OKLAHOMA DEPARTMENT OF LABOR
(FINAL INVESTIGATORY REPORT)
FATALITY ACCIDENT
BELL'S AMUSEMENT PARK
APRIL 20, 1997


CONCERNS, FINDINGS, CONCLUSIONS AND RECOMMENDATIONS



POSSIBLE FAILURE CAUSE THEORIES:

I. CONCERN: FOREIGN OBJECT IN CHAIN TROUGH

FINDING: No evidence to substantiate theory. Nothing was recovered from
either the trough or the surrounding area to support this theory. No
indications of any impact were present.

CONCLUSION: The accident was not the result of a foreign object being 
present in the chain trough.



II. CONCERN: OCCUPANT BEHAVIOR

FINDING: A. Side-to-Side Rocking
               1. No physical evidence exists to substantiate this theory.
               2. Evidence is present to discount this theory. Under 
                  controlled conditions, the chain could be shaken loose
                  from the "dog" on the yellow and black cars only, but it 
                  required prolonged, violent and vigorous cars shaking of
                  the cars by individuals standing on either side.    
         B. Forward Lurch
               1. Can only be performed prior to the curve of the incline
                  at the 27-degree angle stretch of track. However, all 
                  three occupants would have been required to produce 3 g's
                  of force each in order to pull the car free of the chain.
                  This is neither a credible event nor is it supported by 
                  eyewitness statements.

CONCLUSION: The accident was not the result of occupant behavior.



III. CONCERN: ACCIDENTAL STOPPAGE OF CHAIN

FINDING: Conflicting testimony exists between the "kicker" operator and 
the "station break" operator. It is not clear who stopped the chain and 
when the action occurred. 
         A. "Kicker" operator states he went to turn off the chain
         following the accident but it was already stopped. 
         B. "Station break" operator states he turned off the chain, but 
         he cannot recall when the action was taken.
         C. Chain STOP buttons are located at both the "kicker" and 
         "station break" operator positions. At the "kicker" operator's
         position, the chain STOP button is located on a panel adjacent 
         and to the left of the panel on which the green START button 
         which releases a car is located.
         D. Both panels are located behind the "kicker" operator. After
         loading a car, the operator must either turn around or reach 
         behind to press the green START button. 
         E. The location of the chain STOP buttons suggest both can be
         accidentally pressed.

CONCLUSION: It cannot be ruled out that either the "kicker" operator or 
the "station break" operator might have inadvertently pressed the chain 
STOP button. However, the chain STOP buttons are safety devices. 
Therefore, it is inconceivable that pressing either button would have 
been a contributing factor. The accident was not the result of accidental
stoppage of the chain.



IV. CONCERN: CHAIN DOG RIDING UP ON THE EDGE OF THE CHAIN TROUGH

FINDING: Wear patterns indicate the "chain dog," located at the rear of 
each car, rides up the side and onto the top of the left leg of the chain 
trough. This is evident on both the trough and the corresponding side of 
the "chain dog." This action, coupled with the sloping bottom surface of 
the "chain dog" and its normal release of the chain near the top of the 
hill, can raise the "chain dog" far enough to disengage the chain 
prematurely. The car then coasts forward a short distance before coming to
a stop in the sawtooth. 

         A. Under controlled conditions, the "chain dog" prematurely 
            disengaged from the chain four out of five times near the 
            top of the hill. But, it was determined, in this location,
            the natural momentum of the car would carry it over the crest
            of the hill.
         B. Under normal operation of the ride, the chain did not 
            disengage prematurely.

CONCLUSION: Premature release of the chain by the "chain dog" near the 
top of the chain hill cannot be ruled out as a probable contributing 
factor to the accident. However, repeated attempts to recreate this event
under normal operation of the ride were unsuccessful.



