Commission de sécurité des consommateurs

 

 

Whereas

 

 

 

Following two fatal accidents, which involved young children and which occurred in private pools equipped with immersion detection alarms, in August 2005, the Commission initiated a referral procedure proprio motu on the safety issues raised by these safety devices (referral no. 05-096).

 

 

1. The first accident occurred on 23 August 2005 at the named locality Le Chabian in Aigaliers (Gard département) and involved a two and a half year-old child of Belgian nationality, Tije S., who was spending his holidays at a rented home with his family. The French gendarmerie report recorded the child’s father’s statement, to wit, “In the early afternoon we were all in front of the house, around the pool. I was with Geert^[1] under the arbour over the terrace, and with two of the children, and we were chatting. The pool is about fifteen metres from where we were sitting. My partner, who was coming out of the house, asked where our son Tije was. (…) My fourteen year-old son, who was reading in an lounge-chair beside the pool, looked up and yelled that Tije was in the pool. He immediately dove in and grabbed Tije. He handed the child to his mother who laid him on the lounge-chair. His uncle, who is a surgeon, and his wife, a radiologist, immediately gave a cardiac massage to the child. I called the SAMU [emergency medical services]. Unfortunately, nobody was able to revive Tije. The pool is equipped with an alarm system that triggers a siren when an object of given volume is in contact with the water. In the early afternoon, we shut off the alarm and went swimming. The older children were in and out of the pool at will… When the smaller children went swimming, an adult was there and in the water… The water has to be calm for a given amount of time - I don’t know how long - for the alarm to reset.”

 

The gendarmerie report established on 18 September 2005 states the following facts, “Although the pool was equipped with an sound alarm, as it had been switched off in the afternoon so that family S., the tenants, could swim, the sound-alarm detection device stayed in inactive monitoring mode because of the swimmers in the pool. Consequently, Tije unfortunately seized the “opportunity” of the “failure” of the safety system, which only resets to active mode after about 10 minutes[2] once the pool water has become completely calm, to get into the pool where he drowned.”

The owner, who was also questioned by the gendarmerie, stated, “Since I bought the house, I have had it renovated. I had company X. build a pool near the house. The concrete pool was dug in the rock. The pool is 5.50m x11.50m. On 31 May 2005, I bought the safety system at (…) and this is the one, i.e., system “A”, installed in my pool. I enquired and was told that it was the only safety system compliant with standards. […] I mounted the alarm system and when the “Belgians” came, I showed them how to use it, e.g., standby mode, alarm activation, and so on. I insisted on the fact that when they get out of the water, they have to stay by the pool and make sure that no child goes in the water during the time its takes for the alarm to reset, (police note: the water has to be completely calm before the alarm resets automatically), which takes a minimum of about 8 to 10 minutes.”

 

2. The second accident occurred in the Loiret département. As the family did not want to make any statement, the only information that the Commission could collect was in the email dated 9 December 2005 and sent to the CSC by the Sauve qui veut Association, “The alarm was brand “A”. I went on their website and there seems to be a more recent model, (…) where the device can make the difference between the stir in the water caused by the wind and the one caused by a falling body, so it does not trigger the alarm but goes into inactivation mode anyway. Actually, that’s the whole problem with these alarms. Because if the pool water is stirred up (by the wind or after swimming) the device cannot reset to monitoring mode. That’s what happened to us. Gusts of wind would trigger the alarm, so we set the device on standby (not completely off). The device should have then automatically reset to active mode once the water became calm but the wind force and our swimming prevented it from doing so. So I would say that this type of safety device is very inaccurate not to mention that it is also complicated to use.”

 

3. After the Commission initiated the referral procedure proprio motu, it learned about the following accidents.

 

- A fatal accident occurred on 28 August 2005 in the département of La Réunion, involving circumstances - but that were different than the two previous cases - where the alarm was not triggered. The gendarmerie reports detail the circumstances of the accident.

 

In a report, the mother underscored that the alarm was in active mode during the drowning, “Our pool was equipped with an alarm that is always on. I trusted the alarm. We had run tests and it worked every time.”

