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December 2017 Conveyor (LV-025) Incident

Report of Investigation

This report complies with sections 25-5-704(b) and 25-5-715(4) of the Colorado Revised Statutes
(“C.R.S.”) and the Colorado Passenger Tramway Safety Board Rule 23.3, which require a “report of
investigation” following an incident “when a death or injury results from a possible malfunction of a
passenger tramway.”1 This report provides an overview of the Colorado Passenger Tramway Safety Board
and details the incident, the investigation, and the findings of the Board.

Overview of the Colorado Passenger Tramway Safety Board


Colorado law established the Colorado Passenger Tramway Safety Board (“Board”) to assist in
safeguarding the life, health, property, and welfare of this state through its licensure, inspection and
regulation of passenger tramways. Since the establishment of the Board in 1965, there have been seven
lift related fatalities as a result of three incidents in Colorado. 2

To meet its objective of safeguarding the public, the legislature placed the primary responsibility for
design, construction, maintenance, operation, and inspection for passenger tramways with area
operators, while empowering the Board to prevent unnecessary mechanical hazards in the operation of
passenger tramways, and to assure reasonable design and construction, accepted safety devices and
sufficient personnel, and that periodic inspections and adjustments are made which are deemed essential
to the safe operation of passenger tramways. See §§ 25-5-701 and 705, C.R.S. Toward this end, the
Board is authorized to issue licenses, collect fees, receive complaints, conduct investigations, prosecute
or enjoin persons violating the Passenger Tramway Safety Act, hold hearings, impose discipline on area
operators for such violations, establish technical and safety committees, and promulgate such rules as
may be necessary and proper to carry out the provisions of the Passenger Tramway Safety Act, including
the use of the standards found in the American National Standard for Passenger Ropeways-Aerial
Tramways and Aerial Lifts, Surface Lifts, Tows, and Conveyors-Safety Requirements, as promulgated by
the American National Standards Institute (“ANSI standards”). See § 25-5-704 (a), C.R.S.

A public passenger tramway shall not be operated in the state of Colorado unless licensed by the Board.
§ 25-5-709(2), C.R.S. All lifts in Colorado must be licensed annually prior to the operating season. See
§§ 25-5-711, 712, and 713, C.R.S. Prior to annual licensure, each Colorado lift must be inspected by
Board inspection engineers3 to confirm no unreasonable safety hazard exists, and to confirm that the lift
is in reasonable compliance with the current ANSI B77.1 Standard, the Passenger Tramway Safety Act
and Board Rules. See, § 25-5-712, C.R.S. The Board inspector conducts a visual and audible inspection
of: all safety systems and functions of the lift; functionality of all drive systems; brake systems; speed
controls; stops and tower safety systems, and any other lift specific systems, including records and other
documents. Once the inspection is complete, the Board inspector provides a list of the deficiencies

1
This report was prepared in furtherance of the Board’s duty to investigate and report as set forth in §§25-5-704(b) and 25-5-
715(4), C.R.S. and Board Rule 23.3, and does not, in and of itself, resolve any pending disciplinary complaints before the Board.
2
Colorado Tramway related fatalities occurred in 1976-four fatalities as a result of a cable incident; in 1985- two fatalities as a
result of a bullwheel failure; and, a 2016 fatality as a result of a rare dynamic event.
3
Board Inspection Engineers are required to be licensed as professional engineers in the state of Colorado pursuant to §25-5-
702(5), C.R.S., and Board Rule 22.5.

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observed during the inspection that must be addressed prior to licensure of the lift. See, Board Rule
22.4.4. The area operator must certify that these deficiencies have been addressed before the lift is
licensed for public operation. See, Board Rule 20.2. When the inspector finds deficiencies that may be
a risk to public safety, “the inspector shall issue an immediate report to the Board for appropriate
investigation and order” pursuant to section § 25-5-715(5), C.R.S., and Board Rule 22.4.5.

In addition to the annual pre-licensure inspection, the Board inspectors conduct unannounced operational
inspections during each operating season of the year. See, § 25-5-715, C.R.S., and Board Rule 22.3.2.
These inspections focus on operational issues and confirm that deficiencies noted in the annual inspection
have been corrected and that the lift is being maintained and operated in a safe manner. See, Board
Rule 1.1.

Further, the Board must approve and inspect any major modification to a lift pursuant to § 25-5-710,
C.R.S. Prior to major modifications4 of any lift, licensees are required to submit documentation that
includes a verification statement that the design is in compliance with the applicable rules. The
submission must also include a proposed acceptance test procedure to demonstrate the modification
meets applicable rules and standards. See, Board Rule 21.3.7. A Board Inspector must be present during
the acceptance test. See, Board Rule 21.3.11. Upon successful completion of the test, the area must
submit additional documents confirming that the modification was installed according to the original
proposal. After all documentation has been reviewed, the Board may issue a license to allow public
operation of the lift.

