Page 1 of 12 KENTUCKY DEPARTMENT OF AGRICULTURE Office of Consumer and Environmental Protection Division of Regulation and Inspection Amusement Rides Branch FINAL REPORT Louisville Zoo train ride accident June 1, 2009
Page 2 of 12 TABLE OF CONTENTS Accident report Exhibit 1 Louisville Zoo map Exhibit 2 C.P. Huntington Field Inspection and Test Guide Exhibit 3 Louisville Zoo train, tram, and carousel procedures/scripts Exhibit 4 Louisville Zoo pre-opening checklist for June 1, 2009 Exhibit 5 Kentucky Department of Agriculture inspection reports for Louisville Zoo train ride for 2007, 2008 and 2009 Exhibit 6 Kentucky Department of Agriculture Stop Operation Order on Louisville Zoo train ride Exhibit 7 Louisville Zoo train ride operator s statement on accident of June 1, 2009 Exhibit 8 Louisville Zoo train ride brake shoe measurements Exhibit 9 Louisville Zoo train ride brake adjustment measurements Exhibit 10 Memorandum of Feb. 13, 2009
Page 3 of 12 INVESTIGATION REPORT C. P. HUNTINGTON TRAIN #312 LOUISVILLE ZOO LOUISVILLE, KENTUCKY Pursuant to Kentucky Revised Statutes Chapter 247, the Kentucky Department of Agriculture, Office of Consumer and Environmental Protection, Division of Regulation and Inspection, Amusement Rides Branch, is charged with the responsibility of regulating the operation of amusement rides in Kentucky. BACKGROUND On Monday, June 1, 2009, at approximately 4:30 p.m. EDT, an injury accident occurred at the Louisville Zoo (Zoo) located at 1100 Trevilian Way, Louisville, Kentucky, involving C. P. Huntington Train #312. The train turned over in a curve near Gorilla Forest 1. The train engine and cars came to a stop on their sides off the tracks, resulting in various injuries to most of the twenty-nine passengers and the operator. The weather was clear and sunny and was not a factor in this incident. Terminology Notes This report refers to the train laying over, not to a train derailment. A layover occurs when a train tips over, usually due to speed while going through a curve. A derailment is when a train leaves its tracks, usually due to a defect in the track or the train wheel system. Train #312 is made up of a locomotive and three passenger-bearing coaches. The locomotive and each coach have two trucks (flat beds on top of wheels). Train #312 has three different braking controls. The brake lever is a small lever attached below the seat in front of the dash panel 2. This lever, when pulled to the left, applies air pressure to the brake shoes on the trucks, pushing them against the wheels of the train. This is the lever used for normal stopping of the train. The parking brake is to the right of the dash panel of the train. This is a black mechanical lever with a split end handle. To engage the brake, one must squeeze the handle and pull it back. Once engaged, it then must be squeezed and pushed forward to release. The emergency brake is referred to as the coach air brake valve in the manufacturer s manual. 3 This button, located on the dash panel, is visible to the operator. This button is used to fill the air tanks on the coaches and is used to stop the train during an emergency. 1 Exhibit 1, Zoo Map. 2 Exhibit 2, C.P. Huntington Field Inspection and Test Guide, item 3, page 6. 3 Exhibit 2, C.P. Huntington Field Inspection and Test Guide, item 10, page 6.
