STATE OF CALIFORNIA Page: 1

DEPARTMENT OF INDUSTRIAL RELATIONS

DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE SECTION
2424 Arden Way, Suite 340
Sacramento, CA 95825
(916) 263-3511
X PERMANENT AMUSEMENT RIDE FIELD REPORT TEMPORARY

OFFICE INSPECTOR INSPECTOR I.D. DATE INSPECTED STATE I.D. NUMBER

SA JAMES DENNY D5354 05/28/2017 P01038

DATE INSPECTION TIME INSPECTION FEE SURVEY TYPE SPECIAL CALL

CERT / PERMIT
EXPIRES 05/26/2018 51.75 Hour(s) $10,091.25 AI
AMUSEMENT PARK NAME CONTACT PERSON TELEPHONE NUMBER

The Wave at Emerald Glen Park Damian Sandholm (925) 833-6649

ADDRESS CITY ZIP

4201 Central Parkway Dublin 94568

RESPONSIBLE PARTY TELEPHONE NUMBER

City of Dublin (925) 833-6649

ADDRESS CITY STATE ZIP

100 CIVIC PLZ DUBLIN CA 94568

AMUSEMENT RIDE NAME AMUSEMENT RIDE CLASSIFICATION

The Emerald Plunge Class 2

MANUFACTURE NAME TRADE NAME

Whitewater West Speed Slide

Permit Number Tag Validation

Billing Information
Fee Type Insp Date Start Time Finish Time Elapsed Time Amount Billed
Inspection 05/28/2017 09:00 14:15 5.25 $1,023.75
Inspection 05/28/2017 15:15 16:00 0.75 $146.25
Inspection 05/29/2017 08:00 13:30 5.50 $1,072.50
Inspection 05/31/2017 08:00 12:30 4.50 $877.50
Inspection 05/31/2017 13:30 18:00 4.50 $877.50
Inspection 06/01/2017 07:15 09:45 2.50 $487.50
Inspection 06/01/2017 10:45 12:45 2.0 $390.00
Inspection 06/01/2017 13:45 17:15 3.50 $682.50
Inspection 06/12/2017 08:15 12:45 4.50 $877.50
Inspection 06/12/2017 13:45 16:00 2.25 $438.75
Inspection 06/13/2017 11:00 12:45 1.75 $341.25
Inspection 06/13/2017 13:45 16:00 2.25 $438.75
Inspection 06/14/2017 07:15 12:45 5.50 $1,072.50
Inspection 06/15/2017 07:45 11:00 3.25 $633.75
Inspection 06/15/2017 11:30 13:30 2.0 $390.00
Inspection 06/15/2017 14:30 15:30 1.0 $195.00
Inspection 06/21/2017 07:45 08:30 0.75 $146.25
Total 51.75 $10,091.25
REQUIREMENTS SECTION
Notification in writing that each of the listed items have been complied with shall be provided to the Division by the required
due date. Please send all written correspondence to the address listed above.
 STATE OF CALIFORNIA Page: 2
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE SECTION
2424 Arden Way, Suite 340
Sacramento, CA 95825
(916) 263-3511
X PERMANENT AMUSEMENT RIDE FIELD REPORT TEMPORARY

OFFICE INSPECTOR INSPECTOR I.D. DATE INSPECTED STATE I.D. NUMBER

SA JAMES DENNY D5354 05/28/2017 P01038

REQUIREMENTS DUE DATE: Prior to Operation

REQUIREMENTS EXPLAINED TO (NAME) POSITION TELEPHONE NUMBER

Damian Sandholm Recreation Supervisor (925) 833-6649

On May 27, 2017 at or around 4:34 p.m. Senior Engineer Scott Prather (SE Prather) with the Amusement Ride and
Tramway Unit (ART) of Cal/OSHA was notified by telephone by Micki Cronin, the Assistant Director of Parks and
Community Services for the City of Dublin, that an accident had occurred on the Emerald Plunge water slide. Ms. Cronin
stated that at approximately 12:10 p.m. that day a ten-year-old male patron had come out of their slide in the lower run out
section. Initially the child received on site first aid attention and later was taken by his parents to a local hospital for further
medical treatment. That same day SE Prather contacted ART Associate Engineer for Cal/OSHA, James Denny (AE
Denny) and assigned him to investigate the accident. AE Denny arrived on site the following morning to begin his
investigation.
As a result the following preliminary requirements are being issued to the Owner/Operator.
Upon completion of the investigation a detailed report will follow.

