Ava-May Littleboy

Head of Standards Governance 

BSI  

389 Chiswick High Road 

London W4 4AL 

Jacqueline Lake   

Senior Coroner for Norfolk  

Norfolk Coroner Service  

Carrow House  

301 King Street 

Norwich NR1 2TN 

By Email 

19 May 2020 

Re: Ava-May Littleboy, deceased 

Coroner’s Report under para 7, Sch 5 to the Coroners and Justice Act 

2009 and regs 28 and 29 of the Coroners (Investigations) Regulations 

2013 

I. 

Introduction  

1.  This  letter  constitutes  the  response  of  The  British  Standards  Institution 

(BSI) to the Coroner’s Report dated 2 April 2020 (“the Report”), wherein 

BSI was requested to take action to prevent future deaths.   

2.  BSI  would  like  to  express  at  the  outset  its  deepest  sympathy  and 

condolences for the family of Ava-May Littleboy, the child killed in the tragic 

accident which is the subject of the Report.  

1 

 
 
 
 
 
 
 II. 

Executive Summary 

3.  BSI’s  role  as  the  National  Standards  Body  (“NSB”)  is  to  facilitate  expert 

committees to achieve consensus on industry standards and best practice 

and to act as the publisher of standards and specifications. Its role is similar 

to that of the private standards company ADIPS, which is mentioned in the 

Report, albeit BSI has a broader remit. 

4.  BSI is not a regulatory body nor an enforcement authority. It is therefore 

unable  to  advise  on  regulatory  matters,  which  are  a  matter  for  HM 

Government.  Nor  is  it  able  to  compel  or  monitor  compliance  with  its 

standards,  which  are  voluntary  documents.  As  such,  BSI  is  unfortunately 

not the right body to take action to prevent a  reoccurrence of this tragic 

event. More detail on the role of BSI can be found below.  

5.  BSI does not consider that it is able to supplant the work of the Amusement 

Device Safety Council (ADSC), which functions in a similar fashion to BSI in 

the area of amusement park machinery. Instead, any question for increased 

control of devices such as that involved in the accident the subject of the 

Report  is  one  for  regulatory  authorities  and  the  Health  and  Safety 

Executive.    

III.  BSI expert committee feedback 

6.  In  order  to  assist  the  Coroner,  BSI  referred  the  Report  to  the  following 

expert  committees,  which  it  considered  might  have  knowledge  and 

expertise relevant to this matter:   

a.  SW/136/22/2 Trampoline parks 

Under  the  direction  of  SW/136/22,  this  committee  is  responsible  for  the 

United Kingdom’s input into the European Committee CEN/TC 136/WG 17 

Trampoline parks and tasked with  establishing technical requirements for 

trampoline parks.  

2 

 
 
 
 
 
 
 
 
 
 b.  CEN/TC 136/WG 17 

The task of the working group is to establish safety requirements for design, 

construction,  inspection  and  maintenance  of  trampoline  parks  and  their 

components.  The  task  also  includes  specifying  minimum  operational 

requirements  to  ensure  an  appropriate  level  of  safety  and  service  when 

used for recreational, training, educational or therapeutic purposes. 

c.  CW/15 Safety of toys – 

Under the direction of the Standards Policy and Strategy Committee, this 

committee is responsible for the development of standards within the field 

of  safety  of  toys  on  activity  toys,  chemical  properties,  flammability, 

interpretations  of  standards,  mechanical  and  physical  properties, 

microbiology, phthalate plasticizers in toys, and the UK input into European 

standards  through  CEN/TC  52  (WG3,  WG5,  WG10,  WG11,  WG12  and 

WG13) and into International standards through ISO/TC 181 (WG1, WG6, 

WG7, WG8, WG9, WG10 and WG11). 

7.  The collective feedback of the above experts was as follows:  

a.  The standard BS EN ISO 25649-3:2017 (Floating leisure articles for 

use on and in the water. Additional specific safety requirements and 

test  methods  for  Class  A  devices)  might  be  extended  to  cover  the 

device which caused the tragic accident the subject of the Coroner’s 

Report.  

b.  Even if it did fall within that standard, however, or if a separate 'air 

trampoline'  BSI  standard  was  developed,  the  concerns  would  still 

arise  unless  there  was  also  a  statutory  requirement  to  report  a 

'breach'. 

c.  The other committees did not consider the equipment to fall within 

their scope.  

d.  Instead,  the  proper  route  to  preventing  future  accidents  is  by 

regulation.  

3 

 
 
 
 
 
 
 
 8.  BSI concurs with the committees that the issue is one for regulation, not 

voluntary standards.  The balance of this reply will expand further on that 

point.  

IV.  The role of BSI  

9.  BSI’s  role  as  the  NSB  is  established  by  Royal  Charter.  BSI  has  several 

governing documents (available online):  

a.  BSI’s Royal Charter and Bye-laws 1981;  

b.  A Memorandum of Understanding (MoU) of 20 June 2002 between 

the United Kingdom government and BSI in respect of BSI’s activities 

as the United Kingdom’s NSB;    

c.  BS 0: 2016 ‘A standard for standards – Principles of standardization’ 

(BS 0) 

10.Article  1.2  of  the  MoU  provides  that  BSI’s  role  as  the  NSB  should  be 

interpreted  to  include  the  management,  co-ordination  and  understanding 

of: 

a)  “British Standards” and “other standardization products”;  

b)  participation by BSI in European and international standards bodies, 

and other international activity undertaken in the interests of BSI as 

the United Kingdom’s NSB;  

c)  promotion,  marketing,  distribution  and 

information  activities 

concerned  with  British  Standards,  BSI’s  other  standardisation 

products, and standardisation generally;  

d)  support any corporate infrastructure activities intended, wholly or in 

part, to enable paragraph 9(a) to (c) above.  

The Director of Standards has the primary responsibility for the activities 

set out in paragraph 9(a) to (d). BSI’s present Director of Standards is Dr 

4 

 
 
 
 
 
 
 
  
 11.BSI  develops  and  distributes  standards  in  response  to  the  needs  of  UK 

stakeholders,  which  include  UK  Government  and  business.  Standards  are 

technical  documents  representing  good  industry  practice.  They  are 

voluntary documents drafted by independent experts.  

V. 

Standards committee structure  

12.Under  Section  V  of  the  Bye-Laws,  BSI  has  established  a  strategic  policy 

committee,  “SPSC”  (Standards  Policy  and  Strategy  Committee)  to  advise 

on the preparation of standards.  

13.The  present  composition  of  SPSC  is  set  out  on  BSI’s  website  at 

https://www.bsigroup.com/en-GB/about-bsi/governance/Learn-more-

about-SPSCs-members/.  

14.Each  individual  standard  is  the  responsibility  of  one  technical  committee, 

under  the  overall  authority  of  SPSC  (cl  28  of  the  Bye-Laws).  A  technical 

committee  may  be  responsible  for  more  than  one  standard,  and  may 

establish subcommittees to deal with individual standards or other discreet 

areas  of  its  work.  The  committees  referred  to  in  section  III  of  this  letter 

above are examples of technical and sub-committees under SPSC.  

VI.  Status of Standards  

15.The defining characteristic of standards is that they are voluntary, agreed 

by industry experts and users, including manufacturers, health and safety 

representatives,  regulators  and  consumer  groups.    They  do  not  have  the 

status of legislation or regulation (unless specifically referred to in a statute 

or  regulatory  instrument,  which  is  extremely  rare  though  not  unknown), 

although they may be used as one means of demonstrating compliance in 

appropriate  circumstances.  They  may  also  become  privately  enforceable 

between individual entities by being incorporated into a contract.   

5 

 
 
 
 
 
 
 
 
 
 
 16.Paragraph 4.14 of BS 0 provides:  

Voluntary status  

British  Standards  are  voluntary  in  that  there  is  no  obligation  to  apply 

them  or  comply  with  them,  except  in  those  few  cases  where  their 

application  is  directly  demanded  by  regulatory  instruments.  They  are 

tools  devised  for  the  convenience  of  those  who  wish  to  use  them. 

In certain circumstances the actions of third parties might have the effect 

of making the application of a standard a commercial necessity, e.g. in 

a contract, but BSI has no control over these actions and is not a party 

to them. 