V. CONCERN: FAILURE OF THE NYLATRON INSERT

FINDING: A plastic insert is that part of the anti-rollback device which
engages the sawtooth if and when the "chain dog" disengages from the chain.
         A. Nylatron, a low-friction lubricated nylon manufactured by 
         Polymer Corporation, is a different type of plastic containing 
         dissimilar material properties than the insert specified by the
         Wildcat 's manufacturer, Schwarzkopf GmbH.
         B. Nylatron is not recommended by its manufacturer for use in an
         anti-rollback device.
         C. The insert was fabricated on site by Bell's personnel without
         benefit of Schwarzkopf's drawings and calculations for the part.
         D. The Nylatron insert in the anti-rollback device shattered, 
         allowing the black car to roll unimpeded back down the chain 
         hill.

CONCLUSION: The use of an inappropriately brittle material in a 
non-redundant safety device resulted in the failure of the anti-rollback
device rendering it incapable of preventing the accident.



GENERAL PARK MAINTENANCE:

I. CONCERN: ADEQUATE TRAINING OF PARK PERSONNEL

FINDING: The testimony of park personnel indicates no formal training of
those individuals responsible for day-to-day maintenance and repair of 
the Wildcat roller coaster. The park's owners also have no formal training
on the maintenance or operation of the Wildcat roller coaster. Bell's did 
not possess a copy of the Wildcat's Operating Instructions which includes: 
a schematic plan and description of the roller coaster framework and 
equipment; instructions for operating the ride; and, some maintenance 
requirements for the framework, equipment and cars. Supervisors had no 
scheduled or consistent oversight of maintenance performed.

RECOMMENDATION: The ODOL recognizes the value of on the job training (OJT).
However, maintenance personnel performing repairs should, at a minimum, 
be certified mechanics. The industry needs to develop the criteria 
necessary to establish a certified training program.


FINDING: Park employees were not provided with written instructions or 
formal training on the operation of a given ride. Training was provided by
another employee with previous experience in a ride's operation. No 
records are kept to verify an employees training or knowledge of a ride's
operation. 

RECOMMENDATION: The owner/operator shall establish an adequate training
program for all ride operators and maintain records reflecting the 
training of these individuals. It is further recommended some form of 
national certification of key park personnel be required. ODOL rules will
be changed to reflect these recommendations.



II. CONCERN: MAINTENANCE RECORDS/MAINTENANCE

FINDING: The Wildcat's Operating Instructions indicate all scheduled and
unscheduled maintenance work is to be documented in a log-book. No such 
records were maintained by Bell's. Supervisors had no scheduled or 
consistent oversight of maintenance performed on the ride.

RECOMMENDATION: ODOL rules shall be changed to specifically require 
maintenance and repair records be maintained by the owner/operator. Ride
inspectors shall verify maintenance record keeping at the time of 
inspection.


FINDING: ODOL investigators found numerous discrepancies in critical parts
of the Wildcat's cars which might have been contributing factors to the 
accident. 
         A. The "chain dog" on the black and yellow cars was mounted 
         higher than on the blue and purple cars. 
         B. The wheels were of various diameter width from one car to 
         another, affecting the height of the "chain dog." 
         C. The plastic insert in the anti-rollback device extended 
         further than recommended by the Operating Instructions. 
         D. Following an incident April 13, 1997, in which the chain came
         off the sprocket at the top of the chain hill, a maintenance 
         worker removed the chain dog from the black car, sanded it down,
         and replaced the device on the car. The ODOL was not notified of 
         the incident, which reportedly occurred several times in Fall 
         1996, or the modification. 
         E. The ride was altered or modified without notification of the
         ODOL and in possible violation of the Amusement Park Safety Act, 
         Title 40 O.S. 1991 464, which states in part:

              [W]henever any additions or alterations are made which 
              change the structure, mechanism, classification or capacity
              of any amusement ride, the operator or owner shall file with 
              the Commissioner of Labor a notice of his intention and any 
              plans or diagrams requested by the Commissioner of Labor.

         F. The ride was altered or modified without notification of the 
         ODOL in violation of the Amusement Ride Safety Rules, 
         OAC:380:55-15-4(3), which states in part: 

              The Department of Labor will conduct ride inspections for the
              following: (3)After any modifications or alterations to the 
              ride.
         
         G. The owner/operator of the park substituted the material used 
         for the plastic insert in the anti-rollback device with material 
         which did not meet manufacturer's specification in apparent 
         violation of the Amusement Park Safety Act, Title 40 O.S. 1991 464,
         and in violation of the Amusement Ride Safety Rules, 
         OAC:380:55-15-4(3), noted above.