R1) The Owner/Operator shall contact the manufacturer and obtain detailed, written performance testing, setup and
installation procedures that identify all of the variables that affect the safe operation of the ride. At a minimum the
manufacturer shall address all of the following in developing these procedures: T8CCR 344.8(a), 3195.3(a) and
3195.5

1. The range of testing shall include riders that represent the smallest and largest body types
that are permitted on the ride, and specify a realistic minimum number of test runs per
each test subject. Where it is impractical to use live test subjects, a suitable surrogate
testing apparatus such as a crash test dummy shall be used. The use of water bags will
not be acceptable.

2. The complete range of water variables affecting the operation of the ride, including the
influence of water flow and the water levels in the shutdown lane.

3. Determining the placement of the hydraulic transition zone between the slide and the
shutdown lane.

4. How braking forces in the hydraulic transition zone affect riders including but not limited to
the smallest and largest body types permitted on the ride.

5. Procedures to analyze the testing data in order to establish rider restrictions, rider
suitability, ride performance and ride parameters. All testing results and collected data
shall be tabulated to demonstrate the safe performance of the ride.

6. These written procedures shall be reviewed and certified by a licensed engineer and
approved by the Cal/OSHA ART Unit prior to conducting any testing.
 STATE OF CALIFORNIA Page: 3
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
AMUSEMENT RIDE SECTION
2424 Arden Way, Suite 340
Sacramento, CA 95825
(916) 263-3511
X PERMANENT AMUSEMENT RIDE FIELD REPORT TEMPORARY

OFFICE INSPECTOR INSPECTOR I.D. DATE INSPECTED STATE I.D. NUMBER

SA JAMES DENNY D5354 05/28/2017 P01038

R2) Upon completion of requirement #1 the Owner/Operator shall contact the manufacturer and arrange for testing to be
conducted. All testing shall follow the procedures established per requirement # 1 and shall be witnessed by the
certifying licensed engineer of record and the Cal/OSHA ART Unit. All testing shall be completed prior to public
operation. T8CCR 344.8(a) and 3195.5

R3) In addition to the setup and installation procedures, the Owner /Operator shall contact the manufacturer and obtain
specific operational testing procedures to be performed periodically that will allow the Owner/Operator of the ride to
determine if the ride is operating within the prescribed operational limits of the ride during the life of the ride. T8CCR
3195.5

COMMENTS/NOTES

See attached (pages 4-21).

 Page 4 of 21

Description of the Ride

The Emerald Plunge is a body-style water slide manufactured by Whitewater West of

British Columbia, Canada. This type of water slide, commonly referred to as a speed
slide, has an extreme angle and a straight-line descent. This configuration allows gravity
to propel riders to high speeds. Commissioning of this slide occurred in March of 2017.
The slide opened for public operation on May 27, 2017, ninety minutes before the
accident occurred.

The slide is 177 feet long, 42.5 feet tall, and has a maximum descent angle of 63
degrees. Fiberglass molded into U-shaped trough sections that measure 36 inches
across make up the slide’s flume trough (riding surface). These flume trough sections
affix to a tubular steel tower that houses stairs and two platforms. Attached to the
platforms are several other water slides of different designs also manufactured by
Whitewater West.

Riders enter the Emerald Plunge slide at the top-level platform and sit inside a start tub.
After receiving the dispatch signal from the operator, riders release themselves into the
slide, assume the appropriate body position, and make their way down the slide until
they contact the brake area, also known as a shutdown lane. The shutdown lane is a
flat section of flume located at the end of the water slide intended to allow riders to slow
down and come to a stop before exiting the ride.

On this particular water slide, the shutdown lane is 97 feet long. When a rider enters
the shutdown lane, they contact a hydraulic transition. This transition is the entrance to
the braking area, created by the force of water coming down the slide and contacting
the shallow pool of water located in the shutdown lane flume. The location of the
hydraulic transition and the amount of water located in the shutdown lane are the
variable elements that set the dynamic attributes for the slide’s brake functions. This
dictates how quickly a patron will slow and come to a stop at the end of the ride.

By installing a weir in the end of the shutdown lane, Whitewater West is able to adjust
the amount of water exiting the slide to vary the depth of the water in the shutdown lane
flume. A weir is essentially a water dam that controls how fast water exits the shutdown
lane. A larger weir causes less water to exit the shutdown lane. This results in a greater
water depth and a more aggressive and faster stop, causing riders to stop in a shorter
distance. A smaller weir allows more water to exit, resulting in a shallow water depth
and a slower, more gradual stop. This will cause a rider to take a longer distance to
stop.

