What Are The Factors Leading To The Mindbender Incident?
Abstract
The following report contains an in depth analysis of the factors leading to the Mindbender incident of 1986. Initially the crash itself is discussed including details on what the event was like for anyone who was there. Following this is an extensive investigation on each factor that lead to the derail of the coaster, the lack of maintenance of the ride being the main reason for the crash. Then the relationship between plant safety and occupational safety and how several risk control measures that were not in place is looked at along with Reasons’ Swiss Cheese model being applied. Finally plant safety, occupational safety, and the risk control measures that were not in place are considered, resulting in a clear hypothesis on the …show more content…
The six wheel bogie were attached to a single axle on the rear of the final cart by means of 4 hex head recessed cap screws through a cap plate at a clearance of only a quarter of an inch to the track rail. Due to the poor maintenance of the car – as listed above – when the screws became loose they could scrape along the bottom of the track. This was the loud metallic noise that was heard during the morning of the day of the crash. After all four screws had become loose then scraped along the track there was no longer anything attaching the cars to the wheel bogies’, and once the car rode through an area of uplift before the last loop, the final car …show more content…
It was well know that Schwarzkopf GmbH was going bankrupt during the process of the coaster being made, and many of the components had not been planned for use in such a ride. These business decisions were all made with the goal of saving money. Anton Schwarzkopf, the owner of the company was contracted to inspect and supervise the whole construction of the ride, nevertheless with his company going bankrupt and only himself to blame Triple Five Corp did not want his presence around the ride causing bad publicity. Ultimately with his expertise being roller coasters this proved a very unwise decision on Triple Corps behalf.
The relationship between plant safety and occupational safety, and the risk control measures that were not in place
The well knows Swiss Cheese model explained by Hollnagel et al. (2006) states that accidents in complex system occur through the accumulation of multiple factors and failures. The model suggests multiple contributors (the holes in cheese slices) must be aligned for any adverse events to occur. Barriers in a system (the slices themselves) are intended to prevent errors that result in these adverse events.
When applying this theory to the crash it is clear there must have been many ‘holes’ in the design and maintenance process that lead the bolts coming loose, and not enough ‘slices’
The following report contains an in depth analysis of the factors leading to the Mindbender incident of 1986. Initially the crash itself is discussed including details on what the event was like for anyone who was there. Following this is an extensive investigation on each factor that lead to the derail of the coaster, the lack of maintenance of the ride being the main reason for the crash. Then the relationship between plant safety and occupational safety and how several risk control measures that were not in place is looked at along with Reasons’ Swiss Cheese model being applied. Finally plant safety, occupational safety, and the risk control measures that were not in place are considered, resulting in a clear hypothesis on the …show more content…
The six wheel bogie were attached to a single axle on the rear of the final cart by means of 4 hex head recessed cap screws through a cap plate at a clearance of only a quarter of an inch to the track rail. Due to the poor maintenance of the car – as listed above – when the screws became loose they could scrape along the bottom of the track. This was the loud metallic noise that was heard during the morning of the day of the crash. After all four screws had become loose then scraped along the track there was no longer anything attaching the cars to the wheel bogies’, and once the car rode through an area of uplift before the last loop, the final car …show more content…
It was well know that Schwarzkopf GmbH was going bankrupt during the process of the coaster being made, and many of the components had not been planned for use in such a ride. These business decisions were all made with the goal of saving money. Anton Schwarzkopf, the owner of the company was contracted to inspect and supervise the whole construction of the ride, nevertheless with his company going bankrupt and only himself to blame Triple Five Corp did not want his presence around the ride causing bad publicity. Ultimately with his expertise being roller coasters this proved a very unwise decision on Triple Corps behalf.
The relationship between plant safety and occupational safety, and the risk control measures that were not in place
The well knows Swiss Cheese model explained by Hollnagel et al. (2006) states that accidents in complex system occur through the accumulation of multiple factors and failures. The model suggests multiple contributors (the holes in cheese slices) must be aligned for any adverse events to occur. Barriers in a system (the slices themselves) are intended to prevent errors that result in these adverse events.
When applying this theory to the crash it is clear there must have been many ‘holes’ in the design and maintenance process that lead the bolts coming loose, and not enough ‘slices’