RECOMMENDATION: A copy of this report shall be turned over to the 
appropriate law enforcement agencies for possible prosecution for 
violating the Amusement Park Safety Act, Title 40 O.S. 1991 469, which 
states:

              Any violation of the provisions of this act shall be a 
              misdemeanor. Conviction thereof shall be punishable by a 
              fine not exceeding One Thousand Dollars ($1,000.00) or not 
              more than one (1) year in the county jail, or both such fine
              and imprisonment. Each day of violation shall constitute a 
              separate offense.



ADDITIONAL ODOL RECOMMENDATIONS

OFF-SEASON MAINTENANCE: All mechanical rides will undergo a complete 
inspection to include the removal of all load-bearing and wearing parts 
to be inspected by an engineer at the ride owner's expense. Rides coming 
into Oklahoma must provide proof of such inspection for each ride or 
submit to a detailed inspection before a permit for operation is issued.

SELF-INSPECTION WAIVER PROGRAM: This program is not related to the Bell's
incident but is designed for traveling amusement shows. The Waiver Program
should be evaluated to include a full inspection by a certified engineer 
who will ensure the operation of the ride is within the manufacturer's 
guidelines. Evaluation should also include the possibility of discontinuing
this program.

LIABILITY INSURANCE: A rules change should be considered which would 
increase the minimum coverage of liability insurance from $300,000 to 
$1 million. This would provide more coverage in the event of a major loss
and would encourage the underwriter to be more involved in ride safety.

INCIDENT REPORT: A new rule shall be added to reflect language in the
Amusement Ride Safety Act. An owner/operator would be required to notify 
the Department of Labor of any incident involving injury or mechanical 
malfunction which requires the removal or modification of any part of a 
mechanical ride. 

NATIONAL STANDARDS: The ODOL should consider participation in the Council
for Amusement and Recreational Equipment Safety (CARES), an organization 
of ride safety administrators. Participation would provide the ODOL another
opportunity to render input in determining amusement ride industry 
standards.


NOTE: The recommendations of Zahl-Ford and Emtec are contained later in 
this report.




APPENDIX A
AMUSEMENT RIDE SAFETY ACT OF 1982
Title 40 O.S. 1991, 460-469


Title 40 O.S. 1991, 460. "Rules and regulations" states:

The Commissioner of Labor shall promulgate rules and regulations for the 
safe installation, repair, maintenance, use, operation and inspection of 
all amusement rides necessary for the protection of the general public 
using amusement rides. 


Title 40 O.S. 1991, 461 1,(2),(3) and (4). "Definitions" states, in 
pertinent part:

As used in Sections 1 through 10 of this ACT:

1. "Amusement ride" means a mechanical device which carries or conveys 
passengers along, around or over a fixed or restricted route or course for
the purpose of giving its passengers amusement. 

2. "Operator" or "owner" means a person who owns or controls or has the 
duty to control the operation of an amusement ride and includes the state 
and every state agency, and each county, city and all private or public 
corporations and political subdivisions.

3. "Certificate of inspection" means a certificate issued by the 
Commissioner of Labor which indicates that an inspection of the ride has 
been performed pursuant to rules and regulations adopted by the Department
of Labor; and

4. "Permanent amusement park ride" means an amusement ride which is 
stationary or cannot be easily moved and which is located on the same 
premises on which it is operated for no less than ninety (90) days.



Title 40 O.S. 1991, 462(A),(B),(D), and (E). "Certificate of inspection"
states, in pertinent part:

D. No person shall operate an amusement ride without a certificate of
inspection.

E. All amusement rides shall be inspected before they are originally put 
into operation for the use of the public, and thereafter, at least once 
each calender year

D. The Commissioner of Labor may cause the inspection herein provided for
to be made by his safety inspectors.

E. If, after inspection, an amusement ride is found to comply with the 
rules and regulations of the Commissioner of Labor, the Commissioner of 
Labor shall issue a certificate of inspection which shall authorize the 
operator or owner to operate the rides. 



