Dreamworld tragedy: Inquest begins as families await explanation over ‘enormous heartbreak’
THE lead forensic crash investigator of the fatal Dreamworld accident has told the inquest the disaster was not a totally unforeseen accident. HOW DAY ONE UNFOLDED
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- Last moments of Dreamworld victims
- Ride operators represented by Queensland’s best barristers
- Inquest into tragedy to be held in two parts
THE long-awaited coronial inquest into the Dreamworld tragedy has begun. The courtroom is packed with lawyers.
THE FIRST DAY OF THE INQUEST HAS NOW CONCLUDED. SEE OUR ROLLING COVERAGE BELOW
4.45pm The lead forensic crash investigator of the fatal Dreamworld accident has told the inquest into the deaths of four people the disaster was preventable and not a totally unforeseen accident.
During evidence, Senior Constable Steven Cornish of Queensland police’s Forensic Crash Unit said that after the investigation, he believed there were a series of preventable safety features that could have been put in place to prevent the deaths of four people in the October 2016 tragedy.
Under cross-examination by barrister Steven Whybrow, Snr Const Cornish said the potential for a fatal accident to occur was “always there”.
“The two rafts colliding, if the safety mechanisms were in place to stop the ride on the drop of a water level, the rafts had never got to the point they got to,” he said.
The inquest was also told that if the two-second emergency stop button located at the end of the ride had been pressed at any time before the rafts collided, the tragedy could have been avoided.
“If it was pressed in that 30 seconds would it have made a difference?” Mr Whybrow asked.
Sen-Const Cornish said: “Yes.”
“They (the rafts) touch three times, before they get to that point... If it (the button) had been depressed at any time this would have avoided the tragedy,” he said.
The inquest has been adjourned until tomorrow.
12.50pm A memo was sent to Dreamworld staff less than a week before the Thunder River Rapids ride malfunctioned and killed four people, discouraging operators from pressing an emergency stop button that could have shut down the ride down almost instantly.
During cross-examination by barrister Steven Whybrow, for victims Kate Goodchild and Luke Dorsett, the inquest was told staff were not aware of what the emergency stop button did, including operator Courtney Williams, who was on duty on the day of the fatal accident.
“She wasn’t aware about what the switch really did and (there was) a recent memorandum published by Dreamworld dissuading people from pressing that button,” Mr Whybrow said.
The inquest heard there were two types of emergency stop buttons on the ride, one at a control panel at the start of the conveyer belt that stopped the ride in nine seconds and another closer to the end of the ride that stopped the ride within two seconds.
On October 19, Dreamworld issued a memo to staff working on the Thunder River Rapids ride saying here was a set criteria when the two-second e-stop could be pressed, namely if the person at the control panel area could not be reached by the other ride operator.
A raft could travel 4m in nine seconds, but only 0.7m in two seconds, the inquest heard.
Det Sgt Brown also told the court several people had raised concerns that the buttons to stop the ride in the control panel were confusing.
“It is a confusing control panel and that has been raised by the auditors,” she said.
The court heard when the ride malfunctioned, the ride operator at the control panel “wasn’t sure which button to press” under the stress.
The court heard if one of the many problems that occurred on the ride in the lead-up to the tragedy had been addressed, the deaths could have been prevented.
Mr Whybrow described to the court the Swiss-cheese model of risk mitigation, where defences are layered on top of each other like slices of Swiss cheese to avoid emergency situations.
“In this case the opposite applies, there area whole number of little things and if one of them had been addressed it could have prevented this tragedy,” he said.
Det Sgt Brown agreed.
12.11pm Barrister for Kate Goodchild and Luke Dorsett, Steven Whybrow, is now cross-examining Det Sgt Brown about the e-stop button on the ride. Says it was “totally unmarked”.
One of the main ride operators during the Dreamworld disaster was told of the emergency stop button that could have shut down the ride in two seconds: “Not to worry about that button no one uses it”
A memo was sent to staff less than a week before the deaths saying only to use the e-stop button if the "main control panel cannot be reached".
— Alexandria Utting (@alexutting) June 18, 2018
“It is a confusing control panel and that has been raised by the auditors,” Det Sgt Brown said.
12.05pm Det Sgt Brown said the immediate response by the individual employees was “in my opinion quite well done”.
She said documents from Dreamworld could have been better set out because it was hard to “determine what documents related to what”.
12pm Operators relied “simply on a scumline” rather than a ruler or an indicator to tell the water level was no longer at a “functional level” the inquest hears during cross-examination by barrister Matthew Hickey, for Cindy Low’s family.