17.Paragraph 9.2 of BS 0 provides:  

Relationship with the law 

Standards are always subordinate to the law. It is important that they 

are drafted so as to avoid any confusion between the provisions of a 

standard and requirements imposed by law.  

In  general,  it  is  not  acceptable  for  standards  to  contain  provisions 

that  are  already  requirements  imposed  by  law,  nor  to  contain  any 

statement recommending or requiring compliance with the law. It is 

also  not  advisable  to  quote  legislation,  and  no  attempt  should  be 

made to offer any interpretation of the law. Advice should be sought 

from  BSI  staff  if  circumstances  arise  where  this  appears  to  be 

necessary.  

Reference to particular legislation is permissible where it is relevant 

and  potentially  helpful  in  applying  the  standard.  Lengthy  lists  of 

legislation should be avoided as there is a risk that the user might 

believe  any  such  list  to  be  definitive  and  exhaustive.  The  user’s 

attention  should  be  drawn  to  the  possibility  that  any  reference  to 

legislation  might  become  out-of-date  during  the  lifespan  of  the 

6 

 
 
 
 
 
 
 standard, and no reliance should be placed on it as being a definitive 

statement of a user’s legal responsibilities or potential liabilities.  

Particularly for the purpose of preventing anticompetitive effects or 

impeding  innovation [see  9.1f)],  whenever  possible,  provisions  are 

expressed in terms of performance rather than design or descriptive 

characteristics. 

18. All BSI published standards include the following statement:  

This  publication  does  not  purport  to  include  all  the  necessary 

provisions  of  a  contract.  Users  are  responsible  for  its  correct 

application.  Compliance  with  a  British  Standard  cannot  confer 

immunity from legal obligations. 

19.BSI  is  therefore  not  in  a  position  to  draft  standards  which  would  compel 

operators of machinery such as the trampoline in the Report.  

20.Instead, it would effectively be duplicating the existing work of ADIPS. We 

note that ADIPS’ website (https://adips.co.uk/about/) describes its role in 

the following terms:  

The result is the Amusement Device Inspection Procedures Scheme 

(ADIPS)  the  national  scheme  for  inspection  and  certification  of 

fairground rides and amusement devices. 

ADIPS inspection is carried out by registered inspection bodies (IB’s) 

whose capability to perform competent and independent inspection 

is assessed and monitored on an ongoing basis. 

ADIPS  certification  is  known  as  a  Declaration  of  Operational 

Compliance  (DOC).  Look  out  for  this;  it’s  your  guarantee  that  a 

device has been certified as safe to operate by an independent and 

competent IB. 

ADIPS  is  managed  and  administered  by  the  Amusement  Device 

Safety Council (ADSC) which is made up of representatives from all 

7 

 
 
 
 
 major  industry  trade  associations.  It  is  operated  by  ADIPS  Ltd.;  a 

not-for-profit company  

21. The ADSC thus serves a similar role to BSI, in a narrower context.  

22.According to the Report, the trampoline this case was inspected but a DOC 

was not awarded, because the device was considered to have a fundamental 

defect.  

23.The Report then notes that the scheme operated by ADIPS is voluntary and 

not linked to regulatory control, either under HSE or by the Local Authority 

withholding planning consent for the running of the fairground. There was 

accordingly  nothing  stopping  them  claiming  compliance  separately  and 

setting up the trampoline. 

24.BSI reiterates that it would not be able to create a compulsory scheme to 

augment or replace that of ADIPS. On the contrary, any British Standard 

and accompanying certification/assurance scheme, either run by BSI’s own 

testing house (which is an entirely separate business to BSI’s work as the 

National  Standards  Body)  or  a  third  party  testing  house,  would  have  the 

same status as ADIPS, namely it would be a voluntary scheme, and would 

not  constitute  the  only  means  of  compliance  with  H&S  or  local  authority 

consent. 

25.The use of such standards might be made compulsory by means such as 

the  owner  of  the  land  on  which  the  trampoline  was  installed  including  a 

condition requiring certification in a contract for the use of the land, local 

authorities making certification a condition for granting permission for the 

commercial  activity  which  involved  the  trampoline,  or  by  the  Health  and 

Safety Executive. However, BSI would not have any part in implementing 

or enforcing such requirements. This is a matter for HM Government and 

the HSE.  

8 

 
 
 
 
 
 
 
 26.BSI believes that this letter and attachments constitutes a full reply to the 

Coroner’s Request. If, however, the Coroner has any further questions or 

requires clarification, BSI would be pleased to assist.  

Yours sincerely  

 BA/LLB (Hons) 

Head of Standards Governance 

BSI, 389 Chiswick High Road, London, W4 4AL, UK 

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9

Health and Safety 

   Executive 

Foundry House 
3 Millsands 
Riverside Exchange 
Sheffield S3 8HN 

Tel: 0203 028 5056 

http://www.hse.gov.uk/ 

Head of Unit 
Dr 

Coroner’s Officer 
Norfolk Coroner’s Service 
Carrow House 
301 King Street 
NORWICH 
NR1 2TN 

Via email 

4 September 2020 

Dear Jes 

                                                Re: Ava-May Littleboy  

1.  This letter constitutes the response of the Health and Safety Executive (HSE) to the 

Coroner’s Report dated 2 April 2020, sent to HSE on 15th July 2020. The Coroner has 
asked whether there is any action that HSE is able to take that may assist in the 
prevention of future deaths. 

2.  HSE would like to express at the outset its deepest sympathy and condolences for the 

family of Ava-May Littleboy, the child killed in the tragic accident which is the subject of the 
Report. 

Background 

3.  HSE holds the national policy lead for health and safety law which applies to the 

fairground industry including the supply, hire and use of inflatable play equipment for 
commercial purposes, although it does not apply to private, domestic buyers and users.  

4.  Enforcement allocation is split between the Health and Safety Executive (HSE) and Local 

Authorities and is dependent upon the type of amusement equipment in use. HSE is the 
regulator for fairground rides and associated equipment used on fairgrounds and theme 
parks whilst Local Authorities enforce sites with equipment such as coin-operated 
children’s rides outside shops, bouncy castles at pubs, hotels and other LA-enforced 
premises. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  HSE has a dedicated team (the National Fairground Inspection Team – NFIT) whose 

responsibilities include proactive inspection of fairgrounds as well as reactive investigation 
e.g. of concerns and serious accidents.  In common with HSE’s overall strategic approach 
to regulation, proactive inspection of the fairground industry is based on targeting areas of 
highest risk.  

Legal Framework 

6.  Sections 2 and 3 of the Health and Safety at Work etc. Act 1974 respectively place duties 
on (i) those operating fairground equipment (including inflatable devices) to ensure, so far 
as is reasonably practicable, the health, safety and welfare of their employees and (ii) that 
members of the public are not, so far as is reasonably practicable, exposed to risks to their 
health and safety.   

7.  Section 6 of the 1974 Act places a duty on designers, manufacturers, importers and 
suppliers of fairground amusement equipment to ensure that, so far as is reasonably 
practicable, it is safe and without risk to health, when used in connection with entertaining 
the public. 

8.  The Provision and Use of Work Equipment Regulations 1998 require that fairground 

equipment is maintained in an efficient state, in efficient working order and in good repair, 
and subject to inspection at suitable intervals to ensure its continued safe operation. 

HS(G) 175 - Fairgrounds and amusement parks: Guidance on safe practice 

9.  The operation of fairground amusement devices is generally considered to be a high 
hazard activity.  That is to say that an untoward event arising from operation of 
amusement devices, including inflatables, could have serious consequences, involving 
serious multiple injuries or fatalities.   

10. In such situations, it is important that the risk, or likelihood, of such an event occurring is 

reduced to the lowest degree reasonably practicable, with a higher level of precautions 
taken than would generally be expected in situations of low hazard, i.e. where any harm 
which materialised would be minor.  

11. In recognition of this, HSE has worked with the industry to produce detailed guidance on 
the precautions to be taken. HSE publication HS(G)175, ‘Fairgrounds and Amusement 
Parks: Guidance on safe practice’ focuses on the safety of employers, employees and the 
general public using fairgrounds and amusement parks and gives advice on measures to 
control risk. It provides advice on issues relating to attractions, including design, 
manufacture, inspection, operation, maintenance, repair, and modification and is free to 
download from the HSE website.  

