Draft:Toshimaen Drowning Incident

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Toshimaen Drowning Incident
Toshimaen swimming pool (November 2019). The nearly rectangular pool surrounded by the flowing pool on the right of the photo is the site. (Based on an aerial photograph from the Geospatial Information Authority of Japan's Map and Aerial Photograph Viewing Service, Ministry of Land, Infrastructure, Transport and Tourism; original photograph has been cropped and processed)
Date15 August 2019
TimeAround 14:00 (JST)
Location‘Fluffy Water Land’ pool attraction at Toshimaen amusement park, Nerima-ku, Tokyo
Coordinates35°44'36.8"N 139°38'41.3"E
Also known asToshimanen swimming pool fatal accident
CauseLack of lifejackets and supervision
Outcome"A" (8-year-old girl) deaths

The Toshimaen Drowning Incident (Japanese: としまえんの水上設置遊具による溺水事故) refers to a tragic event that occurred on 15th August 2019 at the 'Fluffy Water Land' (ふわふわウォーターランド) attraction in Toshimaen, an amusement park that was then located in Nerima, Tokyo.[1] This attraction featured water-based inflatable play equipment.[2] A young girl, referred to here as 'A', who was wearing a life jacket, was found floating beneath the play equipment and subsequently drowned.[3]

This incident became the subject of an investigation by the Consumer Affairs Agency.[3] It was concluded that the girl had fallen into the water, slipped under the play equipment, and was unable to escape due to the buoyancy of her life jacket.[4]

In response to this incident, the Ministry of Economy, Trade and Industry (METI) established guidelines for the safety of water-based play equipment.[5]

Accident site[edit]

Examples of water-based play equipment (Image different from those at Toshimaen)
The main gate of Toshimaen where the accident occurred (photo taken in January 2019)

The accident occurred at Toshimaen, which opened in 1926, with the pool opening three years later in 1929.[6] The 'Fluffy Water Land' had been in operation since 2016.[3] The "Fluffy Water Land" was installed in a competitive swimming pool with eight lanes, measuring 50 metres in length, 20 metres in width, and a depth ranging from 1.2 to 1.9 metres. There were areas where someone of person A's height could not touch the bottom.[3][7][8] The "Fluffy Water Land" had more than 10 water-based play equipment, known as air toy types.[8][2] These are professionally referred to as 'air membrane structure toys',[9] which float on the water surface by inflating them with air. They are easy to store when deflated and can be reshaped in various ways, which are their advantages.[2] However, there were no nets or similar installations to prevent entry under the toys.[8] The planning and design of the "Fluffy Water Land" were carried out independently by Toshimaen, and the toys were procured from a manufacturer in China.[10] The toy that person A fell from was large enough for about 15 adults and children to play at once.[11] According to a man quoted by Tokyo Sports, who uses the "Fluffy Water Land" with his children every year, the toys are more than 30 centimetres thick and have a slippery surface, making it impossible for children to climb onto the toys from the water on their own. Even adults would struggle to escape if they ended up under the toys while wearing the life jackets mentioned later.[12]

At the "Fluffy Water Land", users had to be taller than 1.1 metres and were required to wear life jackets provided for drowning prevention and to prevent entry under the toys.[10] The life jackets provided at the "Fluffy Water Land" were solid-structured, using expanded polystyrene for buoyancy, and were shaped like a waistcoat. The waistcoat was worn by putting both arms through and fastening it at the front, with adjustments made accordingly.[13] In addition, users of the "Fluffy Water Land" were verbally asked if they could swim on their own. Many users were also seen wearing armbands, according to eyewitnesses of the accident.[14] At the "Fluffy Water Land", it was not uncommon for people to fall into the water from the toys, and on top of that, there were people who dropped their goggles into the water at a rate of two per hour.[11]

Accident[edit]