The Incident- Magic Carpet Conveyor (LV-025) at Loveland Ski Area


Description of the Incident

On the morning of December 28, 2017, lift maintenance worker, Adam Lee, became entangled in a
return deflection roller of the return terminal of the LV-025 conveyor at the Loveland Ski Area
(“Area”). Mr. Lee was in the tunnel beneath the conveyor at the time of the incident. Mr. Lee became
entangled with the return deflection roller and did not survive the entanglement. The official cause of
death has not been released by the Clear County Medical Examiner.

Description of the Lift

This “lift” is a 2013 Magic Carpet conveyor. The conveyor belt has a 30-inch wide rubber belt with a
slope length of 70 feet and is driven by a 5 HP (horsepower) electric motor. The belt runs on a steel
framework that supports the belt for skiers traveling from the bottom terminal to the top terminal and
returns, beneath the upper belt, via support rollers spaced at five-foot intervals. The maximum
licensed speed of the conveyor belt is 115 fpm (feet per minute); however, the conveyor normally
operates at a speed of 80 fpm for skiers.

The tension system is a passive system utilizing two all-thread bolts on each side of a sliding frame that
holds the return tension roller. Access to the tension roller and tension adjustments can only be made

4
A major tramway modification is defined as: an alteration of the current design of the tramway which results in:
a change in the design speed of the system; a change in the rated capacity by changing the number of carriers, spacing of
carriers, or load capacity of carriers; a change in the path of the rope; any change in the type of brakes and/or backstop devices
or components thereof; a change in the structural arrangements; a change in power or type of prime mover or auxiliary engine;
or, a change to control system logic. Board Rule 1.2.4.3.

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from the lower terminal hatch. The tension roller and tension adjustments can not be accessed from
the tunnel beneath the conveyor.

This conveyor is an unusual design5 in that it is elevated two feet on a frame that has guardrail
material on the bottom of the frame to act as skids. The conveyor is stored in a nearby parking lot
during the summer. Annual inspection of the lift is conducted in the parking lot, allowing inspectors to
visualize all components of the lift, including the tension system and support rollers. When sufficient
snowfall occurs, the conveyor is slid into position on the slope for the ski season.

The framework underneath the conveyor has a 26 inch high x 48 inch wide crawl space from the top
access hatch to the bottom terminal. When boards are placed vertically along the outside of the
conveyor this creates a “tunnel” which is cleared of snow beneath the conveyor. This keeps the snow
from filling in under the conveyor and affecting normal operations. The snow beneath the bottom
terminal prohibits access to the tension unit beyond the bottom deflection roller from the tunnel. As
such, there is no exit from the tunnel at the bottom terminal. (See Attachment A).

Investigation

The Investigation of this matter commenced on December 28, 2017, the date of the incident, and
concluded December 29, 2017. The investigation included an on-site inspection and witness interviews.

Initial Assessment

Immediately following the incident, Area representatives evacuated the LV-025 conveyor and closed the
conveyor for public operation. The Area immediately contacted the Clear Creek County Sheriff's
Department and then notified the Board Supervisory Tramway Engineer, Lawrence Smith, P.E. (“STE”),
at 12:07 p.m. The STE responded to the Area, arriving from Denver at 2: OO p.m.

Witness Interviews

Area personnel were interviewed by the STE on December 28, 2017. These witness statements
provided the STE with the following timeline of events and the functioning of the conveyor prior to,
and following the entanglement.

The LV-025 conveyor opened and was operating for normal skier traffic beginning at 9:00 a.m. on
December 28, 2017. The conveyor operator observed no indication of mechanical or electrical
problems with the conveyor. Between approximately 10:15 a.m and 10:30 a.m., the conveyor
operator witnessed maintenance worker Adam Lee arrive at the top terminal. Mr. Lee smiled and
waved to the operator as he opened the hatch cover of the conveyer and accessed the crawl space
beneath the conveyor. The conveyor was in operation at this time and continued to operate normally
to the skiing public. The conveyor operator had not called for lift maintenance to respond to the
conveyor.

5
This is one of two such conveyors in Colorado.

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At 11:22 a.m., the conveyor automatically stopped, indicating an overspeed fault. Following ski area
procedures, the conveyor operator notified Area lift dispatch, who in turn notified lift maintenance to
respond to the conveyor. A lift maintenance worker arrived within two to three minutes of the
maintenance dispatch. Lift maintenance made two attempts to clear the overspeed fault and restart
the conveyor belt. Each restart immediately indicated a speed reference fault and the belt did not
move.

Suspecting an ice buildup on the drive or return roller that was jamming the roller and prohibiting belt
movement, lift maintenance accessed the top terminal crawl space and inspected beneath the
conveyor. Inspection of the top drive roller revealed no indication of ice buildup or any other issues
that may have stopped the conveyor belt.

