Fatal Lack of Error Proofing


Safety rules not followed on ride that killed worker | Chicago Tribune

A safety precaution put in place for a thrill ride after a fatal accident three years ago wasn't being followed when a worker was killed on the same ride, an amusement park official acknowledged Saturday.

The ride's new operator, his view apparently blocked by a high back on the ride's seat, started the Mind Scrambler while Garin was kneeling on a seat bench, Spano said.

Tartaglia said the operator noticed Garin and shut the ride down within 20 seconds, but she had already been thrown to her death. Only one attendant was on duty when Garin died, he said, despite a safety measure put in place after a 7-year-old girl died in 2004.

Not a lot of details in the article, but it's a shame that the process (or lack thereof) allowed the ride to be started at a dangerous time. The employees were, I'm sure, told to “be careful” but the ride wasn't error proofed, and a young woman died, the 21 year old worker.

It seems like rides like this should have dual controls, dual switches that BOTH workers have to turn at the same time. This would help ensure that neither of them were in a dangerous zone. There should be some sort of “lock out” strategy or methodology, as would be very common in just about any U.S. factory today (at least if people are following the rules).

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. How strange! We just had an amusement park mishap locally. Although in this case it was a patron, not an employee: Girl’s Feet Severed on Ride and she didn’t die, although the papers have been remarkably quiet over the state of her feet.

    The thing I like most actually comes from a follow up article about the investigation: “The accident Thursday prompted at least eight theme parks across the country to close similar thrill rides until they could be inspected”.

    Seems sensible.


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