At the time, A was an 8-year-old girl in her third year of primary school, residing in Asaka City, Saitama Prefecture.[7] On the day of the incident, A, along with her father (hereafter referred to as B), mother (hereafter referred to as C), and one-year-old sister (hereafter referred to as D), visited the pool at Toshimaen.[7] A, who was over 1.1 metres tall, was wearing a life jacket.[7] She began using the pool with B around 1 pm.[15] At approximately 1:30 pm, B lost sight of A and asked the lifeguards to search for her. However, the lifeguards merely used a loudspeaker to call out,[16] "Is A here?" and directed B to the lost child centre, without immediately conducting an underwater search. They asked B to wait until 2 pm.[8]

Just before 2 pm, a lifeguard dived into the water to search for A but was unable to find her.[17] At 2 pm, a routine inspection began, during which all pool users were asked to get out of the water.[7] A was found by a lifeguard around 2:10 pm.[7] She was discovered face down under a mat-like play equipment, approximately 2.5 metres long, 5 metres wide, and 30 centimetres thick, still wearing her life jacket.[18] According to pool patrons who witnessed A being pulled out of the water, she was pale and limp when she was rescued, and a person believed to be C was screaming.[17] A was unconscious and in critical condition. According to witnesses, she received cardiopulmonary resuscitation before being transported to the hospital,[14] where her death was confirmed around 4 pm.[7]

At the time of the accident, there were approximately 270 people using the "Fluffy Water Land", and there were seven lifeguards on duty.[7] It was reported that no abnormalities were observed during the routine inspection at noon, which included underwater checks.[7]

Other[edit]

On the day of the incident, Toshimaen cancelled operations at the "Fluffy Water Land" as well as its evening pool operations (Night Pool), and suspended all pool activities from the following day, 16th August.[7] The pool reopened on 23rd August, but the rental of large inflatable rings was discontinued, and it was decided that the "Fluffy Water Land" would not operate until the end of the pool season in 2019. The "Fluffy Water Land" remained closed in 2020, leading up to the closure of Toshimaen itself on 31st August of the same year.[2]

In response to the incident, the non-profit organisation Safe Kids Japan collected information on similar accidents and reported that even after the incident at Toshimaen, there were reports of accidents involving fractures from falling off water play equipment. At a meeting held at Tokyo Institute of Technology on 27th August 2019, the organisation pointed out that due to the large size of the play equipment, a person who fell under it would become completely invisible. Furthermore, there were no stairs to climb up from under the equipment, the number of lifeguards was insufficient and their positioning and height were inappropriate, and there was no device to indicate location. Ryuhiro Yamanaka, the chairman of Safe Kids Japan, emphasised that information on similar accidents should be compiled and shared, and measures should be thoroughly implemented to prevent the same accident from happening again.

Investigation of cause and reproduction • experiments[edit]

Initial response by the Consumer Affairs Agency[edit]

In a press conference held on 21st August 2019 by Akiko Ito, the Commissioner of the Consumer Affairs Agency, when asked about the need for warnings, investigations into the cause, and consideration of safety measures in relation to this incident, Ito responded, "At this stage, it is not the time to say what we want done." In a press conference held on 23rd August by Takehisa Nakagawa, Chairman of the Consumer Safety Investigation Committee of the Consumer Affairs Agency, and his deputy Masaaki Mochimaru, it was revealed that a basic survey targeting pool accidents at kindergartens and similar institutions had been initiated.

At the 88th meeting of the Consumer Safety Investigation Committee held on 28th November of the same year, it was decided to investigate the cause of this accident under Article 23, Paragraph 1 of the Consumer Safety Act. The decision was based on the fact that there were fatalities in this accident (extent of damage), similar play equipment is installed in at least 26 locations nationwide (public nature), it is unclear why water-based play equipment is dangerous, making it difficult for users to take action to avoid danger themselves (possibility of avoidance by consumers), and many new water-based play equipment have been installed in the past five years, with many more expected to be installed in the future (frequency). Koji Kitamura, a senior researcher at the Artificial Intelligence Research Centre of the National Institute of Advanced Industrial Science and Technology, Tetsuya Kimura, an associate professor at the Graduate School of Technology Management, Nagaoka University of Technology, and Takayuki Matsumoto, Vice Chairman of the Japan Lifesaving Association, were appointed as expert committee members to conduct the investigation. Subsequently, plans for a re-enactment experiment were discussed at the 35th Service Accident Investigation Committee meeting held on 10th January 2020, and at the 90th Investigation Committee meeting held on 27th January of the same year.