The location of the hydraulic transition in the shutdown lane is also adjustable. By
moving the transition, the manufacturer is able to adjust how fast and at what location
this brake function is applied. By adjusting the water flow rate coming down the slide,
 Page 6 of 21

Supervisor for the City of Dublin Parks and Community Services; and Micki Cronin,
Assistant Director for the City of Dublin Parks and Community Services supplied the
pre-opening inspection detail of the Emerald Plunge for the day of the accident for
review. At that time, the Division learned that the facility had made contact with the
manufacturer, Whitewater West, and at their request, had closed the Dublin Screamer
slide located next to the Emerald Plunge. The Dublin Screamer is another water slide
located at the facility. These two water slides utilize the same water pump system to
supply water to the water slides.

AE Denny requested to review the training records for the slide operators, the personnel
who performed the pre-opening inspection, along with the accident report generated by
the facility. Jeff Dybdal, Recreation Coordinator-Aquatics for the City of Dublin,
presented these documents for review and was the park representative who, as part of
the pre-opening inspection, confirmed the water flow rate of the slide at the time of the
accident as being 274 gallons per minute (GPM).

The facility accident report stated that the injured patron was riding the slide in the
proper riding position, and when he contacted the landing area, he rose above the flume
and fell out of the slide. It further stated that the patron walked away, with assistance,
to the first aid room and received gauze for his right shoulder, large adhesive bandages
to his right elbow and knee, and had ice applied to his right hip. According to the report,
he had light abrasions on the lower left side of his back.

SE Prather arrived at the facility at around 9:30 a.m., and joined AE Denny in reviewing
the documents. SE Prather requested to review the construction drawings for the water
slide. Mr. Rooney gathered and provided the drawings to the Division. The drawing
package presented was marked as Whitewater West’s series 200 drawings. These
drawings depicted the location where the hydraulic transition and the water level in the
shutdown lane flume were to be set.

The Division then reviewed the media footage that captured the accident as it occurred.
From this footage, the Division observed the following conditions:

• The patron remained in correct riding position throughout the drop and entry to
the hydraulic transition section.
• Upon contact with the hydraulic transition, the patron’s feet came up and to the
left side of the shutdown lane. His body turned perpendicular to the flume and
the direction of travel.
• He slid on his back and shoulders on the left side of the shutdown lane sidewall
until finally falling outward onto the concrete.
 Page 7 of 21

The Division took this footage and captured screen shots in order to observe the
patron’s interactions with the water slide at the time of the accident. These screen shots
revealed that the patron was, in fact, riding the slide as intended.

A brief meeting took place with the following attendees:

• Mr. Sandholm
• Ms. Cronin
• Joshua Headley, Senior Project Manager for C. Overaa & Co., the building
contractor responsible for the construction of the Emerald Glen Park facility;
• Michael Boitnott, P.E. Capital Improvement Program Manager for the City of
Dublin Public Works Department.

During the meeting, the Division went over the investigation process, Representatives
from the City of agreed to preserve the ride, documentation, and the area located
around the Dublin Plunge water slide, and offered any assistance that they could
provide to the Division.

Next, the Division went to the location of the Emerald Plunge and began the physical
investigation of the slide. SE Prather and AE Denny obtained measurements at the
slide shutdown lane and compared these to the video footage taken at the time of the
accident. From this comparison it was determined that the patron travelled
approximately 35 feet on top of the fiberglass shutdown lane flume before contacting
the walkway next to the slide. The Division was able to confirm this with the existence
of small skin particles left behind on the concrete. Small scuffmarks in the oxidation of
the gelcoat on the slide shutdown lane were also evident where the injured patron slid
along the fiberglass flume. SE Prather went to observe the flow rate adjustment valves
located under the slide structure. These valves restrict the amount of water flow
pumped to the slide. SE Prather noted that the valves were set and locked as
Whitewater West had left them.

Next, city employees started the slide pump and waited for the water to equalize. The
Division took measurements at the hydraulic flow transition and of the water depth
inside the shutdown lane. These measurements were compared to the manufacturer’s
visual signage affixed to the slide and the series 200 drawings mentioned earlier. The
intent of the signage is to provide visual indicators for the Owner/Operator to verify that
the flow rates and water levels are within the operational limits established by
Whitewater West during the time of commissioning and testing. Based off these
measurements, the Division has verified that the measurements matched the visual
indicators established by Whitewater West, and that the slide was operating as the
manufacturer had intended.
 Page 9 of 21

contained the measurements used to place the visual indicators previously mentioned.
In the document, Whitewater West documented the static water depth measurement at
each shutdown lane joint with the drainage holes plugged.

