Camden Parks and Recreation · Snow Bowl
P.O. Box 1207 · 20 Barnestown Rd · Camden, ME 04843
Conditions: 207 236-4418 Office 207 236-3438 · Fax 207 230-0490
Email: info@CamdenSnowBowl.com · www.Camden SnowBowl.com
Toboggan Chute Incident Report
Prepared by Jeff Kuller, Camden Parks and Recreation Director
At approximately 2:30 p.m., Feb. 9, 2008 during the US Toboggan National Championships team 268 (Haraka Haraka!) with four individuals, was released down the Jack Williams Toboggan Chute at the Ragged Mountain Recreation Area (also known as the Camden Snow Bowl during winter operations). Witnesses did not notice anything unusual about this team's initial launch down the chute. The team used a new Camden Snow Bowl toboggan, one of eight toboggans recently acquired by the Snow Bowl. These new toboggans meet the standards for use in this chute. They were used by many teams throughout the weekend prior to, and subsequent to this incident.
Shortly after launching down the chute the toboggan began to swerve in an unusual and unprecedented fashion. The launching team noticed this strange run and continued to watch the toboggan until it came to a stop, leaning on its side near the bottom of the chute, but not yet across the finish line.
Within less than 20 seconds of the release of the first toboggan, a second toboggan was released down the chute. This toboggan was owned by Unity College and carried four women of team 321 (WE LEAD'S). This toboggan impacted the first toboggan as the first team was in the process of getting off their stalled toboggan. The fourth person on the first toboggan had already stood up and stepped out of the chute when the second team struck.
Within seconds, two members of the Camden Ski patrol responded to the scene. The patrol had a station on Hosmer Pond near the bottom of the chute, less than 50 yards away. After an initial assessment of the accident scene, a series of radio calls were made to request the assistance of additional ski patrollers who were located at the ski area and around the toboggan area, as well as additional equipment including several backboards, cervical collars and oxygen tanks. Several bystanders with medical training also joined in the effort to stabilize, assess and treat the accident victims. During the entire weekend event, the Camden First Aid Association had an ambulance stationed at the boat launch area of the pond, about 150 yards away. The CFAA personnel were contacted by radio immediately and prepared to receive the injured people. CFAA also called in additional ambulances. In all, four ambulances were used to transport six people. The injured were loaded onto ski patrol toboggans (one of which was stationed on the ice for the event, and another brought by snowmobile immediately) and transported by ATV's and snowmobiles to waiting ambulances at the boat ramp. Within a few moments of the initial crash the Camden Fire Chief, who was also stationed at the event and had been pre-designated Incident Co-Commander along with the Director of Parks and Recreation, took over to coordinate traffic control and ambulance staging. When the first of the injured people was assessed at the ambulance, a decision was made to call for a Life Flight helicopter transport. The Fire Chief radioed Knox County Emergency Dispatch and provided the coordinates for the helicopter landing site, which had been pre-determined and plowed two miles away at the Oak Hill Cemetery Annex. That helicopter was flown to Eastern Maine Medical Center. The other five injured people were transported by ambulance to Penobscot Bay Medical Center. It is believed that emergency management after the accident was well-planned and timely.
By Saturday evening, four of the individuals were released from the hospital with minor injuries. One remained in each of the hospitals in Rockport and Bangor. Both of these individuals were released by Monday.
Later Saturday afternoon 14 witness statements were obtained from individuals at both the top of the chute and the bottom of the chute. After reviewing the information and concurring with the Event Committee and the Town Manager, the Parks and Recreation Director made the decision to resume the event the next day. Initial analysis indicated that the accident was not caused by any mechanical malfunction of launching or safety mechanisms at the top of the chute. Rather, it appears that the second toboggan was prematurely loaded onto the launch platform. By focusing carefully on the standard launching procedures and clarifying communications among the crew at the top of the chute, everyone agreed that this kind of incident would be avoided in the future. The racing event was continued the next day and was completed safely without further incident.
The top of the chute and the launching sequence.
The standard sequence of operations and communications of toboggan launchings during the National Championships is as follows: A toboggan is set on the rear loading platform. A team of three or four volunteers helps the contestants load onto their toboggan, intertwining arms and legs. Some teams prefer to sit upright, while others lie back upon one another. Contestants are also briefed about the need to remain in that position for the entire ride, to keep arms and legs on the toboggan or wrapped around the person in front of them, or to hold the rope on the sides of the toboggan with knuckles facing inward.