Re-enactment experiment[edit]

Schematic diagram of a subject entering the bottom of water-based play equipment

The re-enactment experiment was conducted in a pool with play equipment identical to that in place at the time of the incident. The buoyancy of the life jackets worn by the test subjects was set to match the ratio of buoyancy to body weight of the life jacket worn by the victim. The experiment consisted of two parts: a research experiment to verify whether various actions while wearing a life jacket would lead to the subject ending up under the play equipment, and a confirmation experiment to verify whether a subject could escape if they ended up under the play equipment while wearing a life jacket.

In the research experiment, three types of tests were conducted: a falling into water test, a play equipment sway test, and a climbing action test. In the falling into water test, it was found that if a subject fell from the play equipment in various positions, they would invariably end up under the play equipment if they fell upside down while twisting their body from a standing position, or if they fell straight forward from a standing position and then moved their arms once underwater (4 out of 4 times and 3 out of 3 times respectively). It was also revealed that if a subject fell upside down while peering into the water with their knees against the play equipment, or if they fell straight backwards from a standing position and then moved their arms once underwater, they would end up under the play equipment 2 out of 3 times. Additionally, it was found that there was a risk of ending up under the play equipment if a subject fell straight into 1.5 metres of water and kicked off the bottom, or if they ran into the play area and fell into the water head or feet first. In the play equipment sway test, eight adults jumped around in the play area to sway the play equipment on the water surface, and it was investigated whether a subject who surfaced after falling into the water could end up under the play equipment through the gap between the play equipment and the water surface, but no such gap was observed. However, it was suggested that there was a possibility of dry drowning, aspiration, or disorientation due to the intense spray of water around the swaying play equipment. Furthermore, it was suggested that there was a risk of drowning if a person's body ended up in the gap between the play equipment, which is inevitable due to the structure of the play equipment, after falling into the water. In the climbing action test, it was verified whether a subject who fell from the play equipment into the water could end up under the play equipment again if they tried to climb up from the tip of the play equipment, but it was found that there was no such possibility.

In the confirmation experiment, two types of tests were conducted: a buoyancy resistance test and a play equipment sway impact confirmation test. In the buoyancy resistance test, it was found that while it took about 10 newtons of force to pull a subject who was underwater but not under the play equipment using a rope, it took about 200 newtons of force to pull out a subject who was floating face down under the play equipment. For comparison, even when a male university competitive swimmer swims using the crawl stroke, which generates the most propulsion, the average propulsion force is 155 newtons with a standard deviation of 25 newtons. Therefore, it was suggested that it would be difficult to escape from under the play equipment even for an experienced diver if a resistance of 200 newtons was applied. In the play equipment sway impact confirmation test, it was investigated what kind of impact would occur to a subject under the play equipment when the play equipment was swayed on the water surface. It was found that it was difficult to escape because the subject moved up and down with the sway of the play equipment, and furthermore, if the play equipment swayed while the subject was relaxed underwater with the upper part of their head or back stuck to the play equipment and their lower body hanging down, the upper body was pushed downwards and moved towards the feet, making it more difficult to escape as they moved towards the centre of the play equipment. It was suggested that this phenomenon could have occurred after the accident, leading to the possibility of drowning.

In addition, it was found that even if floating islands were installed instead of air play equipment, if a person ended up under the floating island, it would be difficult to breathe unless they came out from under it, leading to the risk of drowning. On the other hand, if there was a space under the play equipment, even if a person ended up under the play equipment, they could still breathe in that space, even though the height of the space would be reduced by about half when a person was on it, making it effective in preventing drowning.