Title 40 O.S. 1991, 464. "Notice of erecfion of ride or additions or
alterations" states: 

Before a new amusement ride is erected, or whenever any additions or
alterations are made which change the structure, mechanism, classification
or capacity of any amusement ride, the operator or owner shall file with 
the Commissioner of Labor a notice of his intention and any plans or 
diagrams requested by the Commissioner of Labor.



Title 40 O.S. 1991, 465(A) and (C). "Temporary cessation of ride - Orders 
­ Enforcement" states, in pertinent part: 

A. The Commissioner of Labor may issue a written order for the temporary
cessation of operation of an amusement ride if it has been determined 
after inspection to be hazardous or unsafe.

C. Any order issued by the Commissioner or his authorized representative 
may be enforced in the district court in an action for an injunction or 
writ of mandamus upon the petition of the district attorney or Attorney 
General. Provided further, an injunction, without bond, may be granted by 
the district court to the Commissioner, for the purpose of enforcing this 
act.



Title 40 O.S. 1991, 469 "Violations - Penalties" states:

Any violation of the provisions of this act shall be a misdemeanor. 
Conviction thereof shall be punished by a fine not exceeding One Thousand
Dollars ($1,000.00) or not more than one (1) year in the county jail, or 
both such fine and imprisonment. Each day of violation shall constitute a 
separate offense. 




APPENDIX B
CHAPTER 55. AMUSEMENT RIDE SAFETY RULES

OAC:380:55-1-1. "Purpose" states:

These rules are promulgated as required by Title 40 O S Section 460. 
They are specific as to definitions, adopted national standards, and 
rules for the safe installation, repair, maintenance, use, operation, and
inspection of amusement rides in Oklahoma.



OAC:380:55-1-2. "Definitions" states, in pertinent part:

"Act" means the Amusement Ride Safety Act which was enacted as Title 40
Section 460 of the Oklahoma Statutes 1982.

"Inspection" means the process by which inspectors determine the safety
status of an amusement ride at the scheduled inspection site.

"Inspector" means an individual determined qualified by the Commissioner 
of Labor based upon the inspector's background, training and experience 
who inspects amusement rides covered by the Act.

"Operator" means the person who is physically operating the ride during 
that period of time when it is open to the public.

"Owner" means the actual owner or other person acting for the owner in a
management capacity, a person who owns or controls or has the duty to \
control the operators and operation of an amusement ride.

"Scope of inspection" includes: access and egress ramps, steps, walkways,
the mechanical or physical ride itself to include foundation, supports and
blocking. Also included within the scope are power sources and amusement 
area or midways which may become hazardous to the public.



OAC:380:55-7-1. "Reporting ride related fatalities or injuries" states, 
in pertinent part: 

The following reporting rules pertain to those ride related fatalities or
injuries to the public due to improper operation or mechanical failure of 
the ride, ride parts or missing ride parts occurring within the inspection
scope of the Amusement Ride Safety Act and this chapter.

(1) Fatalities shall be reported by the owner/operator or his designee to
the Commissioner of Labor or his designee immediately after the protection
of life, limb and property.

(2) The owner/operator shall report injuries according to their severity 
as follows: 
     (a) Injuries requiring hospitalization shall be reported to the 
     Commissioner of Labor or his designee immediately after the 
     protection of life, limb and property. 



OAC:380:55-7-2. "Investigation of ride related fatalities, injuries, or 
incidents" states: 

The Commissioner of Labor shall have authority to investigate all ride
related fatalities, injuries, and incidents as defined in 380:55-7-1. No 
ride involved in a fatality or injury as described in 380:55-7-1(2)(a) 
shall be operated, moved, repaired, or tampered with, except to protect 
life, limb and property, until authorized by the Commissioner of Labor or 
his designee. Three (3) work days shall normally be considered sufficient 
to complete the mechanical inspection portion of the investigation.



OAC:380:55-15-4. "Required Department of Labor inspections" states, in 
pertinent part:

The Department of Labor will conduct ride inspections for the following:

(3) After any modifications or alterations to the ride.

(5) Rides may require additional inspections after reportable accidents.