Page 4 of 12 Injury Incident During the first use of Train #312 on June 1, 2009, it carried a ride operator and twenty-nine passengers. The train departed the loading station nearest the Zoo entrance and proceeded to climb the first hill on its route. After reaching its crest, the train began to descend and pick up speed. As the train entered the tunnel, the ride operator said she felt it was moving substantially faster than the manufacturer s maximum speed of twelve (12) miles per hour. The ride operator attempted to slow the train by pulling and then pumping the brake lever, an action she says a fellow employee had once told her might be effective. The ride operator then attempted to pull a mechanical lever that she thought was the emergency stop brake. The mechanical lever she attempted to pull was the parking brake for the locomotive section of the train, not the emergency brake. The train continued to gain speed through the downward-sloped tunnel, and it rocked back and forth as it exited the tunnel. As the train approached a right turn at Gorilla Forest, the train tipped over on its left side, left the tracks and came to rest in gravel bordering the track. The occupants of the train sustained various injuries, including broken bones, strains, cuts, scrapes and bruises. The operator stated that she then radioed for help and reported the location of the train. Louisville Metro Police and EMS were called immediately. Louisville Metro Police secured the scene. Mark Zoeller of the Louisville Zoo reported the accident to the KDA. Operator and Witness Statements (Synopsis-not verbatim) The train operator provided a written statement to the KDA as well as an in-person narrative the morning following the incident. The KDA also attended the deposition of the train operator, which was scheduled by parties to litigation surrounding the incident. The KDA is not involved in this litigation. The operator provided the same description of the incident on both occasions. The information relevant to the incident is as follows: The operator stated that the date of the incident was the first day she operated any Zoo train by herself without an instructor or other Zoo personnel. The Zoo had a training period for potential train operators, the completion of which allowed an operator to be certified by the Zoo to operate the trains. This program of training and certification was created by the Zoo and is not mentioned in the operator s manual from Chance Rides Manufacturing (Chance), the manufacturer of the train ride. The operator received her certification to operate the trains alone on June 1, 2009. She stated that the Zoo operates three similar trains, and that each is identified by its color scheme. Train #312 was commonly referred to as the green train. The operator stated that she had never before operated Train #312, either with an instructor or by herself, prior to picking up the passengers involved in the incident. The operator stated that she had never been provided nor had she ever seen the manufacturer s operation manual prior to the incident. She was familiar only with the manual developed by the Zoo for the trains. 4 The Zoo train manual did not contain a description of train controls, nor did it contain a description of how to stop the train in the event of an emergency. The operator stated that the Zoo train manual focused on the speech to be given during the train operation. 4 Exhibit 3, Zoo Train Manual
Page 5 of 12 The operator stated that during the operation of one of the other trains, she had been cautioned by her instructor, Nelson Gilmore, that she needed to reduce her speed going downhill near the Gorilla Forest because she had been going too fast. The operator stated that she had never received any training on the emergency brake system on Train #312. She had been trained only on use of the regular brake lever and the parking brake on the other two trains. (The other two trains do not have the same type of emergency brake system present on Train #312.) She stated that, prior to the incident, she did not know where the emergency brake system was on Train #312. The operator stated that, on the day of the incident, another Zoo employee performed the daily inspection on Train #312 and showed her how to check portions of the train 5. Train #312 had been parked on the side holding track area near the rear of the Zoo (See exhibit 4). The operator boarded and drove the empty train along the normal route starting at the rear train station and ending at the passenger train station near the entrance of the Zoo. She stated that, when she engaged the brake, the train brakes were sluggish, and the train stopped several feet past the normal (intended) stopping line. The operator checked the air pressure gauge, which read normal; however, she did not report the sluggish brakes to her supervisor or maintenance employees. At the train station, the operator performed her normal ticket taking duties. Once the operator loaded the train with passengers, the train left the station and started up the track. The operator started her normal speech that the train operators give, which contains information about the Zoo. The train proceeded in a normal manner until after it reached the top of the hill near the giraffe exhibit 6. The operator stated that she pulled the brake lever as the train proceeded down the hill, but she did not feel resistance. The train continued to gather speed while going downhill as it got closer to the tunnel. The operator stated that, at the entrance to the tunnel, she felt the train was out of control. The operator then attempted to pump the brake lever by pulling the brake lever and releasing it, then repeating rapidly. She said she had been told to do this by another train operator who was not her instructor. She stated that she attempted to reach for what she thought was the emergency brake. (The lever she reached for was actually the locomotive parking brake.) She was not sure if she was able to apply what she thought was the emergency brake or not. The operator stated that, as the train exited the tunnel, she was still engaging the normal brake, and the train was going extremely fast. She then let go of the brake lever to steady herself in the operator seat as the train entered a small curve that rocked the train. After the curve, the operator felt a big jolt to her left, and the train lay over and came to rest in the gravel alongside the tracks at the Gorilla Forest exhibit. The operator then called for help over the radio. 5 Exhibit 4, Zoo Pre Opening Checklist 6 See Exhibit 1.
