A referral has been made to the Office of Industrial Relations to consider if there is sufficient evidence to show Ardent Leisure committed breaches under workplace laws
Dreamworld inquest findings into Thunder River Rapids Ride tragedy
The Coroner has blasted Dreamworld and referred its parent company Ardent for investigation over the disaster saying there was a 'total failure' leading up to the tragedy. It comes as heartbroken families addressed the court saying they have 'broken souls'.
Dreamworld has been blasted and its parent company Ardent may face prosecution after bombshell inquest findings deemed it had 'total' and 'systemic' failure in the lead up to the 2016 tragedy that claimed four lives.
Dreamworld's parent company Ardent Leisure has been referred to the Office of Industrial Relations over the Thunder River Rapids ride tragedy that killed four people more than three years ago.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died after the raft they were travelling in flipped when the theme-park ride malfunctioned on October 25, 2016.
Almost four years on, Queensland Coroner James McDougall this morning handed down scathing 300-page findings into the tragedy where he labelled Dreamworld's actions a 'total failure' and the hazards on the Thunder River Rapids ride posed 'significant risk' to patrons.
He said there had been a "systemic failure by Dreamworld to ensure all aspects of safety" and referred Ardent Leisure Limited to the Office of Industrial Relations (OIR).
SEE HOW IT PLAYED OUT IN COURT IN THE LIVE BLOG BELOW
"It is reasonably suspected that Ardent Leisure may have committed an offence under workplace law," Mr McDougall said.
"Whether there is sufficient evidence to proceed to prosecution is a matter for OIR."
Engineer Thomas Polley, who was contracted by Dreamworld to complete the theme park's annual safety compliance inspections eight days before the ride malfunctioned, was also referred to the Board of Professional Engineers of Queensland for his "failure to properly inspect the ride".
He had deemed the ride structurally safe before the tragedy occurred in 2016.
Mr McDougall found he had fallen below the industry standards expected of an engineer.
Family members of the victims gave heart-wrenching victim impact statements at the start of the proceedings, saying they have 'broken souls' and carry guilt they were not there for their loved ones.
The brother of Cindy Low gave an explosive statement calling Dreamworld 'cowboys' and taking aim at his fellow family members.
In his handing down of findings today, the coroner found there were "frighteningly unsophisticated systems" at the park when it came to risk-management and record keeping.
"I find that shoddy record keeping was a significant contributing factor," Mr McDougall said.
He also found there was "no evidence Dreamworld ever conducted a proper risk assessment in the 30 years of operation of the ride".'
The inquest heard instead Dreamworld relied on an in-house staff who were not trained to assess risks.
"This failure by Dreamworld to adequately ensure the safety of the ride… was done so at the peril of Ms Goodchild, Mr Dorsett, Ms Low and Mr Araghi," Mr McDougall said.
Mr McDougall was scathing in his findings saying there was a 'total failure' and 'significant risk to the safety of patrons' due to the hazards identified on the ride which included the wide spacing of slats of the conveyor belt, steel support railing, the impact of pump failure and the absence of an emergency stop button.
He said the hazards 'would have been easily identifiable to a competent person' if they had been commissioned to assess the ride and there was 'ample evidence for a disaster of this nature occurring had notice been taken and lessons learnt from preceding incidents'.
He said the cause of the tragedy was the failure of the ride’s south pump.
The inquest recommendations handed down this morning include:
- Changes to the regulatory framework that governs the inspection and licensing of major amusement park rides in Queensland "to ensure that a more structured and compliance focused regime is implemented".
- Safety management systems be put in place at current rides.
- That all amusement rides comply with Australia Standards.
- Annual risk assessments must be conducted by trained professionals.
- These assessments must "involve the detailed consideration of the device, including all possible control system functions and variations, as well as a detailed examination of the operation of the ride during all modes of operation and possible emergency conditions".
- A full risk assessment must be done at stipulated intervals, as suggested by the manufacturer or at a mandated time.
- Regulations that a major risk assessment of a ride must ensure a device is visually observed and a low probability of failures is considered.
- The major risk assessment must observe how the machine handles adverse events.