- A fatal accident occurred on 19 April 2006, in the pool of a house in Saint-Chef (Isère département). Since September 2005, the house had been rented to a couple from New Zealand. A fifteen month-old baby drowned when it fell in the pool, which was covered just with a bubble pool cover on the surface of the water and equipped with an immersion detection alarm. The Commission contacted the Saint-Chef gendarmerie authorities. According to the officer in charge of the investigation, the alarm installed in the pool was brand “A”. The first facts uncovered by the investigation revealed that the battery in the device was faulty. The pool owner stated that he had made the device available to the tenants. When it had been installed in the pool in July 2005, it was in perfect working order and the instructions were in the pool maintenance shed. The child’s mother stated that she had not checked battery status because she had not heard any beeps indicating that the device was faulty.

 

 

In a letter dated 16 October 2005, the Commission was petitioned by Mr. Michel M. who explained that he was puzzled when he read the instructions of another model, belonging to the “A” range of products (referral no. 05-109), combined with an ‘A.D.’ remote alarm device. The petitioner stated, “On October 11 2005, I purchased an immersion detector for my pool. As I had little time to run tests and enjoy the advantage of the manufacturer’s warranty, my priority was to read the guide to the installation and use of the device very carefully.”

-         The test sheet only referred to the central detection unit (did it not apply to the remote unit?)

-         Paragraph 8 (page 11) said that if the device stopped working, “it was left to retailer’s discretion to offer a standard exchange. Neither the retailer nor company M. are required to replace the device automatically…”

 

 

 

The CSC has already addressed safety issues in private pools. In its Recommendation of 6 October 1999, it advocated legislation that would make safety systems for pool protection mandatory, with a preference for safety fences, viz., permanent physical obstacles that materially block young children’s access to the pool. 

 

-         A fence is a permanent physical obstacle between a child and the pool; it has proved its efficiency abroad by reducing the number of drowning accidents substantially, specifically in Australia and New Zealand.”

 

Since the issuing of the Recommendation, the CSC has expressed its reservations about pool alarms, and specifically immersion detection alarms, several times.

 

Following the accidents that occurred in 2005, it was important for the CSC to analyse whether immersion detection alarms for pools could be considered as safety equipment as defined by legislators in Act No. 2003-9 of 3 January 2003 on pool safety, that is to say, “serving to prevent the risk of drowning.”

 

As the public authorities have not conducted a census of the drowning accidents in 2005,[3] the report on fatal drowning accidents of children under five,[4] which is probably not exhaustive, and which the Sauve qui Veut Association compiled in a census on accidents in private pools in 2005, shows a sharp drop in the number of accidents compared to 2004 when 17 deaths were reported. This is due to the positive impacts of the Act on pool safety.[5] However, unfortunately the following accidents occurred:

 

-          3 cases of drowning in unprotected pools

-          3 cases of drowning in pools equipped with immersion detection alarms claiming to be compliant with standards

-          1 case in a pool covered with a non-compliant tarpaulin

-          1 case in a pool equipped with a fence and an alarm and while adults were inside the bathing area perimeter.

 

The Fédération des professionnels de la piscine (FPP, a trade association of pool professionals) also reports with satisfaction that since the implementation of the Act of 3 January 2003, the number of fatal drowning accidents of children under five has dropped, viz., 17 cases in 2004 compared to 25 in 2003. From June to September 2005, 10 accidents occurring in inground pools subject to the Act[6] were reported to the Federation. Five out of the ten accidents occurred in pools without any safety devices, three accidents happened in pools equipped with alarm systems claiming to be complaint with standards or with a “fence plus alarm” system, it is not known whether the said system were compliant with standards or not. One drowning accident happened in a pool equipped with a fence, it is not known whether the said fence was compliant with standards or not. One drowning accident occurred but the description of the accident circumstances is not known. 

 

 

 

 

France is the only European country with a legislative and regulatory system on pool safety.