Verification of life jackets[edit]

While no defects were found in the life jacket worn by the victim, an investigation was also conducted into the possibility that structural issues with the life jacket could have contributed to the accident. The investigation revealed that in a normal life jacket, there are six buoyancy materials on each of the left and right front sides, and four on the back. However, in two defective life jackets that the operator of the water-based play equipment at Toshimaen had stored as faulty products, two of the buoyancy materials on the left front had moved to the back, and two on the right front and one on the left front had moved to the back, with an additional two on the left front having shifted towards the back. This suggested that if the buoyancy materials on the front shifted during use and moved to the back through the shoulder openings, making it difficult to keep the wearer's face above water, this could potentially cause a drowning accident. It should be noted that none of the life jackets bore any of the safety certification marks such as the "Sakura Mark", "CS Mark", or "RAC River Education Life Jacket Certification Mark".

Investigation of similar accidents[edit]

As a result of investigations into similar past incidents, two similar cases were identified. One of these occurred in June 2000, when a primary school first-year girl became unconscious and later died after slipping under a floating island during free play in a swimming lesson. The other incident occurred in July 2012, when a primary school first-year girl drowned under a large kickboard in a pool during summer holiday swimming instruction, with 69 children in the pool at once and 16 large kickboards floating on the water. Both of these incidents, unlike the Toshimaen incident, occurred with floating island-type water play equipment. The parents of the girl who died in the 2000 incident told NHK in an interview after the Toshimaen incident, "I thought the same accident had happened again," and called for the lessons of the accident to be shared and the cause to be investigated. As both were accidents involving floating island-type equipment, this is the first known accident involving air play equipment installed on water.

In addition, according to a testimonial posted on Safe Kids Japan, in July 2018, the year before the accident, a boy under 10 years old managed to escape after slipping under the play equipment at the same Fluffy Water Land in Toshimaen by removing his life jacket himself. Ryuhiro Yamanaka, the chairman of the board, pointed out that the boy was able to respond in this way because his life jacket was loose, and if it had been properly worn, he might have failed to escape. Similarly, Yamanaka pointed out that if this testimonial, which was posted in the summer of 2018, had been considered, the accident might have been avoided.

Verification of safety measures in similar facilities[edit]

Water play equipment like that found in the "Fluffy Water Land" is lightweight and easy to remove in rainy weather, and because the material is soft, it had been installed in many beaches and pools in the years leading up to the accident. However, as it is not fixed to the ground, it is not subject to the Building Standards Act. As a result, there were no specific safety standards set by the Ministry of Land, Infrastructure, Transport and Tourism, and safety measures were left to the discretion of the operators. Therefore, the Consumer Safety Investigation Committee conducted a survey of 26 facilities in Japan that have water play equipment installed, covering four areas: business operations, scale/manufacturers, operating conditions/use conditions, and danger information/safety management status.

In the survey on the year of establishment, there were three facilities established before 2011, while there were ten facilities established in 2018-2019, indicating a recent increase as of 2020. Regarding the number of play equipment, nine facilities had more than 30 pieces, the highest number. Regarding the manufacturers of the play equipment, 12 out of the 22 facilities that responded said they were domestic companies, and regarding the sellers, 19 out of the 25 facilities that responded said they were domestic companies. Regarding the depth of the water where the play equipment is installed, all five facilities in pools were less than 2 metres, while 15 out of 19 facilities in the sea were more than 2 metres. Regarding restrictions for individual use, ten facilities had height and age restrictions, two facilities had height restrictions only, eleven facilities had age restrictions only, and three facilities had no restrictions. Two facilities did not require the use of life jackets. The most common height restriction was "1.1 metres or more" at ten facilities, and the most common age restriction was "6 years or older" or "first grade in elementary school or older" at a total of nine facilities.

Consideration of measures to prevent recurrence[edit]

If there is no gap under the water installation equipment, the body cannot get out when it is under the water installation equipment and cannot breathe (left), but if there is a gap under the water installation equipment, the body can float in this gap so that the face comes out of the water and breathing can be ensured (right).

