On New Year’s Eve 2015, four-year-old toddler Maurycy Biernacki fell from an inflatable structure during an outing with his after-school care group at an indoor playground in Grootebroek, in the province of North Holland. Maurycy fell almost three metres and landed on his head on a concrete floor covered with a thin layer of artificial grass. He died several days later.
The NVWA and the ministries were deeply affected by the fatal accident and the grief of the victim’s bereaved family, according to the report and the response. The research report and the NVWA’s response were substantively assessed by ABD Topconsult. ABD Topconsult concluded that the measures taken by the government and the NVWA were appropriate and had been given a realistic timetable.
Resources and measures
To strengthen the level of inspection, the government is making additional resources available to appoint eight extra inspectors. Supervision of playground equipment will be improved this year through better handling of reports, recruiting more inspectors with the required technical expertise, and providing better support and management for inspectors. In addition, the NVWA is introducing a new IT system that will provide inspectors with better support for planning, follow-up actions and the complete registration of inspections.
Independent fact-finding investigation
In September 2018, the NVWA acknowledged liability for the consequences of the playground equipment accident. Due to the supervisory authority’s inadequate supervision of this company, the operator of the play centre was not sufficiently made aware of his responsibility to create a safe play environment at the centre. As a result, the fatal accident was able to occur.
Following the admission of liability, the Ministry of Health, Welfare and Sport and the Ministry of Agriculture, Nature and Food Quality (the formal commissioning parties), at the request of the NVWA Inspector General, commissioned a full and independent fact-finding investigation. The investigation examined not only what went wrong in the inspection process, but also which improvement measures the NVWA had previously taken, how they had been safeguarded and whether additional measures were needed. The fact-finding investigation confirmed the NVWA’s conclusion that its supervision had been inadequate. During the period examined, inspections were sometimes not carried out fully and on time, work instructions were inadequate and were not followed up in a timely manner, and the management of inspectors was insufficiently effective.
Improvements
After completing the investigation into the accident, the NVWA implemented a number of improvements, such as taking playground equipment without a valid certificate out of service more quickly (immediately), increasing inspectors’ knowledge and coordination by sharing case studies monthly, and appointing a coordinator who immediately assigns reports concerning (unsafe) playground equipment to inspectors. Additional capacity has also been made available to clear backlogs in processing and handling reports and re-inspections. Inspection capacity for amusement rides and playground equipment will more than double.
Within the NVWA, a temporary project organisation has been established to implement further improvements in supervision of the Commodities Act Decree on Amusement and Playground Equipment as quickly as possible. The NVWA is also consulting representatives of the ‘inflatable playground equipment’ sector to prevent the operation of uncertified playground equipment and to inform operators of the importance of proper supervision of the daily use of amusement rides and playground equipment. Discussions are also being held with the Designated Inspection Bodies (AKIs) on improving coordination between AKIs and reducing the risk of misuse of certificates of approval. The AKIs will present a concrete improvement proposal this month.
Given the growth of this sector and the increasing complexity of the equipment, more supervision is not the only thing needed. The Ministry of Health, Welfare and Sport will therefore also put forward additional proposals to improve safety. This year, it will be examined whether the requirements applicable to the inspection of the equipment are adequate and whether the responsibilities of operators and lessors should be tightened. The Ministry of Health, Welfare and Sport will also consider how parents and people hiring playground equipment can be better informed about the risks.