Serious accident on high ropes course

June 2008

Issue

A serious accident occurred on a cow’s tail high ropes course.  On reaching the end of the course participants were transferred from the cow’s tails to a ‘bottom rope’ belay system to protect them on a trapeze jump and, finally, lower them to the ground.  An instructor was stationed on the final platform, to connect the bottom rope to the back of a full body harness.  On this occasion the instructor failed to connect the rope and the participant jumped to the trapeze, let go, and fell to the ground sustaining serious injuries.  The instructor was a very experienced senior member of staff who had operated the high ropes course over many years.

Outcome

Issues to be aware of are that:

• Instructors, no matter how competent and experienced, are not infallible.
• Routine and repetitive tasks are particularly likely to lead to human error. In adventure activities in the natural environment there will frequently be situations where safety is totally reliant on the instructor.  However, we increasingly work in artificial environments performing routine and repetitive sequences of actions. These are particularly susceptible to human error.
• When dealing with routine and repetitive tasks, steps need to be taken, as far as is possible, to create operating systems which do not rely solely on an individual carrying out a sequence of events repetitively and perfectly on each and every occasion.  Forexample connecting a safety rope in such a way that, at least, two people are involved - one to carry out the connection and one to check it.
• Avoid situations where participants give all responsibility to the instructors.  Making participants responsible for their own safety (checked and supported by an instructor) does give at least two pairs of eyes to each task.  In this situation, for example, onus could be put onto the belayers at the bottom to visually/verbally "check" that the jumper is secure before they accept responsibility to safely lower them to the ground. In other situations one participant may DO what is required, a second participant may CHECK it is done correctly, whilst the instructor observes that all is well.  This helps to bring into play the old principal that the best way to learn something is to teach it to someone else.