There are no documents to show Ardent Leisure reviewed the ride after taking over the park in 1998.
“It was something that has affected a lot of people, not just the families or the victims themselves, their feelings were widespread throughout the community,” Det Sgt Brown tells the inquest.
RIDE SAFETY ADVICE IGNORED BEFORE TRAGEDY
RECOMMENDATIONS to install CCTV at the unload area of the Thunder River Rapids ride were never put in place, despite being made more than a decade before the fatal accident.
Lead investigator in the criminal investigation into the Dreamworld tragedy, Detective Sergeant Nicola Brown, told the inquest after a 2001 incident where two rafts crashed into each other, there was an internal investigation undertaken that recommended CCTV be placed at the unload area of the ride.
The CCTV was never installed, the inquest heard.
Det Sgt Brown also told the court there had been a recommendation in 1999 that an emergency stop button that shut off rides immediately -- rather than taking seven seconds to shut down — be installed.
“The 1999 recommendation of positive energy stop didn’t happen then or even later,” Mr Fleming asked.
“No,” Det Sgt Brown said.
She also told the court there was no evidence engineering staff attended the ride second time the Thunder River Rapids malfunctioned on the day it killed four people in 2016.
“There is no evidence any engineering staff attended the second incident,” Det Sgt Brown said.
The court heard there was no evidence anything else was done other than resetting the pump, about an hour before the fatal accident.
Det Sgt Brown also told the inquest there was nothing on the ride that could measure water levels or shut off the ride if the level became too low.
ROLLING UPDATES:
11.45am Inquest hears there was no way to measure the water levels of the Thunder River Rapids ride and there was no switch to automatically shut down the ride if the water level dropped.
11.30am Det Sgt Brown tells the inquest the Thunder River Rapids ride was modified to include shorter planks on conveyer sometime in the 1980s or ’90s, but police were unable to obtain documentation relating to the modification.
RIDE OPERATOR SAVES LIFE OF VICTIM’S SON
A YOUNG ride operator who was on shift on the day of the Dreamworld tragedy saved Cindy Low’s 10-year-old son Kieran from the raft that tipped into the water.
Ms Low, 42, was at the theme park with her 10-year-old son Kieran, six-year-old daughter and her husband Mathew on the day she died.
Ms Low and Kieran were on the Thunder River Rapids ride when it malfunctioned.
Inquest hears 1999 reccomendations to put a "positive energy stop" button on rides at Dreamworld, meaning they would not take seven seconds to stop, were never put in place. @couriermail
— Alexandria Utting (@alexutting) June 18, 2018
Detective Sergeant Nicola Brown told the inquest ride operator Courtney Williams was in the unload area when she realised the water level had dropped and signalled there had been an operational problem.
A security guard viewing the CCTV of the ride upgraded the incident to a more serious alert.
“Once the incident had unfolded, (Courtney) went into emergency mode and assisted everyone she could, including Kieran out of the ride,” Det Sgt Brown said.
ROLLING UPDATES
11.21am The inquest hears there is no evidence that engineering staff attended the ride after it failed the second time on the day of the fatal accident.
“There is no evidence anything was done other than resetting the pump,” Det Sgt Brown says.
11.15am The Dreamworld inquest hears ride operator Courtney Wilson helped children out of the raft after the water level dropped on the Thunder River Rapids ride. “She assisted everyone she could...” Det Sgt Brown says.
The inquest hears an internal investigation recommended CCTV but put at the unload area of the ride, but this has not occurred.
There was no drill training for staff at Dreamworld to determine how they would react in an emergency situation.
RIDE BROKE ‘SEVERAL TIMES’ BEFORE TRAGEDY
THE pump on the Thunder River Rapids ride failed twice in the hours before the fatal accident at Dreamworld in 2016, but the ride continued to operate.
Lead investigator in the criminal investigation into the deaths of Kate Goodchild, Luke Dorsett, Roozi Araghi and Cindy Low, Detective Sergeant Nicola Brown this morning told the inquest the south pump on the ride failed twice before the deaths on October 25, 2016.
Det Sgt Brown told the inquest the pump failed at 11.50pm and 1.09pm but was reset by engineers and continued to operate.
“The problem was described as an earth fault with the south pump, that’s the terminology that was used,” she said.
“At 11.50am, the ride was successfully shut down, engineering attended, reset the pumps and operating continued as per normal.”
The same thing occurred at 1.09pm.