12. Although the Coroner’s report dated 2 April 2020, records that the Inquest heard evidence 
in relation to the content of HS(G) 175 ‘Fairgrounds and Amusement Parks: Guidance on 
safe practice’, it may be of assistance to set out the specific requirements applicable to the 
matters set out in the Coroner’s report.  

2  

 
 
 
 
 
 
 
 
 
 
 
 
 
 13. Specifically, HS(G)175 sets out the roles of the designer, manufacturer, importers and 
suppliers who have a duty to ensure that the attractions are safe for use when first 
supplied and to provide their customers with appropriate information to allow safe use. It 
also details how people undertaking each of these roles can discharge their duties under 
Section 6 of the Health and Safety at Work etc Act 1974. 

14. HS(G)175 also sets out the ‘System for safety of attractions’, which consist of a series of 
‘steps’ and ‘checks’ intended to ensure safety of an amusement device from design, 
through to operation and maintenance of the ride.   

15. This can be found in tabular form (table 1) on page 8 of HS(G)175.  The requirement for 

‘checks’ is intended to avoid a situation where defects, faults and errors could go 
undetected and is consistent with the usual goal of a Safety Engineer, which is the 
avoidance of conditions where a single failure (whether a ‘hardware’ failure or a human 
behavioural failure) could lead directly to a high hazard situation without opportunity for 
corrective action.  

16. The approach by HS(G)175 of requiring steps and checks can be illustrated with the 

example of ride design.  The requirement (or ‘step’) in table 1 is for design “by competent 
designers with knowledge of the relevant standards”.  The additional requirement is for an 
independent check on the soundness of the overall design concept, by the process known 
as ‘Design Review’, which forms part of the pre-use inspection process. 

17. The other aspects of the pre-use inspection process relate to the manufacture of the 

device and include the requirement to complete an assessment of conformity to design 
(ACD) which confirms that the device is manufactured and constructed to the reviewed 
design specification.  

18. The process is then concluded by the completion of the “initial test”, which is a series of 
tests to check that the device operates safely in accordance with the reviewed design 
specification and the instructions in the operations manual.  

19. The first step when considering HS(G) 175 is to identify in Table 2, the type of device that 
is under consideration. The table sets out the recommended action for various types of 
attraction, confirming the need for a design review, assessment to conformity to design, 
initial test and in-service inspection or an alternative.  

20. HSE have considered the devices listed in table 2 of HS(G) 175 and can confirm that the 

device involved in the incident under investigation is not specifically listed.  

21. Although there is reference to “inflatable (bouncy)” the recommendations stipulated in 
table 2 would not be applicable, as the device did not fall within the scope of BS EN 
14960: 2019 or its predecessor BS EN 14960: 2013.   

22. The scope of BS EN 14960 is limited to inflatable play equipment defined as “a structure 
relying on a continuous supply of air to maintain its shape, on or in which users may play, 
bounce”, and as the incident device was a “sealed air unit” the standard would not have 
been applicable.  

23. Therefore, the incident device could not have been inspected under the Pertexa Inflatable 

Play Accreditation (PIPA) scheme, which specifically limits the devices that can be 
inspected under its scheme to those that fall within the scope of BS EN 14960.  

3  

 
 
 
 
 
 
 
 
 
 
 24. Furthermore, HSE do not consider that the device should be categorised as “other 

inflatable (not used for bouncing or sliding)”.  as the incident device was being used 
primarily for bouncing.  

25. There is a further reference to a “pneumatic or air supported structure” in table 2, but HSE 
do not consider the incident device to be a pneumatic or air supported structure HSE 
understand  that this reference applies to inflatable structures such as “inflatable 
start/finish race arches” and other similar structures.  

26. Although the incident device is not specifically listed within table 2 of HS(G) 175, this is an 

indicative list of amusement devices which are used within the UK, rather than an 
exhaustive list. HSE would expect that the principles set out in HS(G) 175 would be 
applied to all types of amusement device imported and used in the UK, including the 
incident device.  

27. Section C of HS(G) 175 details how a designer, manufacturer, importer and supplier of an 
attraction can discharge their duties under Section 6 of the Health and Safety at Work etc 
Act 1974.  

28. In relation to fairground amusement devices, section 6 of the HSW Act states that “it shall 
be the duty of any person who designs, manufactures, imports or supplies any article of 
fairground equipment:  

o 

o 

o 

o 

to ensure, so far as is reasonably practicable, that the article is so designed 
and constructed that it will be safe and without risks to health at all times when 
it is being used for or in connection with the entertainment of members of the 
public; 

to carry out or arrange for the carrying out of such testing and examination as 
may be necessary for the performance of the duty imposed on him by the 
preceding paragraph; 

to take such steps as are necessary to secure that persons supplied by that 
person with the article are provided with adequate information about the use for 
which the article is designed or has been tested and about any conditions 
necessary to ensure that it will be safe and without risks to health at all times 
when it is being used for or in connection with the entertainment of members of 
the public; and 

to take such steps as are necessary to secure, so far as is reasonably 
practicable, that persons so supplied are provided with all such revisions of 
information provided to them by virtue of the preceding paragraph as are 
necessary by reason of its becoming known that anything gives rise to a 
serious risk to health or safety”. 

29. Section C defines the roles of an importer and supplier and sets out what actions they 
need to complete in order to discharge their relevant legal duties under Section 6 as 
follows:  

30. “Importers…You are an importer if you bring a device into the country either temporarily 
or permanently. If you buy a foreign device through an agent who is permanently resident 

4  

 
 
 
 
 
 
 
 
 
 
 
 
 in Great Britain, the agent is normally the importer are responsible for ensuring that the 
pre-use inspections (design review, ACD and initial test) are carried out and that the 
designer and manufacturer have followed the information in this guidance. You can do this 
by checking that the operations manual contains the necessary reports on the pre-use 
inspections. 

31. The device should not be used unless these pre-use inspections have been carried out 

and a suitable documentation and certification has been issued.  

32. It is recommended that in purchase contracts for new devices you should request that 

designers, manufacturers and importers follow the appropriate guidance in this book and 
in Safety of amusement devices: Design. 

33. You should take care to check that the documentation you receive follows the 

requirements of the pre-use inspections in this guidance. Differences in methodology, 
practice, procedures and certification requirements between countries can lead to different 
interpretations of what is required, for example: 

o  use of design criteria inappropriate for Great Britain, e.g. wind loading; 

o 

o 

incomplete review, e.g. with no, or inadequate, attention to control systems or 
passenger-containment systems; 

false assumptions, e.g. that a component or a safety-control system will never 
fail or that it will fail safe. 

34. Suppliers…You become a supplier if you sell (or hire out) any device, new or second-

hand. Make sure you do everything possible to check that the designer, manufacturer and 
importer, as appropriate, have complied with their legal requirements and have followed 
the advice in this guidance. 

35. You should do this by checking that the operations manual contains the necessary reports 
on the pre-use inspections: design review, ACD and initial test. If these have not been 
done, you should take steps to have these completed before the device is first used. 

36. You must provide the controller with all the information and instruction necessary for safe 
use before the device is first used. You should include the reports of pre-use inspections 
and any modifications stemming from them. Written information provided should be in 
English (and in the language of the controller if different). 

37. If you hire out a device, you should confirm that there are documents demonstrating that 
the device has been subjected to pre-use and in-service annual inspection by competent 
persons”. 

38. The guidance set out in HS(G) 175 is well established guidance and is well known and 
understood within the UK fairground industry. Furthermore, HSE would suggest that if a 
person was unable to discharge any of the requirements set out for either the importer or 
supplier, that there would be adequate provision of competent organisations and 
individuals that could provide the necessary assistance on their behalf.  

39. Primarily, in such circumstances HSE would expect any importer or supplier unable to 

meet the requirements set out in paragraphs 72-80 of HS(G) 175 on their own, to engage 

5  

 
 
 
 
 
 
 
 
 
 
 
 
 the services of an Inspection Body (IB) registered with the Amusement Device Inspection 
Procedures Scheme (ADIPS).  

40. The scheme is currently administered by ADIPS Ltd on behalf of the Amusement Device 

Safety Council and is based on the system for the safety of attractions set out in HS(G) 
175.  

41. ADIPS Ltd acts as registration body for the competence assessment, registration and 

administrative control of IBs.  