In terms of measures to prevent a recurrence of this accident, the report suggested that it would be effective to introduce a mechanism that makes the bottom of the play equipment convex, so that even if someone ends up underneath it, they can naturally float up and breathe. Alternatively, stopping the use of life jackets and installing the play equipment in shallower areas could also be effective. Installing guards to prevent falling into the water or entering under the play equipment could also be effective, but there is a risk that if someone falls into the water, they could get tangled in the guard and be unable to float up, so safety needs to be verified. In addition, it was suggested that priority should be given to accident measures such as prohibiting rough play and peering into the water, ensuring distance from the play equipment in case of accidental falling into the water, reviewing surveillance systems and utilising drones and surveillance cameras, reviewing height, age and number restrictions, pre-fall and surfacing training, standardising manuals, thoroughly managing the quality of life jackets, and stopping the widespread installation of floating islands. It was also suggested that thrill-seeking by falling into the water should not be pursued. In addition, it was considered important to post warnings about the dangers and display them on the play equipment itself, and to establish a safety instruction system.

Even in the immediate aftermath of the accident, Ryuji Hojo, Chairman of the Japan Pool Safety Management Promotion Association, had proposed measures such as installing nets or fences under the play equipment and making the play equipment transparent to make it easier to spot people who are drowning. Yoshihito Nishida, an associate professor at Tokyo Institute of Technology who specialises in safety engineering, pointed out that surveillance can be difficult because light reflects off the water surface. Ryuhiro Yamanaka, Chairman of Safe Kids Japan, also pointed out that the term "fluffy" (ふわふわ) used to describe the 'Fluffy Water Land' is at odds with the current situation where many injury accidents are occurring, and suggested that such expressions should be avoided. Hisashi Kuribayashi, Representative Director of the Japan Air Play Equipment Safety Promotion Association, pointed out the need for ongoing and regular safety training, the development of personnel to provide air playground equipment security, and cooperation with organisations working for safety in water activities.

Review and presentation of the report[edit]

The Consumer Safety Investigation Committee meetings were not held from March to April 2020 due to the outbreak of the novel coronavirus (COVID-19), and committee members only reviewed the draft report individually. On 21 May, the report was discussed at the 92nd Investigation Committee meeting, and further deliberated at the 37th Service Accident Investigation Subcommittee meeting on 11 June, before being finalised at the 93rd Investigation Committee meeting on 19 June. In this report, the Ministry of Economy, Trade and Industry was asked to implement emergency measures to prevent recurrence, such as establishing safety standards for water play equipment, providing safety guidance to installers, prohibiting peering into the water, and strengthening inspections. The Ministry of Education, Culture, Sports, Science and Technology was also asked to alert education committees to the need for caution when using floating islands in primary school classes.

In response to these requests, the Ministry of Economy, Trade and Industry held a study group and established the "Guidelines on the Safety of Water Play Equipment" on 25 December 2020. These guidelines specify what should be done by businesses that provide play equipment, businesses that operate play equipment, and all related businesses. In addition, the Sports Agency, a subsidiary of the Ministry of Education, Culture, Sports, Science and Technology, referred to this report in its notice issued on 26 April 2021, "On the Prevention of Accidents in Swimming, etc. (Notice)", and called for the strengthening of surveillance systems when using floating islands in classes, and the cessation of use if safety cannot be ensured. Hisashi Kuribayashi, Representative Director of the Japan Air Play Equipment Safety Promotion Association, pointed out that the challenge is how to disseminate these guidelines to manufacturers who are not members of the association, as the guidelines do not have legal binding force.

