Investigation into Entrapment Case of 8/24/2009 at Key Colony Pool

Incident

On 8/24/2009 at approximately 10:00 AM a small child about 3 years old became entrapped in a plumbing line of the Key Colony Pool located at 235 Crandon BLVD, Key Biscayne, Florida. The child was rescued by Fire Department after hours of labor to free the child. The Fire Department had to break apart the concrete of the pool.

Response

On 8/25/2009 the Department conducted a site investigation to try to determine the specific plumbing line that caused the incident and other contributing causes. A records investigation was also conducted to pull recent inspections of the pool and obtain copies of the Department’s approved plans.

Findings

This pool was built in 1980 to serve a condominium building which has more than 32 units and is exempt under Chapter 514.112(b) Florida Statutes and 64E-9 Florida Administrative Code. Therefore, the Department conducts an annual inspection and checks for water quality and life saving equipment only. An application for exemption was submitted to the Miami-Dade County Health Department on 7/25/1996 and the exemption was granted by the Department on 8/5/1996. The condominium community of Key Colony is comprised of four separate building with each building having its own home-owners association. Also there is a fifth association, the Key Colony Homeowners Association, which maintains an area utilized by all 4 buildings which includes the subject pool. The 4 associations for the buildings, Tidemark at Key Colony, Ocean Sound, Emerald Bay, and Botanica were contacted and all stated that leases of less than 60 days are not allowed. Therefore the conditions under which the exemption was granted are still the same and Key Colony is still eligible for the exemption. Additionally, the subject pool is maintained by the maintenance staff of the Key Colony Homeowners Association. The head of maintenance, Mr. Jorge A. Gonzalez obtained a certified pool operators certificate from the Miami-Dade County Health Department. The pool needs some obvious maintenance and repairs. Indeed, seven of the gutter drain covers were found broken and one was found missing (figure 5). There is also an area where the tile is sharp and broken (figure 6). The pool has two main drains with aquastar Virginia Graeme Baker Act compliant main drain covers that flow by gravity to a DE tank. The pool utilizes a recessed gutter system with 23 gutter drains flowing by gravity to the DE tank. The pool has two vacuum lines on the north side of the pool which are approximately 10” below the waterline of the pool. The plumbing line involved in the incident is the northeast vacuum line. The vacuum lines are under direct suction from a secondary vacuum pump. The northwest line had a screw in type cover in place. For the child to become entrapped, it is obvious that the cover was not in place, the vacuum pump was running, and the valve was open. An investigation of the equipment room found that the vacuum line cover was being stored near the entrance to the door (figure 4). Because the suction pipes are not clearly labeled (figure 3), it is difficult to determine which valve is controlling the flow in the vacuum line. Also, during the rescue process many of the pipes were broken. Basically, the main cause of the incident is poor operations of the pool. The cover on the vacuum line was not replaced prior to opening the pool. Secondary causes include running the vacuum pump when the pool is in use, not closing the vacuum line valve, and poor labeling of equipment and valves.

This report was finalized on 8/28/2009.