NC State Fair safety inspectors focused on Vortex mechanics and missed electronic tampering

05/01/2014 7:48 PM

05/01/2014 7:49 PM

The state Labor Department is defending safety inspectors who failed to detect three separate instances of electronic tampering by operators of the Vortex thrill ride at last fall’s N.C. State Fair, where jumper wires were installed to override safety controls several days before five people were hurt when the ride malfunctioned.

“This is an isolated incident,” said Dolores Quesenberry, a department spokeswoman. “The inspectors did what they were supposed to be doing.”

The Labor Department’s report on the accident, released last week, shows that extra inspectors were on hand to scrutinize the Vortex, a ride that was making its first appearance on the State Fair midway. They paid attention to hydraulics, welding and mechanics while operators assembled the ride before the fair opened on Oct. 17.

But the inspectors did not scrutinize the electrical wiring inside control cabinets and a junction box. That’s where the tampering took place, according to the Labor Department report.

Carefully following the manufacturer’s manual, Labor Department inspectors told the Vortex owner, Joshua Macaroni, that he must use his wrench to tighten the nuts – he was, incorrectly, adjusting the bolts – as he assembled the device on Oct. 16 and 17.

Then when the ride stopped spinning during a trial run, inspectors stood back while Macaroni made adjustments in an electrical control cabinet to get the Vortex moving again. Inspectors did not look over Macaroni’s shoulder or check his work to see how he fixed the problem, Quesenberry said.

Later that morning, the inspectors certified that the Vortex was safe for use at the 10-day fair, which drew more than 1 million visitors.

As investigators would discover later, Macaroni had just installed a jumper wire to bypass Vortex safety controls, which prevent the ride from spinning unless riders are secured in their seats with shoulder harnesses and lap bars. According to the Labor Department report, Macaroni and an employee installed two more jumper wires in a junction box, also to override the safety controls, between Oct. 17 and 21.

The accident happened on the evening of Oct. 24.

The Vortex had stopped, with safety restraints released, and riders were climbing out of their seats. Then the ride began spinning again, flinging people into the air. Four members of a Durham family were hurt, two of them seriously, and a ride operator suffered a mild injury.

No changes for 2014 fair

Citing safety law violations, the state Labor Department last week levied $114,200 in fines against Family Attractions Amusement LLC of Valdosta, Ga., the registered operator of the Vortex, and Macaroni and two employees. Macaroni, also of Valdosta, and employee Tim Tutterrow of Quitman, Ga., are awaiting trial in Wake County on charges of felony assault with a deadly weapon.

Labor Department inspectors won’t be doing anything differently when it comes time to check the safety of amusement rides at the 2014 N.C. State Fair.

“There’s not any plan to change the inspection process,” Quesenberry said. She said inspectors focus on making sure the rides and their safety mechanisms perform properly, and not on the underlying electronics.

“They’re basically looking at: Is the light on or off?” Quesenberry said. “They’re not going behind the box to see why it’s off. They’re just going to say to the owner: The light’s not working. Let’s fix the light.”

State Fair officials will trust Labor Department inspectors to make sure the rides are safe.

“In the wake of this senseless tragedy, it’s understandable to ask whether more can be done,” said Brian Long, spokesman for the Department of Agriculture and Consumer Services, which runs the N.C. State Fair. “It appears the Labor Department has already asked these questions and is confident of its existing standards and procedures.”

Ken Martin of Richmond, Va., a safety consultant for fairs and carnivals, said inspectors might find it hard to figure out the electronics of midway rides such as the Vortex.

“You’ve got quite a few things to look at,” Martin said. “These North Carolina inspectors don’t have the electrical background and knowledge. I don’t know if North Carolina could afford to pay somebody with that type of expertise on their staff.”

Quesenberry turned down The News & Observer’s request to interview senior Labor Department officials. She and spokesman Neal O’Briant responded to written questions.

“Ride inspectors inspect for compliance with the manufacturer’s ride manual,” O’Briant said by email. “... The inspectors determine what safety mechanisms are in place and then they test those safety mechanisms to ensure that they are operational. This does not involve examination of the electrical control (junction) box where the jumpers were located at the time of the incident.”

Labor Department inspectors look for loose wires and electrical safety hazards as they check amusement rides at fairs across the state. But they regard the Vortex electronic schematics as separate from the manufacturer’s manual.

“They do not inspect electrical control circuitry,” Quesenberry said by email.

The inspectors did not oversee Macaroni’s electrical repair work on Oct. 17 because their duties do not include “diagnosing operational issues,” the Labor Department report said.

They didn’t think the ride operator would do anything improper.

“When Macaroni went back to the cabinet and fixed the problem with spinning, there was no expectation that he would circumvent safety systems,” O’Briant said by email.

The inspectors were satisfied with the results of Macaroni’s work.

“When he made the repair, the passenger carrier operated correctly,” Quesenberry said by email. “There was no reason for the inspector to question the repair he made.”

Fixed with WD-40

Macaroni has denied that he tampered with the Vortex safety controls, the Labor Department report said. Macaroni’s attorney did not respond to N&O requests for comment.

Inspectors had looked inside the control cabinets on Oct. 17 to check for “anything out of the ordinary,” such as a loose wire. But they did not check the cabinets again – after Macaroni installed the first jumper to override safety controls, and before they certified the Vortex as safe for the public.

Once the ride was certified and fairgoers began lining up to flip and spin in the Vortex, the inspectors were no longer expected to examine the ride, unless something went wrong. Ride operators were supposed to inspect their rides three times each day, comply with the National Electrical Code, and ask permission from inspectors before making any changes that were not consistent with the manufacturer’s manual.

Inspectors returned to the Vortex on Oct. 21 when a problem caused the ride to stop in mid-cycle. Tutterrow told them a button that was supposed to release the safety lap bars had stopped working. The safety sensors relied on a lap bar plunger that was sticking, he said.

Tutterrow appeared to fix the problem with a can of WD-40 lubricant. Inspectors ran a test cycle to make sure the ride and its safety controls were working properly, and the issue appeared to be resolved, the Labor Department report said.

Later, after the Oct. 24 accident, Tutterrow told investigators he had resorted to using an electrical relay to release the lap bars on Oct. 21 – a safety violation, the report said. To fix that problem permanently, he opened the junction box that night and installed a jumper to bypass the safety control for the left half of the ride.

He told investigators that Macaroni had previously installed a jumper in the junction box, some time after the ride was certified on Oct. 17, to bypass safety controls for the right half of the Vortex, according to the report , which said the jumpers also were violations.

Hours after the accident, investigators opened the junction box and discovered the two jumpers, orange and black wire loops. Labor Department inspectors had never looked inside the box because it is not mentioned in the Vortex manufacturer’s manual.

“The NCDOL does not plan to change its inspection procedures,” Quesenberry said by email. “NCDOL inspection policies and procedures would not have prevented an individual from deliberately circumventing critical safety systems after the device was certified by the department.”

That night, as rescue workers took injured riders to the hospital, the inspectors examined the Vortex operator’s booth. They found the control board still illuminated by a bright green safety light, indicating – falsely – that riders were safely secured under their lap bars and shoulder harnesses.

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