The accident involving Ms Goodchild, Mr Dorsett, Mr Araghi and Ms Low occurred less than an hour later.
The inquest also heard communication between ride operator at the control panel and loading people on and off the rafts was difficult because of the noise coming from the pumps.
“The noise that the pumps emit makes the communication between the two areas difficult,” Det Sgt Brown said.
ROLLING UPDATES
10.45am The inquest has heard the Thunder River Rapids ride had broken several times on the day of the disaster as the pump had stopped working.
The pump failed twice before the fatal accident but was reset by engineers, Det Sgt Nicola Brown tells the inquest. Once at 11.50am and once at 1.09pm. The fatal accident happened just after 2pm.
10.40am Det Sgt Nicola Brown is speaking about a video of water levels on the Thunder River Rapids ride: “The water is dropping significantly and quite quickly,” she said.
CONCERNS RAISED OVER TRAGIC RIDE IN 2001
THE Dreamworld Thunder River Rapids ride malfunctioned 15 years before Kate Goodchild, Luke Dorsett, Roozi Araghi and Cindy Low died, the inquest into the tragedy has heard.
The group were killed when their raft flipped on the ride in October, 2016, after one of the pumps failed.
During the opening of the inquest, which today began at Southport on the Gold Coast, counsel instructing the coroner, Ken Fleming QC said there had “sadly” been past incidents on the ride.
The inquest heard in January 2001, two stationary rafts banked up at the unload area of the ride before three rafts came off the conveyer and collided.
One of them also flipped, the inquest was told.
After the incident, emails were sent between staff where they said: “I shudder when I think if there had been guests on the ride,” the inquest heard.
These emails will be tendered during the inquest.
An exhaustive police investigation has recommended no criminal charges be laid against any individuals, but Dreamworld’s operating practices will come under the microscope at the inquest.
Coroner James McDougall will examine the maintenance, safety, staffing and modifications of the Thunder River Rapids, while the inquest will also scrutinise the sufficiency of training provided to staff operating the ride.
There are 37 staff being represented during the inquest
ROLLING UPDATES
10.30am Detective Sergeant Nicola Brown, who led the investigation into the Dreamworld tragedy will now take the stand to give evidence.
10.21am Past incidents and previous breakdowns of the ride will be explored during the inquest, including an incident in 2001 when several rafts collided.
“I shudder when I think if there had been guests on the ride,” staff said via email at the time, the inquest has heard.
Past incidents and previous breakdowns of the ride will be explored during the inquest, including an incident in 2001 when several rafts collided. "I shudder when I think if there had been guests on the ride," staff said via email at the time, inquest hears. #Dreamworld
— Alexandria Utting (@alexutting) June 18, 2018
10.17am The inquest has heard the south pump of the ride failed causing the boats to tip and collide, Mr Fleming says.
The two police who conducted the investigation into the incident will be the first to give evidence.
10.07am Ken Fleming, QC, begins his opening address. He says it was about 2pm when the Thunder River Rapids ride had a “significant mechanical breakdown” causing the deaths. “The tragedy of this event has been felt Australia-wide,” he says.
Mr Fleming says the inquest is about sifting facts: “It is not adversarial” but about finding out “what caused the person to die”.
Mr Fleming says the Dreamworld inquest is in the public interest and designed to draw attention to the event and “prevent further such events”. He says the deaths were “sadly... both violent and unnatural”.
BACKGROUND: Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi lost their lives on the Thunder River Rapids Ride in October 2016.
The four ride passengers were killed instantly from compressive and crushing injuries when they were caught in a malfunctioning mechanism on what was billed as a tame family friendly attraction.
Ms Goodchild’s 12-year-old daughter and Ms Low’s 10-year-old son were on the raft that flipped at the end of the ride, but survived.
Since then the families have sought answers and relatives of Ms Low have said how they hoped the probe would prevent others from suffering “such enormous heartbreak”.
Dreamworld suffered steep falls in visitor numbers following the fatal accident and the park’s subsequent 45-day shutdown.
Before Monday’s inquest several hearings were held and attended by lawyers for the four victims, Dreamworld chief executive Craig Davidson, Dreamworld’s parent company Ardent Leisure and the Office of Industrial Relations. At a conference in April at the Brisbane Coroners Court it was suggested the inquest be held in two parts.
Coroner James McDougall last month ordered the list of witnesses needed to attend the inquest be finalised by June 1.
Final evidence submissions were to be made by June 8.
The inquest is listed to open at Southport Courthouse on Monday morning.
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