Report: Glenwood Caverns workers didn’t properly check girl’s seatbelts before fatal plunge
9 page report says death of 6-year-old was the ‘result of multiple operator errors’
Glenwood Springs Post Independent
A nine-page report released Friday found that the Sept. 5 incident that led to the death of a 6-year-old girl at the Glenwood Caverns Adventure Park was the “result of multiple operator errors.”
The Colorado Department of Labor and Employment, Division of Oil and Public Safety reported five key findings, notably that Haunted Mine Drop Ride operators did not notice Wongel Estifanos was sitting on top of her seat belts, rather than secured by them, before the ride began operation. Operators also had insufficient guidance both in training and from the manufacturer’s manual that led to incorrect addressing of error messages on the ride’s monitor, the report states. It found violations of the Colorado Amusement Rides and Devices Regulations and said “enforcement will be pursued via the statutory process.”
“The fatal accident was the result of multiple operator errors, specifically failure to ensure proper utilization of the passenger restraint system (seatbelts), and a lack of understanding and resolution of the Human Machine Interface (HMI) screen error conditions on the control panel,” the report concludes.
The report found that a lack of procedures, inadequate training, more than one operator taking responsibility for a ride during a ride cycle and the restraint system involved all contributed to the operator error.
In the ride immediately preceding the accident, the seat Estifanos occupied was left empty. Ride operators, who were not named in the report, fastened the two seat belts of the empty seat, one of which uses a rod that is pushed into a buckle called the restraint block, which is used for monitoring of seat belt status.
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At the conclusion of each ride, the rod automatically unlocks as operators are intended to unfasten patrons from their belts, resetting the ride’s status. If the rod is not removed and reinserted, an error is thrown on the control panel, as it “cannot have been positioned properly on the next passenger,” according to the report.
Operators had adopted a process of unbuckling and clearing seat belts from seats, the report finds, but had done so inconsistently throughout the day and did not reset the unoccupied seat before Estifanos took it.
In both the manufacturer’s and the site-specific operations’ manuals, operators are instructed to fasten patrons into the seats. The operator was observed allowing guests to fasten their own seat belts throughout the day, the report found. The manuals also instruct operators to visually confirm each guest has seat belts over their lap.
Estifanos was observed having the tail end of the seat belt in her lap, but neither of the actual restraints were in place on her.
A second operator arrived while the restraint block error was active. Operator 2 then reinserted each rod into their buckle, “without understanding and resolving the actual issue — that Ms. Estifanos did not have the seatbelts across her lap.” The report notes that the manufacturer’s operating manual does not instruct operators how to properly address errors.
Regulation violations were found in failures to follow operating procedures and in training to emphasize the inherent risks of the ride or review the manufacturer’s operating manual.
In a statement to the Post Independent, Glenwood Caverns Adventure Park Founder Steve Beckley said, “We have been working closely with Colorado Division of Oil and Public Safety and independent safety experts to review this incident. Earlier today, we received the state’s final report and will review it carefully for recommendations.”
The Haunted Mine Drop ride will remain closed until the Division of Oil and Public Safety re-permits the ride, which is conditional on the resolution of all the contributing factors to the accident and an inspection.
The park reopened Sept. 11.