Note: Measurement 1 begins at the end of the shutdown lane and continues
sequentially backward toward the slide):

1. 7 inches

2. 7 inches

3. 6-3/4 inches

4. 6-1/4 inches

5. 6 inches

6. 5-1/2 inches

7. 5 inches

8. 4-1/2 inches

9. 3-3/4 inches

10. 3 inches

Whitewater West documented the operating water depth measured 3 feet from the weir
as being 10-1/2 inches and distance from the weir and center of the hydraulic flow
transition was 94 feet, 2 inches.

After reviewing these documents, Mr. Headley and Mr. Boitnott accompanied the
Division as they returned to the Emerald Plunge to continue taking measurements. The
Division compared the measurements taken with the measurements recorded on the
Whitewater West Shutdown Lane Depths Recording Sheet. The Division observed that
these measurements were consistent with what Whitewater West had established and
recorded in their documentation.

Mr. Headley then informed the Division that Andrew Mulligan, Senior Attractions Install
Advisor for Whitewater West, would be arriving at the facility the following day at 8:00
a.m. SE Prather informed Mr. Headley that the Division would arrive the next day to
accompany Mr. Mulligan. SE Prather and AE Denny left the facility at approximately
4:00 p.m. that day.

AE Denny arrived back at the site on the following day at approximately 8:00 a.m. and
met with Mr. Mulligan. After introductions, AE Denny joined Mr. Mulligan in first
 Page 10 of 21

confirming the flow rates, water depth markings, and hydraulic flow transition signage
for the Emerald Plunge and the Dublin Screamer. Upon completion of this inspection for
these two slides, the Division and Mr. Mulligan continued with the same confirmations
on the other water slides at the facility. The Division verified that all of the
measurements taken matched the Whitewater West documentation.

At approximately 9:30 a.m., AE Prather arrived and joined both AE Denny and Mr.
Mulligan. The Division and Mr. Mulligan made contact with Mr. Boitnott and Mr.
Headley. SE Prather asked Mr. Mulligan if there was a pre-determined value for setting
the water level and hydraulic flow transition. Mr. Mulligan answered that there was no
predetermined value and added that these variables were set at the time of testing.

Mr. Mulligan then measured the static water level at each joint section of the shutdown
lane for both the Emerald Plunge and the Dublin Screamer. The results of his
measurements, recorded in inches, taken in the direction of travel starting at the angled
portion of the slide and working through the shutdown lane are:

The Emerald Plunge The Dublin Screamer

Joint Section Number
1 4.75
2 5.25
3 6
4 6.5
5 7
6 7.75
7 8.25
8 8.5
9 8.75
10 9.5
11 10
12 10.5
Joint Section Number
1 5.75
2 6
3 6.5
4 7.25
5 7.5
6 8.25
7 8.5
8 9.25
9 10.25
10 10.5

After measurements were completed, the Division and Mr. Mulligan met with the
employees of the City of Dublin. During this meeting, the Division asked questions
concerning the weight range of the testing performed on the slide. Mr. Mulligan
responded, saying that he normally would test as low as 110 pounds when he would
commission a slide. The Division then asked if any testing took place for the lower
weight ranges, such as that of the injured patron. Mr. Mulligan said, “No.” The Division
 Page 11 of 21

also learned the City of Dublin was planning to contract a third party engineer to review
all documentation and findings pertaining to the Emerald Plunge accident. SE Prather
then requested a survey of the slide, the structural members, and concrete slab to
compare them to the construction drawings. This was to ensure that the ride was
constructed and positioned as planned. Mr. Headley agreed. Mr. Mulligan informed SE
Prather and AE Denny that Claudio Barrera, P.E. and Director of Product Development
for Whitewater West, along with Eric Sinclair, Project Manager for Whitewater West and
specific project manager for the Wave at Emerald Glen Park water slides, would be
arriving at the facility on May 31, 2017, to assist with the investigation. The Division‘s
presence was requested at a meeting scheduled for 11:00 a.m. the following day, where
members of Whitewater West, C. Overaa & Co., and the City of Dublin could gain an
understanding of expectations and next-step processes.

The Division then met with Mr. Mulligan and asked for a list of plunge slides with the
same exact angle and height built by Whitewater West. Mr. Mulligan answered that
there were probably a lot, but not fewer than 50 and not more than 150, built over the
last 20 years. The Division asked if he had previously experienced this type of patron
separation from a shutdown lane. Mr. Mulligan stated that he had not experienced this
on this type of slide, but that he had left the water level too high on two speed slides
before, in which the rider rode the shutdown lane wall after going through a curve on
another slide.