42. Furthermore, the ADIPs scheme is currently supported by HSE, and by all the major ride-
owning trade associations who recommend it to their members for the pre-use inspection, 
in-service annual inspection and certification of all amusement devices. 

43. HSE would consider that ADIPs have registered within their scheme suitably qualified and 
experienced IBs who could have completed the necessary pre-use inspection work in 
relation to the incident device.  

Pre use inspection process 

44. In addition, to the guidance in Section C of HS(G) 175 which addresses the roles and 

responsibilities of the designer, manufacturer, importer and supplier, the guidance clearly 
defines the various stages of the pre-use inspection process in Section D.  

45. At paragraph 100 of Section D it states that “The controller of an amusement device is 
responsible for ensuring that the three pre-use inspections are satisfactorily carried out 
before it is put into operation with the public, either for the first time following its 
manufacture or import, or after any safety-critical modification”. 

46. In circumstances where the “controller” does not have the necessary knowledge or 

understanding to ensure that the necessary pre-use inspection has been completed, then 
it would be reasonably practicable to engage the services of an Inspection Body (IB) 
registered with the Amusement Device Inspection Procedures Scheme (ADIPS). 

47. In addition, the guidance states that “The controller may appoint an IB to take overall 

responsibility for arranging the work, confirming the completion of the pre-use process and 
issuing the DOC, although the final responsibility for the adequate completion of the pre-
use inspection process rests with the controller”. 

48. The requirements set out in HS(G) 175 in relation to the “controller” are very well defined 
and HSE would suggest that it is reasonably practicable for the person fulfilling this role to 
discharge their duty by confirming that the necessary pre-use inspection work has been 
completed and that the device is in fact safe for use.  

49. HSE consider that the pre-use inspection process set out in HS(G) 175 provides a suitably 
robust framework for ensuring that fairground amusement devices are in fact safe before 
they it is brought into use for the first time. 

50. The individual aspects of the pre-use inspection process are detailed in Section D of 

HS(G) 175 which can be found in Appendix 1 to this letter.  

6  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Legal Duties 

51. As detailed HSE have published guidance in HS(G)175, which sets out how the  

owner/operator of an amusement device can discharge their legal duties. 

52. Within the guidance HSE recognise and support three industry schemes for the Inspection 

and testing of amusement devices, including the Amusement Device Inspection 
Procedures Scheme (ADIPS), which HSE consider would have been an appropriate body 
to engage to complete the necessary inspection of the device to ensure that it was in fact 
safe. 

53. However, it should be noted that HS(G)175 is guidance and there is no legal requirement 
for the owner/operator to use the ADIPS scheme and they are free to engage the services 
of any competent body to carry out the necessary work to discharge their legal duties. 

54. Additionally, it should be noted that there is no legal requirement imposed on an inspection 
body including ADIPS registered bodies, to report to the relevant Enforcing Authority (HSE 
or Local Authority) the details of any amusement device that has either not been subject to 
a suitable inspection or has in fact failed an inspection.   

55. The duty remains with the owner/operator to ensure that the amusement device is in fact 
safe as required under sections 2 and 3 of Health and Safety at Work etc. Act 1974. 

56. Finally, HS(G)175 states that “any person to whom this guidance is directed who finds a 

generic or serious fault on a device, which could have wider safety implications for that or 
other similar devices, should inform their trade association and the National Association 
for Leisure Industry Certification (NAFLIC). Trade associations may decide to distribute the 
relevant information to their members or others in the interests of safety on fairgrounds”. 

57. HSE can confirm that ADIPS inspection bodies routinely provide safety critical information 
to NAFLIC Technical Committee, who use this information to produce regular technical 
bulletins for their membership, which details the safety critical defects with amusement 
devices along with the remedial action required to address these issues. 

58. It is also worth noting that NAFLIC maintain a digital library of these technical bulletins on 

their website, which can be freely accessed by their members and other parties. 

Future work 

59. HSE continue to work with industry stakeholders in the entertainment and leisure sector 
through the Amusement Safety Device Council, to improve the safety of amusement 
devices and following the incident at Gorleston has written to them to remind them of their 
obligations and signposted them to the relevant information. 

7  

 
 
 
 
 
 
 
 
 
 
 
 
 60. Additionally, HSE has reviewed the scope of its existing guidance and intends to publish 
additional guidance on the design, operation and inspection of sealed inflatable devices, 
which is currently being drafted in consultation with representatives of the amusement 
industry. 

61. Finally, the safe operation of amusement devices remains a priority for HSE and Local 

Authorities and forms an integral part of the annual inspection programme delivered by the 
designated team of inspectors who make up the HSE’s National Fairground Inspection 
Team and the Local Authorities Health and Safety Officers.  

62. I hope this reply is helpful in addressing the issues raised in your Coroner’s report dated 2 
April 2020. If, however, the Coroner has any further questions or requires clarification, 
HSE would be pleased to assist. 

Yours sincerely 

Head of Entertainment, Leisure, Consumer and Commercial Services Sector 

8

JOHN  H. RUNDLE  LTD. 

GENERAL ENGINEERS AND SPECIALIST ENGINEERS TO THE LEISURE INDUSTRY 
DEALERS IN ALL KINDS OF MACHINE TOOLS AND ELECTRIC MOTORS 

Director 

Tel: 01205 480431 

Web: www.rundles.co.uk 

New Bolingbroke, BOSTON, Lines. PE22 7LN 
Established 1913 

Fax: 01205 480132 

V.A.T.  Reg. No. 128 8013 75 

E-mail: enquiries@rundles.co.uk 

Company Reg. No. 841783 (England) 

~--4JUN 2020 

Jacqueline Lake 

Senior Coroner for Norfolk 

Norfolk Coroner Service 

Carrow House 

30 King Street 

Norwich 

NR1  2TN 

1 June 2020 

Madam, 

Response to Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

This letter is sent in response to your report received  on 6th  May and  I am attaching 
for the record a copy of our solicitors letter to you on 23rd April as it seems to me that 
all matters you have raised have already been entirely and candidly addressed. 

Please ensure that both that letter and this response is sent to the Chief Coroner 
and to the Interested Persons as they need to be read in conjunction with  each 
other. 

There are facts omitted from  your summary which I feel are relevant to your concern. 
Most notably, the visit by Rundles to Great Yarmouth and Gorleston was not typical. 
99 times out of 100, when we visit a park or fairground to inspect equipment, the 
owner of the equipment or his engineer would be with us throughout.  It was very 
unusual to arrive and be told  simply to get on with things by ourselves.  Because we 
would normally be accompanied, we would talk as we went round and we would 
discuss our observations, so if a tie down was not attached it is likely that would be 
mentioned at the time though we have no power to do anything about it. 

In this instance, Mr.  Johnson had requested an inspection of his equipment.  -

-
had previously inspected an inflatable slide and swings for 

met Mr Johnson at Great Yarmouth but was told to just go ahead.  Rundles 

and had 

Page 1 of7 

All dealings are subject to our standard "terms & conditions" and no variation thereof shall be valid unless otherwise confirmed in writing, Condrtions of sa le available on request 

 information about but them but had no information about any other equipment which, 
on arrival, -
inspected the swings 
necessary for that other equipment to  inspect it.  -
and had a look at a Minions inflatable ride at Great Yarmouth and did mention to. 
before leaving for Gorleston that some tie downs were missing. 
-

was also asked to  inspect. A return visit was therefore 

All  communication about the inspection had been with 
was not known to Rundles, not introduced to 
Yarmouth or Gorleston she did not introduce herself as the owner operator of any of 
when he looked at the equipment 
the equipment.  No one accompanied -
at Gorleston. 

and if she was at Great 

Matters of Concern: 

1.  Evidence was heard on  behalf of Rundles that inspection of inflatables 

involves a site visit and a visual inspection of the piece of equipment looking 
for tears and rips,  no entrapment issues and checking the tie downs are all 
properly used.  For new pieces of equipment sight of relevant documentation 
is also required. 

There are factual inaccuracies with  this summary. 

It is not the case that as an inspection body ("/8 ")  Rund/es would be checking 
that all tie downs are properly used on an inflatable. That is not their role. Nor 
is it part of any inspection to check the adequacy of what a tie down is fixed 
to,  be it a  peg or a post,  or whether the ground is suitable which is just as 
important for the securing of an inflatable.  This is all for the controller and 
operator to determine. 