Page 6 of 12 The passenger statements confirm and describe the same actions and movements of the train as the operator described. Each statement noted the increased speed heading into the tunnel and the excessive speed through and exiting the tunnel prior to the layover of the train. Past KDA Inspections The KDA has records of inspections on Train #312 for the years 2007-2009. 7 The inspection reports are attached 8. The C. P. Huntington Train #312 was delivered new to the Louisville Zoo in 2000. Train #312 has a maximum load limit of forty-two (42) passengers, fourteen (14) passengers for each of the three coaches 9. The train had been in service for nine years, and there had been no prior reports of a layover or derailment to the KDA. The 2009 inspection took place on January 22. During the inspection, KDA inspectors first walked the entire length of the track while Zoo employees warmed up the three trains operated by the Zoo, including Train #312. The inspectors spot checked the tracks and then returned to the area where the trains were held. The inspectors observed the coach brake units as a Zoo employee activated the emergency brake to verify that the emergency brake button caused the brakes to engage on each coach. The inspectors checked for safety signage and fire extinguishers. Among other measures, the inspectors checked the linkages connecting the coaches for wear and faulty air or wiring connections. No abnormalities were noted. As a suggestion to the Zoo, the inspectors asked the Zoo to review its accident and evacuation procedures. The KDA suggested the review be completed within thirty (30) days. INVESTIGATION Initial Investigation The accident was reported to the KDA by Mark Zoeller of the Louisville Zoo at 5:00 p.m. EDT on Monday, June 1, 2009. KDA inspectors traveled immediately to the Louisville Zoo. Upon arrival of KDA officials at the scene, Zoo officials verified that Louisville Metro Police had secured the area near the train. Louisville Metro notified the KDA investigators that some of the cars had to be moved and a canopy of one car cut off prior to the arrival of the inspectors as part of the emergency response. 7 The record retention schedule, as determined by the Kentucky Department for Libraries and Archives, dictates that series #0403 files [Amusement Rides Inspection and License File] must be maintained for a period of three years, after which they are to be destroyed. 8 Exhibit 5, KDA Inspection Material 9 See Exhibit 2, page 4.
Page 7 of 12 The KDA issued a Stop Operation Order for Train #312 and the other two Zoo trains 10. The ORDER directed Zoo personnel to cease operation of the amusement rides until the investigation of the incident was completed. KDA investigators then requested documentation of maintenance and Zoo inspection records for Train #312. KDA inspectors began their physical investigation of Train #312 at approximately 6:30 p.m. EDT. The inspectors made a visual appraisal of the accident scene and took pictures. Inspectors visually inspected the ride and its components; they did not see any immediately apparent evidence of mechanical or component failure that might have caused the incident. The passengers on the train at the time of the incident had left the Zoo by the time KDA inspectors arrived and could not be immediately contacted. Only Zoo personnel were present. Inspectors took verbal statements from Zoo personnel as they became available and gathered all available Zoo maintenance and operations records. Zoo employees provided to the KDA copies of statements taken from bystanders, park personnel and individuals on the ride at the time of the incident. The inspectors also took statements from two Louisville Metro police officers who were at the scene. The inspectors concluded their initial investigation at approximately 10:00 p.m. EDT. The following day, two KDA employees interviewed the operator of Train #312 and obtained a written statement from her. 11 Supplementary Investigation Following the initial on-site phase of the investigation, the KDA coordinated with the Chance Rides Manufacturing technician, Zoo maintenance employees and Louisville Metro Government officials in continuance of the investigation. The KDA observed the movement to and subsequent storage of the train in the Louisville Underground facility located adjacent to the Zoo property. The train was positioned on its left side and placed on blocks. The trucks for the coaches and the front truck for the locomotive were placed on blocks. The rear truck for the locomotive was moved intact with a large cable binder securing the truck. The train was not damaged during the move. Braking System The KDA took measurements of the brake shoes to assess whether these braking system components were within factory specifications to be in service. It was determined that the factory replacement brake shoes supplied by the manufacturer were slightly narrower than the brake shoe described in the manual. 12 Although the factory replacements were narrower, the specification for the replacement thickness of the brake shoes had not been modified by the manufacturer; therefore, the replacement thickness threshold remained 1 9/16 inches in the middle and 5/8 inch or less on the sides. A chart of the KDA measurements showing the location and 10 Exhibit 6, Stop Operation Order 11 Exhibit 7, Operator Statement 12 Exhibit 2 - Train Manual, pages 25 and 29
Page 8 of 12 measured thickness is attached as Exhibit 8 13. Of the sixty-four (64) brake shoes on the entire train, fifty-eight (58) could be safely and accurately measured. Of those measured, none of the brake shoes was within specifications, and all of the brake shoes should have been replaced, according to the manual. 14 The gaps between the brake shoes and the wheels were also measured to determine if any brakes were out of adjustment. The manual states that the brake shoes must be as close to the wheels as possible without dragging. It is the judgment of the KDA inspectors that any gap of more than 1/8 of an inch is out of adjustment. Forty-four (44) gaps could be measured accurately and safely. Of these, eleven (11) were out of adjustment 15. The KDA observed the train and coaches being placed upright for inspection by a representative from Chance. The purpose of this movement was for the train manufacturer to inspect the train and provide a quote to the Zoo for repairs. The locomotive and coaches were placed on wooden blocks. The train was not damaged during this movement. Dash Panel Components As a part of this inspection, the Chance technician and Zoo maintenance employees started the motor in the locomotive section. The motor started after a couple of attempts and then ran smoothly. After the key was placed in the ignition and turned to the on position prior to turning the key further to start the motor, it was noticed that the low air