SE Prather then inquired about Mr. Mulligan’s background and his time working for
Whitewater West. Mr. Mulligan replied that he had worked for the company for 14 years
and had been testing and certifying water slides for 11 years. Mr. Mulligan also
commented that only 9 or 10 others certify slides for Whitewater West. He then added
that, based on his experience, he would have caught what he believed to be a situation
where the water in the shutdown lane was too deep. SE Prather then asked about how
the certifier makes the determination for the hydraulic flow transition and water depth, to
which Mr. Mulligan responded that each tester might go about it differently. SE Prather
then advised him not to make adjustments until The Division received testing data and
informed Mr. Mulligan that the Division would need to observe any adjustments being
made. Mr. Mulligan agreed, and the Division left the location at approximately 1:30 p.m.

On May 29, 2017, SE Prather visited Waterworld California, another water park facility
located in Concord, California. This facility operates a similar style speed slide to that of
the Emerald Plunge known as Cliffhanger #1. This slide was installed and
commissioned by Whitewater in 1990 and has a height of 56 feet. While at the facility,
SE Prather met with the Park Operations Manager for Waterworld California, Ronald
Walker. Mr. Walker escorted SE Prather to the Cliffhanger ride where they observed
several ride cycles with riders of varying weights and body proportions. Upon initial
observation, SE Prather noticed that the water level in the Shutdown lane of the slide
 Page 12 of 21

was much shallower than that of the Emerald Plunge at the time of the accident. The
hydraulic transition was observed to be long and flat with a gradual increase in water
depth as one gets closer to the end of the shutdown lane.

While observing riders on Cliffhanger #1, SE Prather observed that riders experienced
gradual braking force created by the long flat hydraulic transition. There was no
evidence that a rider might rise up above the water or separate from the Shutdown lane
flume. As SE Prather was leaving the facility, a discussion took place with Mr. Walker.
Mr. Walker stated that the minimum height requirement for the ride is 48 inches tall,
however, they rarely see any riders ride the slide that are in the lower ranges, either
because they are afraid of the ride or because their parents prohibit them from riding.
Mr. Walker stated that most of the riders that choose to ride Cliffhanger #1 are young
adults and teenagers.

AE Denny arrived back at the Wave at Emerald Glen Park on May 31, 2017, on or
about 8:00 a.m. He continued to review and confirm the elevation data and the angle of
the slope percentages provided in the construction drawings for the shutdown lane
areas for both the Emerald Plunge and the Dublin Screamer. SE Prather arrived at the
facility at approximately 9:30 a.m. and joined AE Denny in documentation review.

A meeting took place at 11:00 a.m. The following individuals were present for the
meeting:

• Regional Manager for the Division ART Nancy Medeiros (RM Medeiros)

• SE Prather, Division ART

• AE Denny, Division ART

• Mr. Barrera, Whitewater West

• Mr. Sinclair, Whitewater West

• Mr. Mulligan, Whitewater West

• Zachary Lucas, Site Project Manager for C. Overaa & Co.

• Tom Swift (Mr. Swift), Technical Supervisor for Western Water Features, general
contractor responsible for the construction of the Emerald Glen Park facility

• James Rodems, Director for the City of Dublin Parks and Community Services

• Ms. Cronin, City of Dublin

• Mr. Sandholm, City of Dublin

 Page 13 of 21

• Mr. Boitnott, City of Dublin

• Mr. Rooney, City of Dublin

During the meeting, the Division learned the following additional details that relate to the
ride and the accident:

Whitewater West did not perform any prototype testing on this type of water slide.

They considered the design service proven because similar designs have been in
operation for 20 years

Whitewater West determined that the 48-inch minimum height requirement was
appropriate for the ride because that height represents an age group where the patron
knows how to follow directions, and is capable of determining if they want to ride. They
also stated that 48 inches is a common minimum height requirement in the amusement
industry on other rides such roller coasters.

When asked what data was available to substantiate the 48-inch tall minimum height
requirement, the response was that the information is empirical data and the fact that
slides of similar design have been in operation without incident for so long proves that
the design is safe.

Whitewater West did not test the full weight range because they felt that the higher
weights pose a higher risk during the certification process, and have a greater potential
to contact the end of the shutdown lane.

Whitewater West has used surrogates on other slides where they felt the design might
be to hazardous to test with human riders.

The surrogates consisted of dry bags, commonly used for kayaking, filled with water to
a specific weight.

Whitewater West did not use surrogates during the initial commissioning and testing
performed on the Dublin water slides.

The meeting concluded at 12:30 p.m.

