which the article is designed or has been tested and about any conditions necessary to ensure that it will be safe and without risks to health at all times when it is being used for or in connection with the entertainment of members of the public; and
o to take such steps as are necessary to secure, so far as is reasonably practicable, that persons so supplied are provided with all such revisions of information provided to them by virtue of the preceding paragraph as are necessary by reason of its becoming known that anything gives rise to a serious risk to health or safety”.
29. Section C defines the roles of an importer and supplier and sets out what actions they need to complete in order to discharge their relevant legal duties under Section 6 as follows:
30. “Importers…You are an importer if you bring a device into the country either temporarily or permanently. If you buy a foreign device through an agent who is permanently resident
5 in Great Britain, the agent is normally the importer are responsible for ensuring that the pre-use inspections (design review, ACD and initial test) are carried out and that the designer and manufacturer have followed the information in this guidance. You can do this by checking that the operations manual contains the necessary reports on the pre-use inspections.
31. The device should not be used unless these pre-use inspections have been carried out and a suitable documentation and certification has been issued.
32. It is recommended that in purchase contracts for new devices you should request that designers, manufacturers and importers follow the appropriate guidance in this book and in Safety of amusement devices: Design.
33. You should take care to check that the documentation you receive follows the requirements of the pre-use inspections in this guidance. Differences in methodology, practice, procedures and certification requirements between countries can lead to different interpretations of what is required, for example:
o use of design criteria inappropriate for Great Britain, e.g. wind loading;
o incomplete review, e.g. with no, or inadequate, attention to control systems or passenger-containment systems;
o false assumptions, e.g. that a component or a safety-control system will never fail or that it will fail safe.
34. Suppliers…You become a supplier if you sell (or hire out) any device, new or second- hand. Make sure you do everything possible to check that the designer, manufacturer and importer, as appropriate, have complied with their legal requirements and have followed the advice in this guidance.
35. You should do this by checking that the operations manual contains the necessary reports on the pre-use inspections: design review, ACD and initial test. If these have not been done, you should take steps to have these completed before the device is first used.
36. You must provide the controller with all the information and instruction necessary for safe use before the device is first used. You should include the reports of pre-use inspections and any modifications stemming from them. Written information provided should be in English (and in the language of the controller if different).
37. If you hire out a device, you should confirm that there are documents demonstrating that the device has been subjected to pre-use and in-service annual inspection by competent persons”.
38. The guidance set out in HS(G) 175 is well established guidance and is well known and understood within the UK fairground industry. Furthermore, HSE would suggest that if a person was unable to discharge any of the requirements set out for either the importer or supplier, that there would be adequate provision of competent organisations and individuals that could provide the necessary assistance on their behalf.
39. Primarily, in such circumstances HSE would expect any importer or supplier unable to meet the requirements set out in paragraphs 72-80 of HS(G) 175 on their own, to engage
6 the services of an Inspection Body (IB) registered with the Amusement Device Inspection Procedures Scheme (ADIPS).
40. The scheme is currently administered by ADIPS Ltd on behalf of the Amusement Device Safety Council and is based on the system for the safety of attractions set out in HS(G)
175.
41. ADIPS Ltd acts as registration body for the competence assessment, registration and administrative control of IBs.
42. Furthermore, the ADIPs scheme is currently supported by HSE, and by all the major ride- owning trade associations who recommend it to their members for the pre-use inspection, in-service annual inspection and certification of all amusement devices.
43. HSE would consider that ADIPs have registered within their scheme suitably qualified and experienced IBs who could have completed the necessary pre-use inspection work in relation to the incident device.
Pre use inspection process
44. In addition, to the guidance in Section C of HS(G) 175 which addresses the roles and responsibilities of the designer, manufacturer, importer and supplier, the guidance clearly defines the various stages of the pre-use inspection process in Section D.
45. At paragraph 100 of Section D it states that “The controller of an amusement device is responsible for ensuring that the three pre-use inspections are satisfactorily carried out before it is put into operation with the public, either for the first time following its manufacture or import, or after any safety-critical modification”.
46. In circumstances where the “controller” does not have the necessary knowledge or understanding to ensure that the necessary pre-use inspection has been completed, then it would be reasonably practicable to engage the services of an Inspection Body (IB) registered with the Amusement Device Inspection Procedures Scheme (ADIPS).
