The Weekly Reflektion 13/2022

Human error plays a part in most accidents. Do your investigations stop there?

Injury to boy’s neck after accident on the ski lift. Photo: Private

Do you consider ‘inherently safer design’ in your investigations?

In February this year, an 11-year-old boy was on downhill skis for the first time at a Norwegian ski resort, when he was involved in an accident on the children’s tow rope ski lift. He had used the tow rope 5 or 6 times and was at the top of the lift when he got the tow rope tangled around his neck and was pulled 10-15 m up the slope before the lift was stopped. He was unconscious when rescuers reached him and was evacuated by helicopter to the nearest hospital. He was kept in overnight and released the next day with no long-term injuries.

The accident was assessed as potentially fatal, and the police were called immediately and interviewed witnesses at the location. The police concluded very quickly that the cause was human error, that the 11-year-old had made a mistake and the owners of the ski lift could not be blamed, and the case was closed.

Reflekt have investigated many incidents and in most, some type of human error has been involved. In this case, human error from an 11-year-old who is on skis for the first time should hardly come as a surprise. The police concluded that the straps to his helmet were loose and became tangled somehow in the rope tow. His parents had photographic evidence that his helmet was fastened properly shortly before the accident. In addition, the boy claimed he had been hit on the head from behind immediately before the accident. These observations are not explained by the chain of events described by the police.

In any case, human error is to be expected from any person, but particularly children, and is the starting point for an investigation into the cause of an accident, not the conclusion. What mistakes were made, and why did they result in the rope becoming tangled around his neck? Were there mistakes that others could repeat, and how do we prevent similar mistakes having similar results, perhaps fatalities?

The parents and a ski lift expert challenged the conclusions reached by the police, and two weeks later the police decided to re-open the investigation with a caveat that the re-opening did not mean they thought the conclusion was wrong, but they wanted to investigate further.

Human error was most probably a factor in the accident, but to stop the investigation with human error as a conclusion does not really get to the root of the incident and more importantly fails to provide valuable learning to prevent recurrence. All of us make mistakes, but how do we ensure that these mistakes do not result in disasters? Do you consider inherent safer design in your investigations, or are you happy with an easier ‘human error’ conclusion?