The Human Factors Analysis and Classification System (HFACS) was used to evaluate a complex forensic case. The use of HFACS in forensic human factors is demonstrated via a case study of the death of a roller coaster rider ejected from his seat. The analysis revealed systemic factors for the fatality throughout the amusement park and ride manufacturer organizations. Such system analyses are needed to move park management and state investigators away from their narrow focus on rider behavior as causes of injury incidents, and address systemic factors to make amusement parks safer for guests.