47. In addition, the guidance states that “The controller may appoint an IB to take overall responsibility for arranging the work, confirming the completion of the pre-use process and issuing the DOC, although the final responsibility for the adequate completion of the pre- use inspection process rests with the controller”.
48. The requirements set out in HS(G) 175 in relation to the “controller” are very well defined and HSE would suggest that it is reasonably practicable for the person fulfilling this role to discharge their duty by confirming that the necessary pre-use inspection work has been completed and that the device is in fact safe for use.
49. HSE consider that the pre-use inspection process set out in HS(G) 175 provides a suitably robust framework for ensuring that fairground amusement devices are in fact safe before they it is brought into use for the first time.
50. The individual aspects of the pre-use inspection process are detailed in Section D of HS(G) 175 which can be found in Appendix 1 to this letter.
7
Legal Duties
51. As detailed HSE have published guidance in HS(G)175, which sets out how the owner/operator of an amusement device can discharge their legal duties.
52. Within the guidance HSE recognise and support three industry schemes for the Inspection and testing of amusement devices, including the Amusement Device Inspection Procedures Scheme (ADIPS), which HSE consider would have been an appropriate body to engage to complete the necessary inspection of the device to ensure that it was in fact safe.
53. However, it should be noted that HS(G)175 is guidance and there is no legal requirement for the owner/operator to use the ADIPS scheme and they are free to engage the services of any competent body to carry out the necessary work to discharge their legal duties.
54. Additionally, it should be noted that there is no legal requirement imposed on an inspection body including ADIPS registered bodies, to report to the relevant Enforcing Authority (HSE or Local Authority) the details of any amusement device that has either not been subject to a suitable inspection or has in fact failed an inspection.
55. The duty remains with the owner/operator to ensure that the amusement device is in fact safe as required under sections 2 and 3 of Health and Safety at Work etc. Act 1974.
56. Finally, HS(G)175 states that “any person to whom this guidance is directed who finds a generic or serious fault on a device, which could have wider safety implications for that or other similar devices, should inform their trade association and the National Association for Leisure Industry Certification (NAFLIC). Trade associations may decide to distribute the relevant information to their members or others in the interests of safety on fairgrounds”.
57. HSE can confirm that ADIPS inspection bodies routinely provide safety critical information to NAFLIC Technical Committee, who use this information to produce regular technical bulletins for their membership, which details the safety critical defects with amusement devices along with the remedial action required to address these issues.
58. It is also worth noting that NAFLIC maintain a digital library of these technical bulletins on their website, which can be freely accessed by their members and other parties.
Future work
59. HSE continue to work with industry stakeholders in the entertainment and leisure sector through the Amusement Safety Device Council, to improve the safety of amusement devices and following the incident at Gorleston has written to them to remind them of their obligations and signposted them to the relevant information.
8
60. Additionally, HSE has reviewed the scope of its existing guidance and intends to publish additional guidance on the design, operation and inspection of sealed inflatable devices, which is currently being drafted in consultation with representatives of the amusement industry.
61. Finally, the safe operation of amusement devices remains a priority for HSE and Local Authorities and forms an integral part of the annual inspection programme delivered by the designated team of inspectors who make up the HSE’s National Fairground Inspection Team and the Local Authorities Health and Safety Officers.
62. I hope this reply is helpful in addressing the issues raised in your Coroner’s report dated 2 April 2020. If, however, the Coroner has any further questions or requires clarification, HSE would be pleased to assist.
Report Sections
Investigation and Inquest
On 13 September 2018 I commenced an investigation into the death of Ava-May LITTLEBOY aged 3 years. The investigation concluded at the end of the inquest, held with a jury, on 19 March 2020. The medical cause of death was: 1a Traumatic Head Injury The conclusion of the inquest was: Ava-May’s guardians paid for the use of a trampoline which exploded following which she died
Circumstances of the Death
Ava-May went to the beach at Gorleston with her family on 1 July 2018. She went on an inflatable trampoline, which exploded, throwing her into the air. She died later that day in James Paget University Hospital as a result of her injuries. Questions for the Jury: 1a) When acquiring the inflatable trampoline was an operating/Instruction Manual relevant to the trampoline obtained?
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Review CCTV monitoring SIA licence requirements
Manchester Arena Inquiry
Unregulated recreation safety
Establish standard for event healthcare services
Manchester Arena Inquiry
Unregulated recreation safety
Mandatory Ambulance Liaison Officer at events
Manchester Arena Inquiry
Unregulated recreation safety
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.