Lift maintenance then walked to the bottom terminal to access the bottom return tension roller. Lift
maintenance removed the four bolts of the lower terminal hatch and removed the hatch panel above
the tension roller. Upon removing the cover, lift maintenance discovered the entanglement. The lift
maintenance worker immediately cut the conveyor belt, pulled the tension roller to the limit of its
travel and extracted the entangled worker. Emergency Medical Services were activated. The entangled
worker was identified as lift maintenance worker, Adam Lee. Mr. Lee was transported to an area
medical center where he was pronounced dead.

Review of LV-025 Licensure and Inspections

The LV-025 conveyor at Loveland Ski Area has been licensed to operate since 2013. During that time,
the conveyor was inspected annually for both its licensing and unannounced operational inspections.
During its four years of operation, there have been no reported incidents attributed to mechanical or
electrical failure. There have been no prior injuries associated with the functioning of this conveyor.

The annual licensing inspection for the LV-025 conveyor was completed on September 21, 2017. The
Inspection Report dated September 22, 2017, noted a deficiency regarding the need to verify applicable
drive safeties with manufacturer and obtain testing procedures for overcurrent and overspeed and a
deficiency regarding the need to repair the motor for the snow chute. In addition, the Area was instructed
to complete the applicable items on CPTSB Form 25-06 prior to opening the conveyor for public use which
may or may not have been in place during the inspection. The Area submitted a report to the Board on
November 1, 2017, correcting the deficiencies. (See attachment B).

Site Investigation

At the time of STE arrival, the conveyor was inoperable due to the damage to the belt by lift
maintenance in their attempt to rescue the entangled worker. Visual inspection of the conveyor
confirmed no damage to the conveyor other than the belt and no indication of mechanical or electrical
failure of the conveyor. No snow or ice buildup was noted beneath the top terminal, along the length
of the conveyor, or at the bottom terminal. Inspection of the tunnel revealed nothing apart from the
cut belt that would cause the conveyor to stop operating.

The conveyor, the top terminal, the bottom terminal, and the tunnel were photographed. (See
Attachment A.)

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Findings

At the time of the incident, the conveyor was open to the public under normal skiing operations.
Witness interviews confirm the conveyer was operating without any indication of mechanical or
electrical issues until the conveyor abruptly stopped at 11:22 a.m. Inspection of the conveyor found
no indication of snow or ice buildup beneath the top, along the length of the conveyor or bottom
terminal that would cause the unit to stop operating. No mechanical or electrical system failure was
observed. In addition, there was no damage to the conveyor beyond the belt, which was cut by lift
maintenance in an attempt to rescue the victim.

The conveyor abruptly stopped at 11:22 a.m., as a result of the entanglement of the lift maintenance
worker with the return deflection roller which prohibited belt movement. The prohibited belt
movement caused the conveyor to automatically stop and show an overspeed fault.

The reason Mr. Lee would enter the tunnel beneath the conveyor remains unclear. Industry standards
prohibit the performance of maintenance beneath a conveyor while the conveyor is in operation. 6 In
addition, witness interviews and dispatch records confirm there were no mechanical or electrical issues
with the conveyor and that Mr. Lee was not dispatched to the conveyor on December 28, 2017.

Conclusion
The purpose of the investigation was to comply with sections 25-5-704(b) and 25-5-715(4), C.R.S., and
Board Rule 23.3 that require an investigation be conducted “when a death or injury results from a
possible malfunction of a passenger tramway.”

The investigation confirms there was no malfunction of the passenger tramway related to this incident.
In fact, the conveyor properly shut down when the return deflection roller jammed at the time of
entanglement.

The fatality that occurred on December 28, 2017, at Loveland Ski Area was not the result of a possible
malfunction of a passenger tramway. Accordingly, the Board’s investigation is concluded.

6
Entanglement in the return system beneath an operating conveyor is a documented hazard, typically resulting in serious injury
or loss of limb. Death from entanglement is rare, but not unprecedented.

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ATTACHMENT A
Fig. 1 Top terminal looking downhill.

Attachment A
Fig. 2 Bottom terminal looking uphill.

Attachment A
Fig. 3 Top terminal showing access cover.

Attachment A
Fig. 4 Top terminal showing access cover removed.

Attachment A
Fig. 5 Tunnel beneath the conveyor. View is from next to the top access looking down to the
bottom terminal.

Fig. 6 Tunnel beneath the conveyor showing return belt, return belt support rollers and
framework.

Attachment A
Fig. 7 Side view of bottom terminal showing belt travel.

Fig. 8 View of the bottom tension unit from the tunnel. The belt is removed from its normal
operating position in this photo.

Attachment A
Fig. 9 The normal return belt position is indicated by the cross-hatching and shows the belt
running over the top of the smaller deflection roller. Entanglement point is shown by the blue
arrow.

Attachment A
Fig. 10 The return terminal hatch cover removed showing the tension return roller. The belt was
cut for rescue and not in its normal position. Tension roller (shown with red arrow) is in
approximate position of that during operation. Blue arrows indicate location of tension system
all-thread.

Attachment A
ATTACHMENT B