The Division then met the personnel from Whitewater West, along with Mr. Rodems and
Mr. Boitnott, at the Emerald Plunge at or around 1:30 p.m. Mr. Barrera’s first physical
inspection item was an as-built water grade test that could be attained by completely
blocking off the end of the shutdown lane and measuring the static water level at each
trough joint. Below are the results of his measurements, recorded in inches, as taken in
the direction of travel from the slide portion through the shutdown lane:
 Page 14 of 21

The Emerald Plunge The Dublin Screamer

Joint Section Joint Section
Number Number
1 7.25 1 7
2 7.75 2 7.5
3 8.5 3 8.25
4 9.25 4 8.5
5 9.5 5 9.25
6 10 6 9.5
7 10.5 7 10
8 11 8 10.5
9 11 9 10.5
10 11.5 10 10.5
11 11.5
The next step taken by Mr. Barrera was to remove the 7.25-inch high weir from the
Emerald Plunge and the 7-inch high weir from the Dublin Screamer. After removing
this, the hydraulic flow transition moved forward toward the end of the shutdown lane 19
feet on the Emerald Plunge and 21 feet on the Dublin Screamer. Both flow meters read
275 GPM and the individual gate valves were in the completely open position.

Since these two slides share the same pump system, an adjustment to one valve to
restrict or increase water flow will conversely affect the flow of the other slide. Mr.
Barrera installed temporary adhesive tape to mark the transition areas, and included the
flow rates, for reference. He then adjusted the flow rate on the Dublin Screamer to 215
GPM, which brought the flow rate of the other slide up to 325. At these flow rate
settings the hydraulic flow transition moved 3 feet backward on the Emerald Plunge and
3 feet forward on the Dublin Screamer. Mr. Barrera then adjusted the flow rates to 240
GPM for the Emerald Plunge and 245 for the Dublin Screamer, which brought the
hydraulic flow transition close to a midpoint between the two values listed.

Mr. Barrera explained that he liked the look of the transitions and did not see a need for
much more water depth. The Division inquired as to why this setup was drastically
different from what Mr. Daley had accepted and documented. Mr. Barrera explained
that there was an internal investigation in progress. The Division asked if Whitewater
West reviewed the documents that Mr. Daley submitted for acceptance of his setup.
Mr. Barrera explained again that there was an internal investigation in progress. He
 Page 15 of 21

asked Mr. Mulligan to construct a temporary weir to see the reaction of the transition
and water depth. Mr. Mulligan affixed a taped-on weir that only covered 1 inch of the
flow grate at the end of the shutdown lane. After turning on the pump, and allowing the
water level stabilized, the Division observed the following measurements:

Water depth near the end of the shutdown lane for both slides was 6.5 inches

Water depth just after the hydraulic flow transition in the direction of travel for the
Emerald Plunge was 2 inches, and 2.5 inches on the Dublin Screamer.

Mr. Barrera stated that this setup for both slides was at a point for testing. The Division
left the facility at 6:00 p.m.

The Division returned on June 1, 2017, to observe and record measurements of rider
testing. Whitewater West used the following items to conduct the testing:

• Two green 35-liter dry bags

• Two blue 55-liter dry bags

• a household scale to confirm weight

• a tape measure

• video equipment

Mr. Barrera explained that he and Mr. Mulligan were to be the test riders of both the
Emerald Plunge and the Dublin Screamer, and with the use of the dry bags, they would
be able to adjust the rider weight.

Below are the results of this testing:

Test
Number Assigned Test Rider Weight Number Assigned Equipment Weight
1 Mr. Barrera 187 lbs. 3 Green Dry Bag 0 to 77
lbs.
2 Mr. Mulligan 235 lbs. 4 Blue Dry Bag 0 to
121
lbs.
 Page 16 of 21

Emerald Plunge
Rider and/or Equipment Number Stopping Distance Relative to End of
Test Shutdown Lane
Run
1 4 with a total weight of 93 lbs. Dry bag opened before the end of the
cycle.
2 1 16.5 ft.
3 2 27.5 ft.
4 3 with a total weight of 47 lbs. 48.5 ft.
5 1 20.5 ft.
6 2 28.5 ft.
7 1+3 with a total weight of 230 20.5 ft.
lbs.
8 2+3 with a total weight of 278 28.5 ft.
lbs.
9 4 with a total weight of 78 lbs. 38.5 ft.
10 3 with a total weight of 51 lbs. 43.5 ft.
11 3 with a total weight of 47 lbs. 50.5 ft.
12 1 28.5 ft.
13 4 with a total weight of 60 lbs. 50.5 ft.
14 2 37.5 ft.
Dublin Screamer
Test Rider and/or Equipment Number Stopping Distance Relative to End of
Run Shutdown Lane
1 1 40 ft.
2 2 35 ft.

