Kentucky Department of Agriculture

FRANKFORT, Ky. — A train ride at the Louisville Zoo laid over in a curve last year because it was traveling at excessive speed, it was in poor mechanical condition, and the operator was inadequately trained to operate it, the Kentucky Department of Agriculture said in its report on the accident.

The Department fined the Louisville Zoo a total of $37,000 for six violations found in its investigation of the June 1, 2009, accident. The fines were the maximum allowed by state law for each of the violations.

The accident injured most of the 29 passengers on board the ride and the operator.

The Department’s report states that the train ride descended toward the curve at the Gorilla Forest exhibit at a speed significantly greater than the maximum speed of 12 mph stipulated by the ride manufacturer, Chance Rides Manufacturing of Wichita, Kansas. The operator repeatedly pumped the brake lever in an attempt to slow it down, which was not the correct emergency braking procedure for that train. The operator then attempted to pull the parking brake, mistakenly believing it was the emergency brake. The train ride continued to gain speed and laid over in the curve, coming to rest in gravel bordering the track.

The Department’s investigation found that 58 brake shoes on the train – all the shoes that could be safely and accurately measured – were out of tolerance from the standards in the manufacturer’s manual and should have been replaced prior to operation of the train.

The operator stated in a deposition and a written statement that the day of the incident was the first day she operated any of the train rides at the zoo by herself without an instructor or other zoo personnel, and she had never before operated the train that was involved in the accident. She said she did not receive any training on the emergency brake system on the train.

While investigating to determine the cause of the accident, the Department found that the ground wire for a low air pressure warning buzzer on the train’s brake system was disconnected, and a low air pressure warning light was disconnected and missing except for the red lens on the locomotive’s dashboard. The emergency brake knob that was on the train at the time of the incident was not an appropriate replacement part as specified by the manufacturer. The zoo also did not perform the daily pre-opening test run of the train without passengers as required by the manufacturer’s manual, the KDA report states.

The fines assessed to the zoo include:

• $10,000 for failing to maintain the ride in good mechanical condition in connection with the condition of the brake shoes on the train;
• $10,000 for failing to repair the ride according to manufacturer specifications or recommendations, stemming from the disabled low air pressure warning buzzer and warning light;
• $10,000 for failure to use an appropriate replacement part for the emergency brake knob;
• $5,000 for failure to follow safety guidelines and manufacturer specifications in connection with the operator’s failure to follow correct braking and emergency braking procedures, lack of familiarity with the ride manual and the emergency braking system, and lack of training;
• $1,000 for exceeding the manufacturer’s recommended speed; and
• $1,000 for failing to perform the daily pre-opening test run of the train without passengers as required by the manufacturer’s manual.

Amusement ride inspectors with the Kentucky Department of Agriculture investigated the accident. The inspectors examined the train’s components and the accident scene. They took verbal and written statements from witnesses and zoo personnel. The Louisville Zoo cooperated in the Department’s investigation.

State law requires the Kentucky Department of Agriculture to investigate any occurrence involving an amusement ride or attraction that results in death, significant injury or damage affecting the future operation of the ride or attraction.

The full report is available for download at www.kyagr.com/pr/zootrainreport.htm.

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