It is the operator who has the manufacturer instructions on set up and 
operation and the obligation with  the operator to check,  that it is set up and 
operated correctly.  An inspection of an inflatable requires a deflation test. 
That can have an adverse impact on tie downs which is why they must be 
inspected by the controller before they are reused.  The  trampoline was not 
deflated on the visit. ~ 
inflatables were deflated for his visit  - they may have been,  but a return  visit 
was necessary to inspect them because of the absence of documentation. 

annot now recall whether the other 

If an inflatable is in use then I would expect tie downs to be used,  but that is 
entirely a matter for the controller and operator of the inflatable who I would 
expect to follow manufacturer instruction on this point. 

Our solicitor has already referred you to HSE Guidance 175 which,  to avoid 
confusion about roles, clearly sets out who has responsibility for what.  See 
also Bouncy Castles and Other Play Inflatables: Safety Advice published by 
the HSE. 

Page 2 of7 

 Part of the reason why use of the tie downs is not something an 18 checks is 
because their use is not static.  Something set up correctly one day may not 
be the next.  If the inflatable is deflated and reflated, (as it is for an inspection) 
then that can impact tie downs,  and controllers and operators have a clear 
duty to check this before the ride is reopened,  and recheck it on set up each 
day. The  /8 has no enforcement role and no authority to tell a controller and 
operator how to run his equipment.  It would be particularly dangerous for an 
18 to interfere without the benefit of manufacturer instructions.  Operation and 
use are not the purpose of an AD/PS inspection. 

The purpose of an inspection is to ensure that if set up and operated in 
accordance with manufacturer recommendations, the inflatable would 
be safe to use.  Accordingly,  the condition of the tie downs is checked on 
an inspected device (for example for evidence of tears or loose stitching that 
might impact their integrity) but no check is required or made of what the 
tie downs are attached to,  whether the fixing is secure, or whether they 
are or need to be in use. 

Documentation is needed for all equipment inspected, notjust for new 
equipment.  Because Rund/es had previous inspected the swings and the 
inflatable slide, they had what was needed, but Mr Johnson never provided 
any documentation for any of the  other equipment which is why they could not 
be inspected 

2.  Rundles were requested to carry out an inspection of inflatable equipment 
The inspection took place on 26 June 

belonging to Mr and  Mrs -
2018.  A typed Report of findings dated 2nd July 2018 was sent to 
by email on the 3 July 2018, in which it refers to the site visits carried out "with 
the following  issued noted ... " The report goes on to list findings in  respect of 
the Minion  inflatable (Great Yarmouth) and the Large Slide,  Minion inflatable 
and Trampoline at the Gorleston site and contains photographs  of all the 
respective pieces of inflated equipment. 

This has already been explained to you by our Solicitor. 

to  attend on 26th  June 2018. Having 

Rund/es was asked by 
previously inspected a swing boats ride and an inflatable slide for him 
Rund/es understood that those items were to be inspected again and had 
information in relation to them. 
asked for his other equipment to 
be inspected on the day of the  visit but could not be carried out because no 
information about them was made available. 

The  "Report" you reference has also already been explained to you. See from 
page 8 of our solicitor's letter to you on  23rd April. 

Page 3 of7 

 The  "Report" was created post accident, in response to a request from -

who was looking into the accident and was based on notes and 

photos taken on the day.  It is not and was never intended as an "inspection 
report" and it was not requested or provided in that context.  Since the use or 
non use of tie downs can change with every deflation and reinflation of 
equipment, how it was when seen by -
following 1-einflation,  or on reinflation the next day. 

is no indication of how it was 

The inspecUon (of the slide and swings) would ordinarily have led to the issue 
of an Inspection Certificate, or list of matters to be put right before a certificate 
could be issued  That would include any issues with the  condition of tie downs 
but not their use.  ~ 
out so neither wa~ 
were completed. 

ecided not to pay for the inspections carried 
ither of the two devices on which inspections 

3.  Having inspected the Minion inflatable at the Great Yarmouth site, the Report 
lists the issues found, including that "not all the available tie downs were  in 
use". 

The Minion inflatable has never been inspected by Rundles.  Simply repeating 
your misunderstanding that it was, does not make it so.  This  was explained to 
you fully in our solicitor's letter to you,  attached. 

was asked on his visit on 26th  June to inspect the Minion 

inflatable.  As this was only raised by ~ 
no documentation or manuals in relation to it was available he was going to 
need to return to do that. 
equipment, but these devices were not inspected, nor represented as being 
inspected.  It is clear from the photographs that not all available tie downs 
were in us at that point. 

did have a look at the additional 

n the day of the visit, and 

Our Solicitor deals with this at page 10 of her letter to you.  It would be 
potentially dangerous for us to give you an assurance that we will advise 
controllers and operators beyond what is clearly understood by everyone in 
the industry to  be our role because it is down to the  controller/operator to 
ensure safe operation. Normally though, we  would be accompanied on an 
inspection and we would,  naturally, though there  is no legal duty to do so, 
mention anything which  we felt was untoward at the time. 

I would add again, Rund/es did not inspect the equipment to which you 
refer.  There  was no contract for us to do so and we could not do so as we 
did not have and have never had the information needed to enable us to 
proceed. 

Page 4of7 

 4.  Having inspected three pieces of inflatable equipment at Gorleston, the 

Report of findings lists the issues found in respect of the inflatable large slide, 
including that "Not all the available tie downs were being used correctly." 

Again,  Rund/es did not inspect three pieces of inflatable equipment at 
Gorleston.  The  only inflatable inspected by Rund/es at Gorleston was the 
inflatable slide and 
wife was at the site she did not make herself known to~ 
controller of the equipment on his visit.  The  slide was deflated for inspection 
and tie downs are always rechecked by a controller when they reinflate the 
device as deflation and reinflation can impact the tie downs. 

was not present to discuss that device.  If his 

s 

The context of the "Report" has already been explained. Rund/es has never 
had access to the operating materials for the devices other than the swing 
boats and the inflatable slide. 

5.  In  respect of the Minion inflatable, it is stated that, "Not all the available tie 

downs were in  use." 

Correct. 

6.  In  respect of the inflatable trampoline, evidence was heard on behalf of 

Rundles that the trampoline appeared in good condition.  It was noted this 
was a sealed unit with no pressure relieve valve rather than the usual air flow 
inflatable which Rundles was not familiar with so required as much evidence 
as possible relating to pressure as well as the usual pre-inspection documents 
and the instruction/User manual.  Also noted was that "Not all available tie 
downs were in use." 

saw it on site and his 

The trampoline was not inspected but 
impression as you say, was that it was in good condition. 
Information about it 
was not available which might have allowed an inspection to proceed.  He did 
look at it and take photographs and these did show not all tie downs were in 
use.  As already explained, how it was operated and secured is a matter for 
the  controller and operator. -
manufacturer's information which 
order to  inspect.  Information about previous inspections can be accessed by 
Rund/es on the AD/PS site but there was no evidence of a previous inspection 
on the site. 

was told would be needed in 

was not given access to 

7.  Evidence was heard from  Rundles that not using all the tie downs on an 

inflatable device is considered as being of imminent danger to persons, that 
the device should not be used without the tie downs all being used and the 
advice should be to stop using the device until those defects have been 
rectified.  Evidence was heard that this issue was of even more concern 
following  the "Harlow" incident in March 2016. 

Page 5 of7 

 Failing to use all tie downs required by the manufacturer (which would 
normally be all of them) is dangerous if the inflatable is in use outside,  where 
there would be a risk of its security being compromised by wind.  This is 
something very well known to controllers and operators. 

At no point has Rund/es had access to manufacturer information regarding 
use of the trampoline  We have never inspected the trampoline.  Rund/es does 
not profess to  be an expert in  the set up and operation of the equipment it 
inspects.  Inspections are to establish that equipment is safe IF PROPERLY 
USED per manufacturer instruction. 

Although not part of the /B 's role, if 
his visit as is the usual practice, anything untoward would have been 
communicated at the time.  That  was not an option on the day as he  was not 
accompanied. 

had been accompanied on 

In relation  to the Harlow matter it was re-emphasised by the HSE that 
securing and checking tie downs are the responsibility of the controller and 
operator,  not of the /8. 