Final measurements for each slide are as follows:

The Emerald Plunge: Flow Rate 240 GPM; Operating Water Depth at Visual
Signage Indicator 6.25 inches; Distance from Hydraulic Flow Transition to End of
AF 2 Shutdown Lane Segment 81 feet, 1 inch; and Depth of Water just after
Hydraulic Flow Transition in the Direction of Travel 2 inches.
 Page 17 of 21

The Dublin Screamer: Flow Rate 245 GPM; Operating Water Depth at Visual
Signage Indicator 6.5 inches; Distance from Hydraulic Flow Transition to End of
AE 2 Shutdown Lane Segment 87 feet, 3 inches; and Depth of Water just after
Hydraulic Flow Transition in the Direction of Travel 2.5 inches.

Mr. Barrera stated that these slides were then ready for multiple ride testing and Mr.
Mulligan offered that he could contact a labor service to contract personnel to test the
slides. SE Prather explained that the Division would require a written test procedure,
along with acceptable criteria in order to proceed with testing.

Later that day, as the group was dispersing, SE Prather and AE Denny met with Mr.
Mulligan at around 4:30 p.m. Mr. Mulligan wanted to apologize on behalf of Whitewater
West for the way the slide was set up originally, as it should have never been left that
way and allowed to open. SE Prather requested that before any further testing, the
Division be able to recreate the accident by placing the flow rate and weir settings back
to the original levels and testing a dry bag weighing 78 pounds. Mr. Mulligan agreed to
this request. SE Prather and AE Denny left the Wave at Emerald Glen Park at
approximately 5:15 p.m.

On June 6, 2017, the Division received the following documents:

• 200 Series Drawings (Slide Drawings)

• 2017 Jun 01 Testing (Test videos from 6/1/17)

• 31548 Emerald Glen AS and AF 3D Model (Slide CAD model in .dwg format)

• AE Table and Parts (Fiberglass Section Drawings and Coordinate Matrix)

• AF Table and Parts (Fiberglass Section Drawings and Coordinate Matrix)

• California Speed Slides (List of California Speed Slides by Whitewater West and
Selected Drawings)

• Cert Videos and Pictures 2017 Mar 21 (3/21/17 Certification pictures and test
videos)

Whitewater West provided the Division with nine pieces of video footage captured on
March 21, 2017, of the initial testing and commissioning of the slide. Upon reviewing
these videos, the Division observed a problem that existed during this testing. From the
footage, you can see that riders were experiencing abrupt interactions with the hydraulic
transition. In several instances, riders initially contact the transition and raise up over the
water in the shutdown lane. You can audibly hear a second splash as the rider comes
back down into the water. At this point, the Whitewater West representative should have
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identified this as a problem and adjusted the flow, transition location, and water depth in
the shutdown lane. It is believed that these conditions were a contributing factor to the
accident.

The weight range of these riders who participated in the testing covered a range of 155
lbs. to 205 lbs. Whitewater West depicted these weights in the Commissioning
Inspection Guidelines document under rider information. The difference in weight of the
test riders compared to that of the injured patron (78 lbs.) would have contributed to the
fact that an accident did not occur during this testing. Had a test rider weighing
approximately 78 lbs. gone down the slide during testing, it is plausible that the rider
would have separated from the flume much as occurred during the accident.

In order to confirm this was the case, Whitewater West set the slide variables back to
the original settings that they were at the time of the accident. To test this scenario they
implemented a surrogate testing apparatus in order to prevent injury to a human rider in
the event that a separation from the flume did occur. The surrogate consisted of a dry
bag filled with water. The Division confirmed the weight of the surrogate to ensure it
weighed 78 lbs. to coincide with the weight of the injured patron. Whitewater West
personnel sent the surrogate down the slide, and upon reaching the hydraulic transition,
it raised above the surface of the shutdown lane, proceeded onto the sidewall, and
exited the slide falling onto the concrete. The action of the surrogate was very similar to
the action observed by the Division when reviewing the video footage of the accident.

On June 8, 2017, Joshua Headley of C. Overaa & Co. provided the Division with
documentation from the physical survey of the slide.

Jesse Fullen, a professional land surveyor licensed by the State of California conducted
the survey. The document depicted precise measurements taken on June 2, 2017. The
document contained plotted coordinates overlaid on top of photographs of the slides.
With this document, and a coordinate chart generated on July 17, 2015, provided to the
Division on June 6, 2017, the Division was able to compare the precise coordinates of
specific flume sections in order to verify the proper placement and elevation of the
concrete slab that housed the shutdown lane. Only a slight variation in elevation was
evident from the comparison. This comparison did not reveal any placement issues that
might have contributed to the accident.

