The Weekly Reflektion 03/2023

When organisations are busy, undermanned, and have other important tasks to perform, investigations are often not prioritised. Sometimes the objective is carry out an investigation rather than getting to the root of the problem.

After a potentially fatal accident, do you hope that statistics are on your side, and do nothing?

In February 2022, 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. This was the subject of the Reflektion in week 13, 2022.

The immediate conclusion of the police was ‘human error’, and given that the boy was inexperienced on skis, and only 11, human error seemed a reasonable assumption. In May 2022, the police report was published which concluded that the cause was not human error from the involved person, but it was the rope from the person behind the boy on the ski lift that became tangled around the boy’s neck.

The Norwegian Railway Authority (NRA) (StatensJernbanetilsyn) as the supervisory authority for ski lifts reviewed the police report and in December 2022 concluded that there was no breach of regulations. The NRA have not been to visit the ski lift in question, and based on the police report, have concluded that there are no grounds to call for a formal audit of the lift in question.

NRA stated that, according to the legislation, the individual company is responsible for identifying the causes of incidents, finding appropriate measures to prevent recurrence, and implementing the measures. However, through supervision, the NRA can ensure that incidents are followed up. When questioned about the decision not to call for an audit, the NRA claimed that a repeat of the incident is very unlikely. They based this view on their statistics that showed that in the past 40 years there has been about 2 billion trips on similar ski lifts, and no other comparable incident has been recorded.Therefore, it is very unlikely to happen again.

The police found nothing wrong with the ski lift equipment but stated that the risk associated with using any ski lift increases if the person has little experience, a factor in this incident. Just because there was nothing wrong with the equipment, does not mean that the situation cannot be improved. It is possible for example that the design of the disembarkation area was instrumental in the rope from the lift behind managing to get caught around the neck of the boy.Reporting of incidents from a public facility may be less disciplined that from a workplace, so the accuracy of the NRAstatistics should be viewed with caution. 

Using statistics of doubtful quality to conclude this accident was a one in a billion chance and not likely to happen again seems unjustified. The NRA should take this incident as a wake-up call, and ensure it is not repeated, it may be fatal next time. A formal audit is the least we should expect.