8.  Of concern is that this information, regarded by Rundles as an "issue" and 

causing such concern as would require the device not to be used had it been 
able to be registered , was not conveyed to Mr or Mrs Johnson at the time of 
the inspection of the equipment at Gorleston nor in the subsequent Report 
dated 2 July 2018.  Evidence was heard on behalf of Rundles that the reason 
why this information was not imparted was "not known". 

It is not the role of the /8  to advise on operation and use of equipment which 
they inspect.  The role of the /Bis clearly defined in  the HSE's guidance 

It is even less the role of the IB to advise on the operation and use of 
equipment they are not inspecting which seems to be your suggestion. 

Normally /B 's are accompanied on inspections by the controller or their 
engineer.  Though there ;s no duty to do so, naturally, anything untoward 
noticed would be discussed with them but this is not possible if they are not 
there. 

was not introduced to 

and was unaware if in fact 
she was at Gorleston on the day of his visit.  He did see 
at Great 
Yarmouth prior to his visit to Gorleston and he did inform him on the day that 
not all tie downs were in use on the inflatable at Great Yarmouth which he 
saw while there. 

Page 6 of7 

 If you have a concern that /Bs should have a duty to raise concerns about 
equipment that they don't inspect,  for which they have no information and 
which relates to its use and operation rather than its condition, and even when 
the controller is not on site,  then this should be taken up by you,  as our 
Solicitor suggested,  with the HSE and The Amusement Devices Safety 
Council.  It is not something on which I think I can usefully assist further 

9.  Further evidence was heard that the iPad used to record such inspections 

was not in  use at the time of these inspections as the battery was "flat".  Since 
Ava-May's death, evidence was heard that some steps have been taken  to 
ensure iPad are fully charged before inspections take place. 

I remain utterly bemused by this  Are you suggesting that there is some risk 
of death because an iPad which was a method on trial of recording 
inspections,  Jacked charge?  Inspections were then and remain recorded on 
paper.  This matter is dealt with in full by our solicitor in  her previous Jetter to 
you at page 9 and I have nothing further that I can usefully add. 

I have tried to deal with your questions though  I feel that they were answered in full 
by our Solicitor's previous letter to you.  Kindly direct any further correspondence to 
her. 

Managing Director 

Page 7 of7 

 0  Finch 

Consulting 

Ivanhoe Business Park 
Ashby de la Zouch 
Leicestershire LE65 2AB 
United Kingdom 

enquiries@finch-consulting.com 
+44 (0) 1530 412 777 

Our ref:2206757 

23 April 2020 

Dear Ms Lake 

Inquest concerning the death of Ava-May Littleboy 

1represent John H Rundle Limited ("Rundles") and this letter is sent in response to your communication 

dated 26 March 2020 addressed to the company's MD who is 

Preamble 

The reason Finch Consulting has been asked to respond  on  behalf of Rundles is not just because I am 

a  solicitor  experienced  in  Health  &  Safety  Law,  but  also  because  one  of  my  colleagues  at  Finch 

Consulting, 

was formerly one of HM's Inspectors for the HSE.  Between 2009 and 2017 

-

was  HSE's  operational  policy  lead  for  fairgrounds  and  theme  park  safety,  where  he 

specialised in fairground accidents, led the HSE's investigation into the death of Summer Grant in 2016 

on  an  inflatable which  blew away at a  fair in  Harlow,  and was  largely  responsible  for writing  the  third 

edition  of the  HSE's  Guidance  on  Safe  Practice  in  Fairgrounds  and  Amusement  Parks  (HSG  175). 

Rundles' Managing Directorllllllllllllltvas also on the committee fonnulating that Guidance (and its 

previous versions). 

is in a unique position to help explain the HSE's approach to the Guidance and explain the 

roles  of and  expectations from  those involved in  fairground  equipment from  supply to  operation and to 

maintenance. 

-

has had some input to this letter, to help in explaining why the concern raised  by your letter 

is, with respect, both misdirected and misconceived. 

Your letter 

First of all, I would like to understand please, the proper status of your letter. 

The letter reads in some respects as  a PFD Report.  Like a PFD report your letter has been copied to a 

number of others (presumably the  Interested  Persons).  It does not however follow the Chief Coroner's 

recommended  template for a  PFD report and towards the end of the  letter you suggest that it  does not 

Finch Legal Services is a trading name of Finch Consulting Ltd and is authorised and regulated by the Solicitors Regulation Authority. 
A  list of legal staff names and their professional qualification can be found on our website www.finch-consulting.com. 
Finch Consulting Limited is a company registered in England and Wales under No: 02774164.  The registered office is at Ivanhoe 
Business Park Ashby de la Zouch, Leicestershire, LE65 2AB 

 have  PFD  status  because  you  reserve  the  right  to  make  a  report  under  Regulation  28 of the  2013 

0  Finch 

Consulting 

Regulations if you are not satisfied that your concerns have been addressed. 

The consequence of your letter appears to be that you seek to carry out your regulation 28 duty through 

it by raising a concern that you seek to have addressed,  but because the letter is not a  PFD  report you 

deny our client their right to fuller information 1 about why you have a concern based on evidence to which 

they are not privy and which they have been given no opportunity to consider or challenge. 

As I have no idea what information and evidence led to the concern raised, and you assert that Rundles 

should  address  it through  action  on  their part  (or  else ... ) ,  the  company  has  been  put  by  you  in  the 

invidious position of needing to respond to a concern based on evidence it has been unable to consider 

or challenge. 

Notwithstanding  my ambivalence regarding  the nature of your letter, Rundles is, and  has always been, 

happy to assist in any way that it can  with the investigation into the circumstances of Ava-May's tragic 

accident. This  letter therefore explains  in  some detail why the concern you  have  raised  appears to  be 

misconceived and inappropriately directed. Should there be any queries remaining at the end of this letter, 

please do come back to me and we will endeavour to assist. 

My apologies if any of the following  detail has already been presented to you. The fact you suggest you 

have an ongoing concern which you feel Rundles may be able to address however, suggests to me that 

it may not have been made available to you previously. 

HSG 175 

The HSE Guidance (HSG 175) entitled "Fairgrounds and Amusement Parks: Guidance on safe Practice" 

applies to  inflatable devices and other fairground equipment and devices. The guidance is available on 

line at no cost, at: hse.gov.uk/pubns/priced/hsg175.pdf. 

Whilst HSE Guidance is not mandated (meaning that safe practice can be demonstrated by other means), 

the foreword to the Guidance makes clear that in the fairground and leisure park industry it sets out: 

"appropriate measures for those in the industry to reduce risks, work safely and comply with 

the law" 

1  You have  not set  out the full  factual  basis  for  your concerns  (as required  for a  PFD report per  R  -v- Shrewsbury 
Coroner's Court exp British Parachute Association (1988) 152 JP 123.)  You have also chosen not to fully set out the 
evidence or information on which your concern is based. 

2 

 As it comes from the principal specialist H&S regulator for enforcement of the law, it carries considerable 

0  Finch 

Consulting 

weight. 

On page 5/6 of the Guidance the roles of the various duty holders are described: 

Controllers ...own or otherwise  have control of an attraction and have  a duty to operate and 

maintain it in a safe condition ( emphasis added). 

Operators  are  in  immediate  charge  of an  attraction  and  have  a  dutv  to  operate  it  safely 

(emphasis added) 

Inspection Bodies ... provide inspection and testing services. 

Rundles' role in relation to the fairs  at Great Yarmouth and Gorleston was as an Inspection Body ("18") 

for a  large  inflatable  slide  at Gorleston  CUthe  slide"),  and  swing  boats  at  Great  Yarmouth  ("the  swing 

boats"). 

In  Section  A  of the  HSE's Guidance  (entitled "The System  for Safety of Attractions") a  table  identifies 

what checks are recommended for amusement devices and fairground equipment and by whom those 

checks are to be carried out.  This is  important because if you  interfere with that Guidance by requiring 

one 18 (Rundles) to take on duties beyond what is suggested by the HSE's Guidance,  this actually has 

the  serious potential of creating  additional  health  and safety  risks  by suggesting  that duty holders can 

depend on others to perform roles reserved to them. That I am sure, would not be your intention. 

The Guidance makes clear that attractions require that among other things: 

Operation is carried out "by competent persons, suitably trained ... " (This is not the  IBs). 