warning buzzer and the low air warning light did not function. As a continued part of the KDA investigation, the KDA inspectors requested the Chance technician to open the panel containing the wiring for the low air pressure buzzer. The KDA inspectors asked the technician, who has familiarity and expertise with the system and components, to describe the warning system to those present. During the examination, it was apparent that the wires connected to one side of the buzzer had been disconnected. Because of poor lighting in the storage location, the KDA requested that the panel be replaced in its original position until the parties present were able to meet again with proper tools and lighting to verify the condition of the electrical, air, brake, and warning systems. Emergency Brake Knob The KDA returned with additional inspectors, two of whom were certified electricians. The inspectors tested the functionality of the air braking system. The air system functioned normally, with the exception of the emergency brake knob. This knob controls the emergency brakes and the filling of the coach air tanks, which supply air pressure for an emergency. On Train #312, the emergency brake knob was a round black knob that would need to be pulled to engage the emergency brakes. As described in the manual, the factory knob is an octagonal red knob that would need to be pushed to engage the emergency brakes. The knob on Train #312 functioned opposite of the knob operation as described in the manufacturer s manual. The KDA inspectors connected an air line to a coach truck to test if the emergency brakes would engage if the knob were pulled. The brakes on the coach truck operated normally. Because this truck operated 13 Exhibit 8, KDA Brake Shoe Measurements 14 Exhibit 2 - Train Manual, pages 25 and 29 15 Exhibit 9, KDA Brake Adjustment Measurements
Page 9 of 12 normally and the inspectors did not have any cause to suspect the others would not, additional trucks were not tested. The air system for the locomotive was inspected and tested by the KDA. The system built and stored air pressure normally with no observed problems. The brake lever supplied air to the rear of the locomotive when applied and released pressure when the lever was released. Rapid pumping of the lever by the KDA resulted in rapid engagement and release of the brakes on the tested truck. Warning Buzzer The KDA inspectors removed the entire dash panel from the locomotive section to inspect the warning and electrical systems and compare them with the manufacturer s wiring diagram. The inspectors found that the low air warning buzzer negative ground wire had been disconnected and was affixed with electrical tape next to other wires away from the buzzer. The inspectors also found that the low air pressure warning light wires were disconnected and that the entire fixture, other than the red outer lens on the dash, was not present, including the bulb. The remainder of the panel and wiring appeared to be normal. Inspectors verified that neither low air pressure warning device could have possibly functioned at the time of the incident. Other Components The train had been equipped with a speaker system for the operator to use during train operation. This system was not a factory-installed option. CONCLUSION Upon a comprehensive review of the findings in this investigation, KDA inspectors were able to make a determination regarding the probable cause of the accident. The three contributing factors that caused the layover of Train #312 were: The excessive speed of the train as it went through the downhill curve; The poor mechanical condition of the train; and Inadequate operator training. Mechanical Condition Of the fifty-eight (58) brake shoes measured on Train #312, none of the brake shoes was within manufacturer specifications, and all of the brake shoes should have been replaced, according to the manual. 16 Of the forty-four (44) gaps that could be measured accurately and safely, eleven (11) were out of adjustment 17. 16 Exhibit 8, KDA Brake Shoe Measurements 17 Exhibit 9, KDA Brake Adjustment Measurements
Page 10 of 12 Excessive Speed The train tipped over in the downward curve near the Gorilla Forest exhibit because the train was moving too quickly. The moment the operator thought the train was going at an excessive speed, with or without applying the normal brake, the operator should have immediately engaged the emergency stop to slow the train and potentially prevent harm to passengers. Inadequate Training The operator of the train was inadequately trained. The operator was not familiar with the manufacturer s manual for the ride; the Zoo did not require her to review the manual as part of the certification training. Because the operator had not been trained on emergency braking procedure, she did not know where the emergency brake was located. The two other Zoo trains she had been driving were not equipped with an emergency brake. The emergency stop procedure on the other two trains called for depressing the parking brake lever. The operator attempted to depress the parking brake on Train #312, but this was not the proper procedure or method for an emergency stop, and the train did not slow. The operator had not been provided material or training describing or explaining the differences between the trains she was instructed on and Train #312. When the operator released the brake lever and began to pump the brakes, she repeatedly released the brakes and re-applied the brakes. Each time she commenced the improper braking action, all braking pressure was released. This would cause the train to decelerate at a much lower rate than if the brake lever had been applied and remained applied until the desired degree of slowing of the train had occurred. The action of pumping the brakes made the situation worse. The poor mechanical condition of the braking system may not have slowed the train as rapidly as the operator may have expected, but if the proper braking procedure had been followed, the train may have slowed enough not to lay over. The operator stated that had she been trained on the use of the emergency brake, she would have used it. Items Not Related to the Incident The following actions were analyzed as part of the incident investigation but did not directly cause the incident involving Train #312: Failure to repair train according to manufacturer specifications or recommendations Failure to use appropriate replacement parts Failure to perform or document pre-operation inspections The low air warning buzzer and low air warning light were not wired correctly. The low air warning light fixture, including the bulb, was missing except for the dash side red lens. The air delivery system to the coach tanks and emergency braking system was installed backward from manual instructions. The knob for the control was not the proper shape or color.