Also on June 8, 2017, the Division received the following documents:

• 31548 AF and AE Test Plan RO (Test Plan for Slides AF and AE)

• 31548-AE-S1270-SHUTDOWN-LANE-FLOW-TRANSITION-Rev0-Jun-06-17
(Test Plan Drawing for Slide AE)
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• 31548-AF-S1270-SHUTDOWN-LANE-FLOW-TRANSITION-Rev0-Jun-06-17
(Test Plan Drawing for Slide AF)

These documents contained the proposed testing plan that Whitewater West intended
to utilize to complete the remaining testing.

On June 14, 2017, at or around 12:07 p.m., SE Prather and AE Denny made contact by
telephone with Ed Pribonic (Mr. Pribonic), a California licensed engineer hired by the
City of Dublin as a third party to review all data and documentation involved with the
accident that occurred at the Wave. The purpose of this call was to discuss the test
plan created by Whitewater West on June 5, 2017, and to air the concerns Mr. Pribonic
and the Division had with this plan. Mr. Pribonic sent an email to the Division on June
12, 2017, listing the following concerns with the original testing and submitted testing
protocol:

• The very “mid-range” weight group tested is far from either extreme in ride
weights.

• Reference to ASTM F2376 for water slides, although the state of California has
not yet adopted, it is the accepted standard of care in the industry and states:

o 9.4.2 The test procedure shall include rides that represent the largest and
the smallest body types that shall be allowed on the slide.

o 9.4.3 The test procedure shall be reviewed and approved by a third party
consultant, experienced and an expert in water slide operations.

• California has adopted ASTM F 846-92 for testing which states:

o 6.1.3 Performance Testing - This should consist of a series of specified

tests that can be used to determine that the newly erected ride or device
conforms to the original design criteria.

• Mr. Pribonic concluded that Whitewater did not perform adequate performance
testing and that the result was the ejection incident.

• The new test plan should state exactly how many riders or of what weights and
heights, as distribution of body weight on a rider affects slide performance, and
how many of each weight.

• Dry bags would not produce results translatable to human body shapes.

• A complete range of tests needs to include evaluating the influence of water flow
and shutdown lane water depths.
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• The testing should specify a minimum number of slides per rider, varying in
weight and height, for each variation in water flow and shutdown lane water
depth.

• Nowhere in the protocol does it require changing water flow rates and water
levels and then testing performance results.

• What is the performance envelope?

• How will Whitewater determine exactly what setup parameters will apply to each
slide, what rider demographics will be safely supported, and what performance
measuring parameters will be specified so that the operator can constantly
evaluate the performance of each slide over time?

• Nothing is stated about evaluating the suitability of the slides for small or very
large riders based on the collected data.

The Division was in agreement with Mr. Pribonic that Whitewater West needed a new
test plan that incorporated all above-mentioned items.

On June 21, 2017, the Division issued to the City of Dublin an inspection report
containing the requirements needed to reopen the slide for public operation.

Conclusion

The Division has completed the investigation into the ride accident that occurred on May
27, 2017, on the Emerald Plunge water slide located at the Wave at Emerald Glen Park
in Dublin, California. The Division’s investigation included a physical inspection of the
ride; documentation and video review; and interviews with facility management and City
of Dublin employees, ride manufacturer personnel, site project management including
construction contractors, and a licensed engineer hired as a third party by the City of
Dublin to review all data and documentation relating to the ride accident. Upon
completion of the investigation, the Division has drawn the following conclusions:

• Whitewater West did not have effective development testing procedures in place
for any of their previously built speed slides. This includes outlining the
processes required to set up and validate the performance of a water slide in
order to confirm operational slide parameters, rider suitability, and rider
restrictions against design objectives.

• Whitewater West took the height requirement for speed slides and the Aqua Drop
from a common roller coaster measurement of 48 inches and had no support of
any physical testing or acceleration data to determine the height restriction.
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Additionally, the weight restriction of 300 pounds had no support of physical

testing or acceleration data.

• The manufacturer was primarily concerned with testing the rider mid-to-upper
weight range, and did not include any lower limits.

• The manufacturer admitted to the Division that the slide was originally set up
incorrectly. This setup and a lack of procedures for the setup process are what
contributed to the accident.

• The accident could have been prevented had the manufacturer, prior to releasing
the ride, identified the issues related to the improper set up of the water slide and
corrected the issues.