 

 

The Act of 3 January 2003, which amended the Building and Housing Code, stipulates that,

 

 

 

In fine, the Act provides for the filing of a report with the Bureau of Parliamentary Assemblies before 1 January 2007. The said report must detail accidentology trends and draw up a status report on the implementation of the law.

 

 

It sets forth the following provisions,

 

It was deemed necessary to supplement the said Decree with another decree dealing with the conditions whereby pool owners and professionals could attest that the safety equipment they sold (the professionals), that they already owned or that they installed themselves (the individuals) were compliant with safety requirements.

 

 

It sets forth the following provisions,

 

[...] For the alarms:

-          The alarms must be designed, built or installed in such a way that children under the age of five cannot use any of the switches. The detection systems must be able to detect any child under five going past the system and trigger a warning device comprising a siren. The alarms must not go off in an untimely manner.”

Are deemed meeting the above-mentioned safety requirements, “the systems compliant with French standards or with the standards or technical specifications or with the manufacturing procedures in effect in a Member State of the European Community or in another State party to the agreement on the European Economic Area, and ensuring an equivalent level of safety.”

The references of the standards or regulations must be published in the Official Journal. 

For the systems installed before the implementation of the Act, the provisions stipulate that owners are not obliged to replace their systems if they prove that their system is compliant with safety requirements, either by third-party expertise or by compiling evidence to this effect:

 

The Decree presents a legal problem, i.e., the safety system may be validated if it complies, not with just the standards,[7] but also with strictly defined safety requirements.

 

Therefore, there is a contradiction between the legal obligation to install a standardised system and the possibility left open by the Decree to keep or install a safety system compliant with safety requirements.

 

This situation may have two consequences:

1. In case of accident, a pool owner who has complied with the provisions of the Decree may, however, be liable for not having obeyed the law. Of course, the Act on pool safety does not explicitly provide for an inspection by an administrative authority. However, as for any violation punishable by law, the officers or judicial police officers (certain civil servants of the gendarmerie, the police, the mayor and his deputies) may report a violation. Thus, one cannot rule out that an owner “in good faith” may take action against the public authorities.

 

2. As things now stand, the Decree “lowers” the safety level of products by freeing certain professionals from the obligation of ensuring that their products are compliant with standards.[8]

 

Therefore, the Commission deems that it is necessary one, to establish a coherence between the two legislations, i.e., secure the legal situation of pools owners who - in good faith, and on the grounds of the Decree of 7 June 2004 - have installed a device that is not necessarily compliant with standards and two, to make sure that, in the future, the safety level is not lowered by referring to the standards as sole proof of compliance, as provided for in the Act.

It should be noted that, to date, the references of the standards that should be used for the implementation of the Act of 3 January 2003 are still not published in the Official Journal.

 

 

 

As we have already seen, following the above-mentioned CSC Recommendation, standardisation work was undertaken under the aegis of the Association Française de Normalisation (AFNOR, French association for standardisation). Four standards were designed for the 4 pieces of equipment available on the market, viz.,

 

-          Fences (NF P 90-308),

-          Alarms (NF P 90-307),

-          Pool shelters (NF P 90-309),

-          Covers (NF P 90-306).

 

It deals with perimeter detection alarms and immersion detection alarms. As the preamble to the Standard says, it “defines the minimum safety requirements, the testing methods and consumer information on the alarm systems, which are set up around or in private unfenced in-ground pools for individual or collective use to detect any intrusion, fall or immersion and specifically the intrusion, fall or immersion of children under five within the protection area.”

 

Aside from the provisions common to both alarm systems, the Standard comprises special provisions for immersion detection alarms. 

 

The Standard has undergone alterations and one “A 1” amendment, which was approved in July 2005. The purpose is to detail the testing methods for a more accurate check of the compliance with two requirements of the initial Standard, i.e.,

 

-          Ensure that the wind does not interfere with the alarm detecting a body falling into the water

-          Ensure that the wind does trigger false alarms

 

Standard requirements have not changed compared to what was written into the initial Standard (paragraphs 6.2.2.2. and 6.2.2.3.) in 2004. However, the testing methods were altered in 2005.  