Page 11 of 12 The Zoo replaced the original emergency brake knob that was installed on the train when it was delivered new. The train was not operated for a complete test cycle on June 1, 2009 prior to the incident as the manufacturer s manual requires. VIOLATIONS 18 Violation 1 Fifty-eight brake shoes on Train #312 were out of tolerance for use from the standards in the manufacturer s manual and should have been replaced prior to the operation of the train. This constitutes a violation of 302 KAR 16:111 (1) (l) for failure to maintain the ride or attraction in good mechanical condition. The regulation proscribes a civil penalty of between One Thousand Dollars ($1,000) and Ten Thousand Dollars ($10,000). The KDA assesses a civil penalty of Ten Thousand Dollars ($10,000) for this violation. Violation 2 The low air pressure warning system had been altered and was not functional. The ground wire for the low air pressure warning buzzer was disconnected from the buzzer and taped to the harness with electrical tape. The low air warning light was disconnected, and the entire fixture for the light, except the dash side red lens, was missing. This constitutes a violation of 302 KAR 16:111 (1) (m) for failure to repair ride or attraction according to manufacturer specifications or recommendations. The regulation proscribes a civil penalty of between One Thousand Dollars ($1,000) and Ten Thousand Dollars ($10,000). The KDA assesses a civil penalty of Ten Thousand Dollars ($10,000) for this violation. Violation 3 The emergency coach air brake valve knob installed on the train at the time of the incident was not a manufacturer-approved replacement part. This constitutes a violation of 302 KAR 16:111 (1) (o) for failure to use appropriate replacement parts. The regulation proscribes a civil penalty of between One Thousand Dollars ($1,000) and Ten Thousand Dollars ($10,000). The KDA assesses a civil penalty of Ten Thousand Dollars ($10,000) for this violation. Violation 4 The operator failed to follow correct braking or emergency braking procedures. The operator was not familiar with the emergency brake system. The operator was not sufficiently trained nor was she familiar with the manufacturer s manual. The operator pumped the air brakes, an action that is not suggested in the manufacturer s manual. This constitutes a violation of 302 KAR 16:111 (2) (a) for failure to follow safety guidelines and manufacturer specifications. The regulation proscribes a civil penalty of between One Hundred Dollars ($100) and Five Thousand Dollars ($5,000). The KDA assesses a civil penalty of Five Thousand Dollars ($5,000) for this violation. 18 Exhibit 10, Regulation 302 KAR 16:111 LRC Letter. The violations portion of the amusement rides regulations 302 KAR 16:111 became effective February 13, 2009. The regulation was filed as an emergency regulation and was effective immediately upon being filed. The remainder of the administrative regulations became effective June 5, 2009.
Page 12 of 12 Violation 5 The maximum recommended speed for Train #312 is twelve (12) miles per hour. Based upon the operator and passengers statements, Train #312 was running in significant excess of 12 mph prior to and at the time of the layover. This constitutes a violation of 302 KAR 16:111 (3) (e) for exceeding the manufacturer s recommended speed of a ride or attraction. The regulation proscribes a civil penalty of between One Hundred Dollars ($100) and One Thousand Dollars ($1,000). The KDA assesses a civil penalty of One Thousand Dollars ($1, 000) for this violation. Violation 6 The Zoo did not perform the pre-opening test operation of the train without passengers as is required by the manufacturer s manual. This constitutes a violation of 302 KAR 16:111 (3) (m) for failure to perform or document pre-operation inspections. The regulation proscribes a civil penalty of between One Hundred Dollars ($100) and One Thousand Dollars ($1,000). The KDA assesses a civil penalty of One Thousand Dollars ($1,000) for this violation. Kentucky Department of Agriculture Office of Consumer and Environmental Protection Division of Regulation and Inspection Amusement Rides Branch March 25, 2010