Litigation[edit]

On 8 May 2020, the bereaved family members B and C of the deceased A filed a civil lawsuit in the Tokyo District Court, claiming that A's death was due to a lack of thorough safety management. They argued that, according to the guidelines of the Japan Air Play Equipment Safety Promotion Association, there should have been at least one supervisor per play equipment and a total of more than ten, but there were only seven in total. They sought a total of approximately ¥ 75 million (£ 377,600) in damages from Toshimaen, its parent company Seibu Railway, the contractor in charge of surveillance, and the manufacturer and installer of the play equipment. Toshimaen officials attended A's funeral, but did not participate in the condolence visit and did not comply with the out-of-court dispute resolution procedure. In an interview with the Sankei Shimbun, C stated that there had been comments from Toshimaen and others that the accident was unforeseen, and regarding the document received from Toshimaen after the accident, C said, "The content seemed to be blaming each other for the accident, and I didn't feel any sincerity at all," "What do they think of my daughter's life?" and "I didn't feel any sense of apology at all." It should be noted that the pool management company responded to an NHK interview immediately after the accident, stating that they had not anticipated that someone would enter under the play equipment.

The first oral argument took place on 14 September 2020, but all the defendants indicated a willingness to contest the case and asked for the plaintiff's claim to be dismissed. Seibu Railway merely commented, "We offer our condolences again. We will clarify our claims in the lawsuit". Bunshun Online reported that it is certain that the trial will be prolonged, as all four defendant companies are blaming each other for the accident.

On 6 March 2023, a settlement was reached in the Tokyo District Court. The details of the settlement were not disclosed.

Notes[edit]

References[edit]

Sources[edit]

  1. ^ CSIC 2020, p. 19.
  2. ^ a b c d CSIC 2020, p. 9.
  3. ^ a b c d CSIC 2020, p. 4.
  4. ^ CSIC 2020, pp. 40–41.
  5. ^ "Guidelines on the Safety of Water Play Equipment" (in Japanese). METI. 25 Dec 2020. Archived from the original on 2 Mar 2024.
  6. ^ Kamiya, Enka (26 Aug 2020). "The Unknown History of Toshimaen, Bringing Down the Curtain on 94 Years of History: A Local Reporter's Love". The Tokyo Shimbun (in Japanese).
  7. ^ a b c d e f g h i j "8-Year-Old Girl Dies in Toshimaen Pool Under Floating Play Equipment". The Asahi Shimbun (in Japanese). 15 Aug 2019.
  8. ^ a b c d "Toshimaen Swimming Pool Fatal Accident, Family of Third-Grade Girl to Sue Management Company". Sankei Shimbun (in Japanese). 7 May 2020.
  9. ^ Kuribayashi, Hisashi (23 Mar 2021). "What are the Risks and Safety Measures Related to Water-based Air Play Equipment? We asked experts about their opinions based on the 'report' released by the Consumer Safety Investigation Committee". A Notebook for Creating a Future with Zero Marine Accidents (in Japanese). Archived from the original on 10 Aug 2022.
  10. ^ a b CSIC 2020, p. 17.
  11. ^ a b CSIC 2020, p. 18.
  12. ^ "A life jacket can be deadly? Toshimaen Pool pointed out in 3 fatal accidents". Tokyo Sports (in Japanese). 16 Aug 2019.
  13. ^ CSIC 2020, pp. 10–11.
  14. ^ a b "An 8-year-old girl drowned in a swimming pool and died in Nerima, Tokyo" (in Japanese). Japan Broadcasting Corporation (NHK). 15 Aug 2019.
  15. ^ "Dangers Lurking in Water-Based Play Equipment, No Guidelines, 'Toshimaen' Girl Fatal Accident". Mainichi Shimbun (in Japanese). 31 Aug 2019.
  16. ^ "Girl Dies in Swimming Pool, Missing Shortly After Beginning to Play" (in Japanese). Japan Broadcasting Corporation (NHK). 16 Aug 2019.
  17. ^ a b "8-Year-Old Girl Dies in "Toshimaen" Swimming Pool ... Blind Spot That Even Wearing Life Jackets Couldn't Prevent Accident" (in Japanese). Fuji Television. 16 Aug 2019.
  18. ^ "Toshimaen Pool Accident: Danger Lurking in 'Water-Based Play Equipment': Urgent Need to Review Safety and Monitoring System". Sankei Shimbun (in Japanese). 22 Aug 2019.

Written report[edit]

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