Standard requirements:

 

Standard NF P 90-307 of May 2004 and its July 2005 amendment essentially provide for the following safety requirements and testing methods. 

 

-       Device must be operational 24/7, except when the system is deliberately shut off

-       Built-in siren or remote siren with a wire connection

·                    Activation/deactivation switches:

. Either out of reach of children under five

. Or childproofed and easy to use for adults 

-   Battery life

·                    Solar cells: 20 days

·                    Batteries with plug-in rechargers: 6 hours of power

24 hours to indicate failure

·                    Batteries: 1 year, battery operating-life has to be checked with a testing method defined in Appendix B to the Standard.

-       Device must be operational during and after exposure to heat (70°C), to cold (- 25°C), and to cyclical humid heat (55°C, 93% humidity), but the power cells and batteries must be replaced by an outside power source during all these tests

-          Rainproof and splash-proof

-          Manual off switch on siren

-          Permanent display of system status: monitoring – not monitoring

-          Device activation and inactivation with a special switch that cannot be operated unintentionally

-          If device has a failure signal, it must be a sound signal emitting a different sound than the warning systems and may be supplemented by a permanent light signal

-          Warning signal sound must reach a minimum of 100dBA at a distance of one metre and peak value must be under 115dBC

-          Alarm must go off when a testing device[9] weighing at least 6 kilograms is immersed from pool side

-          Alarm must go off when a testing device weighing at least 8 kilograms is immersed from the stairs, ladders, or an access ramp with a 30% slope

-          Alarm should not go off in an untimely manner in specific conditions, i.e., it should not be triggered by a filtration system, a cleaning robot, or the wind

-          A so-called “wind behaviour” test (constant wind blowing 4 metres per second, equal to 14.4 kilometres per hour or to Force 3, breeze and wind gusts of 8.5 metres per second or 30.6 kilometres per hour).

 

Considering the typology of the accidents that were brought to the CSC’s knowledge, the Standard, as it is now worded, clearly contains insufficient safety requirements to guarantee the reliability of the devices examined by the laboratories.

 

1.       In 2005, two fatal accidents occurred during the variable and uncertain delay before automatic reactivation of the system. However, the Standard does not set a limit for automatic reactivation time nor does it define the required conditions (still water, unambiguous signal for user) for automatic reactivation reset within a given lapse of time.

2.        In 2006, a fatal accident occurred because a battery in the device failed. Warning signals are provided for but the Standard has set no requirements for the duration of the warning before the batteries are completely spent, nor does it make any requirements concerning the clarity of the system failure signal and - especially for a human life-saving system - it does not provide for emergency power back-up, which is only recommended for plug-in devices.

3.       The same accident occurred in a pool equipped with a bubble cover, which is not a safety device. The Standard does not provide for any tests to assess whether alarm operations are disrupted by pool comfort and maintenance equipment, other than the cleaning robot or filtration systems.

4.       Perfectly legitimate questions have been raised on the type of pools in which the tests are run. However, the Standard does not indicate the type of pool in which the test is conducted (out-of-ground, in-ground, impact of the sides or the raft, and so on).

 

Importantly, it should be underscored that the NF mark does provide for requirements that work to improve the safety of the devices, viz.,

 

-          Devices equipped with a reporting system on alarm device status (operating, radio link, power), equipped with an additional siren

-          Reporting by a secure wire or radio connection

-          Automatic reactivation in less than 15 minutes,

-          An event log

-          Battery life:

·                    Solar cells: 1 year

·                    Batteries with plug-in rechargers: 1 week

 

 

 

The CSC had Mrs. Brigitte R., an engineer specialised in product ergonomics, take stock of all the products sold on the French market (in specialty stores, by mail-order or on the Internet).

 

It is interesting to note that,

 

-          Alarm prices range from €300 to €2,690

-          Only one alarm is approved by the NF mark

-          The instructions do not usually indicate whether the product has been tested by a laboratory independent of the company

 

Furthermore, the CSC asked:

 

-          Mrs. Brigitte R. to conduct a risk analysis using the method validated by the European Commission and a study of the ergonomics of immersion detection alarms

-          The LNE (Laboratoire National de métrologie et d’Essais, national testing laboratory) to buy an immersion detection alarm, put itself in the place of a consumer and test it, in November 2005.