Ongoing device integrity is maintained by a series of checks, maintenance, and inspection. These 

include  daily  checks  before  the  device  is  opened  for  use,  and  periodic  checks,  both  by 

competent persons (normally the operator), and in service annual Inspections by competent 

and independent IBs. 

To comply with the Guidance, inspections for Inflatable devices must include2: 

Initial  test (to  check  the  device  conforms  to  the  standards  in  BS  EN  14960  "Inflatable  Play 

Equipment.  Safety Requirements and Test Methods") - this is to check that the  device can  be 

operated  safely  in  accordance with  the  design  specification  and  instructions  in  the  operations 

manual  and  should  be  carried  out  by or on  behalf of the  manufacturer,  supplier  importer and 

2 See pages 8-9 of HSG  175 

3 

 witnessed by an inspection body. The test is only carried out when the device is used for the first 

0  Finch 

Consulting 

time or after safety critical modifications. 

In service Annual inspection (carried out by an 18 to decide whether an amusement device may 

continue to be operated for a specified period of time). 

These requirements cross refer to Section D of the Guidance which is entitled "Inspecting an Am usement 

Device".  In relation to in service annual inspections (with emphasis added}: 

"1 44 In-service annual inspection .. .is for independent and competent IBs to check on the fitness 

of an  amusement device for further use during its operational life.  It is also a check on the 

safety-critical  components  of  an  amusement  device  to  make  sure  that  they  have  not 

deteriorated to an extent liable to cause danger. 

145  In-service  annual  inspection  will  verify whether a  device  is  fit to  be used  for a  specified 

period. ft does not remove the duty on the controller of a device to ensure that the device 

is adequately maintained, nor does it duplicate the pre-use inspection procedure." 

The  HSE makes clear that anchorage  is a  controller/operator (and  not an  IB)  duty at para 227 of the 

Guidance  within  Section  F  which  provides  "Guidance  for  Controllers"  says,  "Take  account  of  any 

manufacturers'  instructions  relating  to  operating  conditions  such  as wind  speed  and  make  sure that 

adequate anchoring points have been used." 

Further advice from the HSE specifically on inflatables3 adds, under the heading "Before anyone Uses it" 

at bullet point two, "Have a good look at the inflatable when it is blown up and  before  use.  You should 

check ... if the  anchor  points  have  been  pulled  out  during  inflation."  The  advice  also  confirms  the 

obligation on owners of the equipment to have an initial test on new equipment and annual inspections 

(as are set out in more detail in the ADIP scheme to which it cross refers). 

The reason Rundles visited Great Yarmouth and Gorleston on 26th  June 2018 was because 

had asked them as an ADIPS4 approved inspection body to carry out the in-service annual inspection of 

the  swing  boats  and  slide.  They  had  inspected  those  devices  previously  and  had  been  given  the 

information necessary to complete those inspections. 

When Rundles  arrived  at Great Yarmouth, 

sked that Rundles also inspect a  number of 

other devices, specifically other inflatable rides that he was operating. This was not possible as Rundles 

3 Bouncy Castles and Other Play Inflatables: Safety Advice hse.gov.uk/eotertainrnent/fairgrounds/inflatables.htm 
4  Amusement Device  Inspection Procedures Scheme 

4 

 
 had  not been given  the  information  they  needed  to  do this  including  previous  inspection  information, 

0  Finch 

Consulting 

manufacturer instructions,  operations  manual  and  maintenance  information. As  a  result, in  relation  to 

those rides, they were able to have a look to see what would be involved in an inspection and took some 

photographs,  but they did not  inspect them  and  it would  have been  necessary to  return to  do this  on 

another day. 

For completeness I should perhaps draw attention to the fact that HSG 175 does say: 

"any person to whom this guidance is directed who finds a generic or serious fault on a device, 

which could  have wider safety implications for that or other similar devices" should "inform their 

trade association and the National Association for Leisure Industry Certification ... ". 

This obligation applies (among  others) to Rundles when carrying out an ADIPS  inspection . Faults and 

defects,  however,  do  not  include  failures  in  set  up  and  operating  procedures  and  although  the 

Guidance could have required any noted issues in those areas to be drawn to the attention of the operator, 

it does not. 

This  was  a  point examined  very closely  following  both  the Summer Grant accident  in  Harlow on 26th 

March 2016 and an earlier accident on ?1h  May 2013 involving a zipline in North Wales which led to the 

death  of Bailey  Sumner.  In  both  cases  the  HSE  made  clear  that  the  inspection  bodies  are  there  to 

comment on the safety of the equipment if used correctly and not to comment on how it has been and 

may be used going forwards. 

ADIP scheme Inspections 

I  am  unsure  what  familiarity  you  have  with  the  Amusement  Device  Inspection  Procedures  Scheme 

("ADIPS"). 

ADIPS Limited administers the ADIPS and is owned by The Amusement Devices Safety Council which 

consists of all the major trade organisations involved in the UK  fairground industry and the HSE which 

attends and advises. The HSE publicly supports the ADIP scheme. 

The purpose of the ADIP scheme is: 

"to ensure that each and every fairground and amusement park ride or device is certified as safe 

for use". 

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 The certification  provided by the ADIPS  is  not and cannot  be for the purpose of ensuring each  ride is 
set up or used correctly. ADIPS  certification,  like an  MOT for a  motor vehicle,  will only confirm  that !f 
equipment  is  set  up  and  operated  in  accordance  with  manufacturer  instructions  and  operating 

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procedures, then the ride will be safe for use for a specified period. 

Under  the  ADIP  scheme,  annual  inspections  (suggested  by  HSG  175)  should  be  carried  out  by 

Independent registered 18s whose ability to perform competent and independent inspection is assessed 

and monitored by ADIPS Ltd on an ongoing basis. Rundles is an established, reputable, registered ADIPS 

approved IB. 

Once an  ADIP scheme  1B  has completed  inspection of any amusement device and  been  paid for their 

services,  the  1B  is  required  to  record  inspection details  on  the central ADIPS database of amusement 

devices  and  ADIPS  Limited  then  will  provide  the  owner/operator  of  the  device  a  Declaration  of 

Compliance  ("DOC")  which  confirms  the  device  has  been  registered  on  the  ADIPS  database  and  is 

certified safe to operate for the time specified in the period covered by the DOC. 

The owner/operators of fairground/amusement park rides or devices  have the obligation to ensure that 

annual inspections on their equipment are arranged, and that at all times they hold a current DOC issued 

by an approved 1B  for each ride/device that they operate. 

There are a  number of IBs,  and it  is not unusual for different IBs to carry out inspections on  the same 

device over the years. Which  1B  is used will often turn  on availability and location as many of the rides 

will move around  the  country.  There  is no obligation on  an  1B  to accept an  instruction, to provide their 

services ex gratis, or to remind operators that a DOC they have previously  issued needs  renewal.  The 

owner/operators need to provide the inspecting  1B  with information about each ride before its inspection, 

particularly: 

manufacturer's information (for any equipment with which the 1B was unfamiliar) to ensure testing 

can  be carried out within the parameters  in which the ride or device is to operate and it is clear 

what safety features exist which must be checked as part of an inspection. 

operating and maintenance information 

the last DOC (for devices which are not new). If Rundles had carried out the previous inspection 

they would have this information already. That applied to the swing boats and the slide. 

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 Insurers of the equipment will normally require proof of current DOCs as a  condition of policy coverage 

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and  renewal.  Those  who  make  pitches  available  for  the  rides  (I  presume  Great  Yarmouth  Borough 

Council in this case) will also typically check that all equipment to be used holds a current DOC and, for 

new equipment  like  the  inflatable  trampoline,  had  had  its  initial  test  as  recommended  by  HSG  175, 

overseen by an 18. 

Visit on 26th  June 2018 

When  Rundles visited the  sites at Great Yarmouth and Gorleston on 26th June it was at the  request of 

for and with the intention of carrying out annual inspections required by HSG 175, under the 

ADIP scheme, on the swing boats and the slide both of which were owned by 

On  arrival at Great Yarmouth, 

asked that other equipment he owned was also  inspected . 

explained that was not possible because he did not have the necessary information about 

that other equipment. -

did have a look at the other equipment while there, to assess what the 

equipment was, and to take  photos, so that  he could  return  to  perform the  inspections on a  later date 

when the necessary information had been sent through. 