When the toboggan is loaded it is slid forward onto the launch platform by the loading crew. The launch platform has a tilting mechanism (like a teeter-totter) which has a latch underneath to prevent it from tilting until the appropriate time. The latch is controlled by a three foot metal lever standing upright next to the fulcrum of the launching platform. In addition to the lever there is a wooden wedge which is placed next to the lever to keep it from being accidentally moved. This lever and wedge is controlled by the Chute Master. There is also a safety gate across the front end of the launching platform. This gate keeps the loaded toboggan from going off the end of the launch platform and onto the chute when the platform is in the horizontal, ready position. The safety gate is controlled by a second person. There is also a third person wearing a headset which is wired to communicate with the Timing Van. The Communicator gives the team numbers to the race timers and also receives a verbal signal from the timers that the course is clear and the timing system is ready. The timing and communication system are of a type which is used throughout North America for ski race timing, and is also used for ski races at the Snow Bowl. The Chute Master, Communicator and Safety Gate Controller all have a good view of the entire chute and run-out area.
At the bottom of the chute past the finish line is a Flagger. His job is to indicate when the chute is clear. He stands next to the run-out. When a toboggan passes him he steps into the run-out and raises his flag across the chute as a stop signal. Once he has determined that the toboggan is at the end of the run-out and the competitors are standing and walking clear of the run-out area he then steps off the run-out and lowers his flag. This "all clear" signal is seen by the timers in the van, who relay the all clear signal to the top of the chute through the telephone communication system. The Timing Crew consists of three people: a timing mechanism operator, a recorder, and an announcer.
This system was developed over the previous 17 years of
running the National Championships. The system has been effective in
maintaining the quick pace of launches required to send hundreds of toboggans
down the chute each day during the event. The crew estimates that a toboggan is
launched about every 40 seconds. At the time of the accident all of the chute
crew at the top, except for one or two new volunteers not known to the regular
crew, had worked in their positions in previous years.
What went wrong at the top of the chute that resulted in the collision:
When the first toboggan went down the chute it immediately began to swerve erratically. This slowed its speed considerably with the end result being that it stopped even before reaching the finish line. When that happened the Flag Man began to run up to the team to offer assistance to get them out of the chute. No "all clear" flag signal was given and no verbal launch signal was sent to the top by the timing team.
At the top of the chute the Chute Master, Communicator and Safety Gate Controller glanced down the chute as they always do to be sure the toboggan was well on its way. As they saw the erratic behavior of the toboggan they continued to watch for several additional seconds. The Chute Master hollered down the chute to tell them to lay back, hoping that the toboggan might settle down into a regular run. Once a toboggan is launched, the platform passively returns to the horizontal position due to the design of the fulcrum. However it does not re-latch by itself, it must be manually reset. The resetting of the launch control lever and replacement of the safety wedge did not occur before the second toboggan was loaded onto the launch platform. The Safety Gate Controller did lower the safety gate back down after the launch.
In the mean time the second team finished loading. What
happened next is still not entirely clear. During the few seconds while the
launch team was still looking down the chute, the second toboggan was moved
forward onto the horizontal, but unlatched, launching platform. The platform
immediately tipped down and sent the toboggan onto the chute. The safety gate
did not stop this launch because it is only effective when the platform is in
the horizontal position. As soon as the platform tilts down to connect with the
chute the safety gate, even when closed, is a couple of feet above the end of
the launch platform. It does not prevent a launch from the tipped platform.
On the loading platform with the weight of four adults and an unwaxed bottom it takes a significant effort for the crew to slide the toboggan forward onto the launching platform. However, in this instance the second toboggan had a highly waxed bottom and four relatively light young adults on it. The loading crew commented that the toboggan slid forward with ease, and they watched horrified as it immediately tipped the launch platform and continued down the chute.
Crew members indicated that there was an unknown volunteer stationed at the back end of the loading platform who had helped with a few previous loads. The identity of this person remains unknown. Apparently a member of the chute crew had asked the announcer to call for volunteers to help at the top of the chute. This announcement was made not long before the accident happened.
In the regular flow of the launchings there was a steady rhythm to the sequence of activities in the loading and launching area. An okay signal from the launching crew back to the loading crew was not routinely used and was not deemed necessary because the launch platform had always been re-set within a couple seconds of a launch.
After the accident, a communication system was put in place to indicate when it was safe to move a toboggan from the loading platform to the launch platform.
Several factors appear to have contributed to this accident:
The unusual run of the first toboggan distracted the launch crew, which interrupted the standard rhythm of loading, launching and resetting the launch mechanism. There was no formal communication system between the launching and loading crews. The launch platform does not automatically reset to a safe position when it comes back to horizontal. When the launch platform is horizontal the only way to know if it is latched and secure is to observe the angle of the control lever. There is no safety gate between the loading and launching platform. An inexperienced volunteer may have contributed to moving the second toboggan onto the launch platform with unusual haste.
Recommendations for Next Year's Event
1) Develop a set of written procedures and a communications protocol between the four stations which control the operation of the chute: the timers, the flagger, the launch crew and the loading crew.
2) Train all staff on these procedures and communications prior to the event.
3) Install a latching system that will secure the launch platform when it returns to the horizontal position automatically, without the intervention of a person.
4) Add a safety gate between the loading and launching platform.
5) Have enough extra trained chute crew available to provide breaks during the day so untrained volunteers are not needed.