 

The following questions were asked:

-          Are there any circumstances where a child can drown despite the existence of an alarm?

-          If so, what are the conditions so that an immersion detection alarm is truly a safety device? 

Principle of the Risk Assessment and Methods

 

The general principle of a risk assessment is laid down in the AFNOR booklet called “FD X 50-252 – Guidelines for risk assessment” still in progress.

 

This method for assessing a risk inherent to a hazard is proposed by the European Commission in its document, PRODUCT SAFETY IN EUROPE: A Guide to Corrective Action including Recalls, June 2004.

 

Mme Brigitte R. conducted a critical analysis of the instructions and ran tests in pools belonging to private individuals.

 

 

 

In normal use or reasonably foreseeable conditions of use, the identified accident scenarios are described below. 

a) Normal use with a device in perfect working order

 

·         Lapsed parental supervision due to device ergonomics

Theoretically, the fall detector is a supplement to permanent parental supervision. Their supervision will be all the more efficient if it is relayed by detector supervision. So, users must know if the detector is operating or not, at all times. None of the detectors clearly display activation status. The central detection unit of product C provides this information very clearly. The words used by the other systems, such as “active monitoring”, “inactive monitoring” or “standby monitoring” are vague.

 

·         No Adult Response

No one is swimming; the device is working. A child falls in the water. The device detects it and the siren goes off. Nobody responds within three minutes.[10] Case of a child that slips from one garden to the next, far from the person who is supposed to supervise the child, and the pool owners are absent. Not all pools are in a fenced-off garden. This is the case when a pool is far from wherever the adult is busy doing something, for instance with the pool on one side and the garden table at the other. This is also the case when there are several adjacent pools. The pool owner may think that the ringing alarm is his or her neighbour’s.

 

·         Adult response is too late

No one is swimming; the device is working. A child falls in the water. The device detects it and the siren goes off. An adult responds, but too late. In 2 minutes and 30 seconds an adult walking at a speed of 4 kilometres per hour covers 167 metres. This is the pace that the adult can sustain over the rough terrain of the house and its surroundings (stairs, doors, and other obstacles). If the pool is at the other end of the garden or if the adult does not react immediately to the siren going off, he or she will arrive too late. This is also the case when someone cannot reach the pool (neighbours in the garden, guard dog, etc.). It is also the case when an adult falls down the stairs as he or she is running toward the pool. 

 

·         Latency

After swimming, the device is not reset by hand; it automatically resets after 4 to 15 minutes (if there is no wind and no counter current stroke system). During this time, a child jumps in the water or slips into the water. The device does not detect it. The child drowns within an average time of 3 minutes. All the devices are concerned by latency. Latency time lasts from 4 to 15 minutes.

 

·         Forced mode

After swimming, the device is switched on by hand but the pool water is still stirred up. The device is in “forced” mode. The user may think the device is working. During this time, a child slips into the water or goes down the stairs quietly. The device does not detect it. All the devices are concerned by forced mode. Forced mode time lasts from 4 to 15 minutes. Users must be warned whether the device is or is not in “active monitoring” mode.

 

·         Counter current stroke system

After swimming, the device is switched on by hand but the counter current stroke system is still on. The pool water is still stirred up. The device is in “forced” mode. The user does not know this and thinks that the device is working. During this time, a child slips into the water or goes quietly down the stairs into the water. The device does not detect it. Users must be warned when the device has not reset to “active monitoring” mode.