The need for information pre inspection would have come as no surprise to 

He had provided 

it for the two inspections previously arranged ( on the swing boats and slide) and in fact a similar absence 

of infomiation had previously led to our clients refusing to inspect one of 

roundabouts and 

a rodeo ride. 

When  the  slide was inspected it was not in  use.  It was deflated and re-inflated as part of its testing.  In 

those  circumstances,  before  reuse  (after  the  inspection)  an  operator  should  check  (as  they  are 

responsible for its safety) that nothing has become loose in the inspection process o has been  moved or 

placed during the inspection such that the unit would not be safe for use. This is the same as their daily 

inspection before the ride is opened. On re-inflation a tie can come undone or get caught. It was not part 

of Rundles' role post-inspection to oversee the setting up of the ride and to check that it was subsequently 

operating  safely  - only  to  check  that  if  set  up  and  operated  in  accordance  with  manufacturer 

recommendations, that it would be safe to use. 

Although  inspected,  no DOC  was ever issued  in  relation  to the  slide, or the  swing  boats. 

failed to  pay for the inspections and in accordance with Rundles' terms of business (and in  line with the 

industry norm), the DOC or report of issues preventing a  DOC, was therefore never issued. 

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 It may be helpful to  add that  is not possible to inspect when  a ride is  in  use as inspection includes,  for 

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example,  examination  of the  condition  of the  tie  downs  which  usually  cannot  be  properly  completed 

without releasing  them.  With  inflatables,  part of the inspection would  involve a test on  the functioning  of 

the air blowers which involves deflation and reinflation. 

When  Rundles  arrived  on  site 

hoped  that  inspections  and  testing  would  proceed  on all 

equipment.  Since  inspections cannot be done when the equipment is in  use,  none of the equipment 
was in use by the public when Rundles was having a look at it on 26th  June. 

Rundles is not in a position and does not seek to suggest that tie downs had been undone in preparation 

for their visit, but many inspections take place when no ties are in use at all because the equipment is 

not in  use at the time and indeed may even be indoors for inspection. My point is that whether or not tie 

downs are in use  is  simply not part of what is  inspected by an  IB. They check the number of tie downs 

and their physical integrity only. 

To suggest that the IB should have an obligation to comment on operational use would be like taking your 

car for an MOT and expecting the mechanics to include a critique of your driving in their observations. It 

simply is not the purpose of an ADIPS inspection. And in this case, as explained, such an inspection did 

not in any event proceed on the inflatables ( other than the slide) because of the lack of documentation. 

The check of whether equipment has been safely installed and is being safely operated is part of set up 

and daily checks required by HSG  175 to be made by the operator as referenced above. 

Rundles "Report•• dated 2nd  July 

What seems to have been relied upon by you as some sort of inspection report from Rundles is not and 

was never intended to be such . Although it is titled "Report of Findings for 

to elevate it 

to the status of a formal report perversely misinterprets the facts. 

The purpose of Rundles' visit as I have explained , was to inspect, test and if appropriate to issue a DOC 

on the swing boats and slide in accordance with the HSG 175 and ADIPS requirements. If testing revealed 

defects  such  that the  unit was not safe  for use,  then  Rundles would  have  identified  those  issues  and 

required a further inspection to verify they had been dealt with before issuing a DOC. Rundles was asked 

on the day to inspect other equipment but refused as necessary information to complete those inspections 

had  not been made available.  They did however have a look at the  other equipment so that they knew 

what to expect on return. 

8 

 Following Ava-May's tragic accident a few days later, -

contacted Rundles and asked for any 

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information that they had about their visit on 26th  June which might help.  The information sent to assist 

in  response to that  request  is the  report.  This  is no more  than  an  informal  summary of notes  made 

regarding  the  swing  boats  and  slide  inspected,  and  observations  about  the  rides  that  could  not  be 

inspected on the day. It summarised the issues in relation  to the inspected slide and swing boats which 

needed rectification , and it provided a copy of photographs taken on the day. 

Although there was no duty or obligation to mention that not all tie downs were seen as being in use, this 

was  included  to  assist  in  giving  a  picture  of what was  observed  as it may  have  been  relevant to  an 

accident investigation. 

The observatior:i  in his notes to 

about some tie downs not apparently being used at Great 

Yarmouth was imparted to -

on the day of his visit by 

This was before his visit 

to  Gorleston.  I  understand  that  this  was 

evidence  to  the  Inquest.  It  would  not  be  an 

observation  included in a DOC. 

The use of the word "Report" in Rundles' summary of its visit might be regarded  as unfortunate with the 

benefit of hindsight, but no one has been  misled  by it.  It is clearly not a formal  report or intended to be 

relied on as an 1B  inspection report. It was as I have said, a summary of notes in response  to a request 

for any information they had, following a fatal accident. 

iPad 

You suggest that the fact that an  iPad  brought by Rundles to the sites was not charged is a  matter for 

concern and that if the situation were to arise again future deaths may occur. 

The use of tablets on  inspections was at the time and remains under trial by ADIPS . Rundles has been 

appointed  as one  of the  registered  IBs  to  trial  their  use.  The  reason  for the  trial  arises  from  an  HSE 

concern that some  IBs might be tempted  in  some circumstances  to sign  off certificates for equipment 

which they had  not gone out to  see and test or that IBs might come  under pressure to backdate DOCs. 

The iPads have tracking devices  in  them  which  enable checks to be  made  (should questions arise) to 

confirm  whether the  iPad was in the area of the  inspected  device on  the date shown on the  certificate 

and can confirm how long that inspection took. They also facilitate immediate online registration DOC's 

that are issued. 

The iPad undoubtedly did lose its charge on the day, after the visit to Great Yarmouth. However, that was 

not the reason that the inspections (other than for the slide and swing boats) did not proceed. That was 

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 due to the fact Rundles had not been asked to do other inspections before they arrived on  site , and the 

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relevant documentation needed to proceed was not made available on the day. 

The lack of the iPad did not compromise the planned inspections on the swing boats or slide which were 

completed in paper format which was and still is the principal way in which the 18 ADIPS inspections are 

recorded. The iPad does not have the functionality to carry out any tests or determine pass/fail criteria. 

The  use  of tablets  for ADIPS  inspections  is still  under trial.  Pen  and  paper alternatives for  recording 

results of inspections remain a commonly used alternative under the ADIP scheme and were used on the 

day. 

Your suggestion that lack of an iPad might lead to further deaths seems to misunderstand the position to 

a degree that I do not feel I can usefully comment further. 

Additional Points 

HSG  175  is  clear about who  has  responsibility  for what in  relation  to inflatables and  other fairground 

equipment  for  good  reason.  Clarity  of  role  is  a  very  important  aspect  of  health  and  safety 

management and avoids reliance by operators on  others to ensure that they set up and operate their 

own equipment safely. 

It is  not  reasonable  and  is  potentially  dangerous,  to  ask  that  Rundles  commit  to  meeting  additional 

obligations that are not required of all the other IBs in the UK, by HSE and industry guidance. 

with  any  operators  he  appointed,  had  responsibility  for  ensuring  that the  tie  downs  on  his  inflatable 

devices were used. If you seek to divert that responsibility to IBs by seeking from  Rundles an assurance 

that they will draw attention to operator issues, you may actually increase the risk of injury and death by 

inherently encouraging an owner or operator to rely on someone visiting or inspecting to pick up on their 

incompetence in operating their equipment. That cannot optimise safety. 

Our client,  and  any IB  in their position, has no  legal obligation,  nor it is suggested  by HSG  175 or the 

ADIP  scheme,  that  they  should  draw  attention  to  any  issues  they  may  observe  regarding  use  of 

equipment on  an  inspection,  never mind  on  a  pre  inspection  visit.  This  is  NOT within  their area  of 

responsibility and goes beyond their remit. 

-

agrees with this and has advised he would expect an IB to note the number of and condition 

of tie  downs on an inspection but due to  varying circumstances,  not necessarily to  see them staked 

down as that is entirely an operational issue and failures in operation are not defects. 

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If you have an issue with the law and guidance then it would be more appropriate to take that up with the 

HSE and with The Amusement Devices Safety Council. 

Please let me know if you have any further questions or need clarification on any of the points covered. 

Please also confirm that this letter deals to your satisfaction with the concern you have raised as far as 

Rundles is concerned. 

Yours sincerely 

Head of Legal 
Finch Consulting Limited 

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