 

·         Tenants

Homes with pools are sometimes rented or loaned. The owners leave the tenants a document with the instructions for all the appliances in the house. The instructions for the alarm are in a pile with all the others. The tenants do not understand or misunderstand how the device works. This is the case for product “A” where the same gesture is used to turn off the switch for swimming and to turn the device on, and where the light or sound signals are not clear. The instructions supplied with the devices are not at all appropriate for occasional users who need to:

-      Understand as intuitively as possible how the device works

-      See simplified, easy-to-reach instructions

-      Be warned about latency time after swimming

 

b) Foreseeable Use

 

·         Moving the central detection unit

The console for the device is on the central detection unit of product “C”. Some users take it with them from the garden to the house, from the main house to the rented house with the pool. It can be forgotten outside while everyone has gone indoors, for example. A fall in the water is signalled by the siren but it cannot be heard in every part of the house.

 

·         Faulty installation

Users install the device themselves. They have to cut off a length of the sensor with a hacksaw so that the sensor reaches a given depth. Cutting the sensor that is an integral part of the device is a tricky operation and may damage the entire device. Users may choose not to do so. Or the sensor is not absolutely vertical and the device is mounted anyway but it will not be at peak efficiency. Tests are not all positive. Users leave the device the way it is. All falls will not be detected. This is the case of all the sold devices that have to be installed and started up by users.

 

·         Unsuccessful and unimportant tests

Users test the device after installing it, and continue to do so on a regular basis. When the tests are partly negative (and when users attempt further adjustments to no avail), users no longer trust the alarm. If users do not have young children at home, they choose to leave the alarm as is, knowing that it is inefficient, just so they are compliant with the law in case of an inspection.

 

·         Failed tests and users do not accept this

Users test the device after installing it, and continue to do so on a regular basis. When the tests are negative (and when users attempt further adjustments to no avail), users no longer trust the alarm.

 

·         Spent batteries

The detector batteries are spent. Users do not realise this or do not know the meaning of the beeps. A child falls in the water. The device does not detect it. This is the case for products “A” and “B”. The central detection unit of product “C” provides clear information.

 

·         Half empty pool

In winter, professionals advise owners to lower the water level in the pool and add wintering products. Many owners cover the pool with a tarpaulin but some leave the pool half filled without any tarpaulin. The detector sensor is not in the water: the device cannot work. The pool is not safe. 

 

·         Drought

During drought and water-use restrictions, it is forbidden to fill pools. The water level goes down and the device loses efficiency. Some falls are not detected. 

 

·         Theft

Alarms are sometimes stolen. The pool owner thinks the pool is monitored but it no longer is.

 

3)    Risk Assessment

 

Below there is a diagram summing up how a fall detector works, in the case of a device in good working order and in normal conditions of use. 

 

 

 

In normal conditions of use, when the device is working and properly detects a fall, its efficiency depends on the adult’s response time and on the adult reaching the child, who is already in the water, fast.

Hazard: drowning

Risk level: Very high

Probability: low (remote monitoring) to very low (very watchful adult)

In this case, the risk is assessed as severe and unacceptable because young children are very vulnerable.

 

In reasonably foreseeable conditions of use, the device is not operating 24/7. The periods when monitoring is inactive (in grey on the diagram) are:

 

-          Latency time after swimming

-          When wind is blowing

-          Full shutdown time

 

During these periods, the hazard stems from drowning due to an undetected fall of a child in the water. The severity is classified as very high: drowning. Probability is linked to:

 

-          Non detection of the fall by the device

-          Adult supervision when the device does not detect the fall

 

If adults are clearly warned of the short latency times, they will supervise the child and be able to respond in time, thus leading to very low accident probability. The table of the Guide of the European Commission (see next page) assesses the risk as serious because children are very vulnerable people. 

If adults are not clearly warned of latency and non-efficiency times, their supervision is the same as when they think the alarm is active, i.e., imperfect supervision. Therefore, the probability of an accident occurring is high. The risk is assessed as serious.

 

The level of risk related to the use of an alarm, even if it is used in compliance with the instructions, is serious in every case.

As young children are a highly vulnerable population, the risk is deemed unacceptable.

The additional analysis of reasonably foreseeable uses further broadens the possible non-detection periods of a child’s fall in the water by the device, and therefore, the level of risk.

 

 

Excerpt from PRODUCT SAFETY IN EUROPE: A Guide to Corrective Action including Recalls, June 2004