- Assessors must run trial days where pumps are shut down, water levels decreased, rafts bottle neck, impact each other, to highlight weaknesses and expose hidden features of the design.
- Assessors must consult theme park records internally and internationally, consider whether the machine was fool-proof, and if not what engineering controls could possibly be utilised.
- They must also look at design records.
- The OIR must continue to develop a code of practice for the amusement device industry in Queensland, which will establish a minimum standard.
- Requirements of the relevant design standards, particularly the critical safety requirements on amusement devices in Australia, Europe and America should be harmonised.
- Steps should be taken to rectify the lack of detailed knowledge held by inspectors.
- The Board of Engineers, in consultation with OIR and other industry groups, should continue efforts to address the shortfall in suitably qualified and experienced engineers to inspect rides.
- That a reassessment of the Australian Standards applicable to waterborne rides (including raft rides) be undertaken.
- Consideration as to whether the requirement for hazard identification and risk assessment should be made mandatory and modifications or alterations must show they do not affect the safe operation and use.
SEE HOW IT PLAYED OUT IN COURT IN THE LIVE BLOG BELOW
Dreamworld CEO John Osborne read a statement to media outside the court after the findings were handed down.
“It is impossible to understand how the families feel, and I can only imagine the heartache the families have felt,” he said.
“I hope that now the Coroner’s report has been finalised, that this will go some way towards furthering the healing process for the families and all those impacted by the tragedy.
“We will now review the Coroner’s report in detail before we provide any further responses tomorrow.”
Updates
Ardent to be referred for breach of workplace laws
Recommendations are now being handed down:
1. The Office of Industrial Relations should change regulatory framework for inspection of rides at theme parks to make sure more compliance is implemented. Parks must comply with updated Australian standards, annual risk assessments must be done by professionals.
Major inspections and full risk assessments must be done by a registered and practicing engineer in Queensland.
Risk assessments should include visual assessments, observations of how the machine handles adverse events, trial days should be done to highlight weakness including shutting down pumps and seeing what the ride does.
2. Office on Industrial Relations develop a code of practice for the amusement device industry in Queensland, which have a minimum standard.
The Board of Engineers with OIC and other industry groups should continue efforts to address a shortfall of engineers who can inspect amusement devices"
The recommendations:
Recommendations are now being handed down:
1. The Office of Industrial Relations should change regulatory framework for inspection of rides at theme parks to make sure more compliance is implemented. Parks must comply with updated Australian standards, annual risk assessments must be done by professionals.
Major inspections and full risk assessments must be done by a registered and practicing engineer in Queensland.
Risk assessments should include visual assessments, observations of how the machine handles adverse events, trial days should be done to highlight weakness including shutting down pumps and seeing what the ride does.
2. Office on Industrial Relations develop a code of practice for the amusement device industry in Queensland, which have a minimum standard.
The Board of Engineers with OIC and other industry groups should continue efforts to address a shortfall of engineers who can inspect amusement devices"
Lucky no one died in earlier incidents
Dreamworld claimed during the inquest there was a 30 year history of no incidents on the ride.
But Mr McDougall says there were other incidents and the fact no one died was "more good luck than good management".
"It is essential for regulation to be effective… regular ongoing and adequate auditing of all aspects of safety… are to be undertaken by the regulator".
– Alexandria Utting
'Systematic failure'
The court has heard there was a "systemic failure by Dreamworld to ensure all aspects of safety".
"Why safety action was not taken earlier that day, I find that very difficult to understand," Mr McDougall said.
– Alexandria Utting
We are now hearing the emergency stop procedure was inadequate and a recommendation to put an emergency stop button was not done but we don't know why.
It made the ride contrary to Australian Standards.
Ride operator Peter Nemeth did a shut down on the ride when he saw the water level was low on the ride, but we don't know when he pressed the conveyor stop. He says he pressed it multiple times but it didn't work, but testing found no issue with the button.
CCTV shows the conveyor slowed to a stop 11 seconds after the rafts collided.
Mr McDougall says the responsibilities placed on staff to operate the stressful ride and supervise others were "clearly unreasonable and excessive". The ride was "complex, confusing and lacked required labelling".
The Coroner says discrepancies in the recollections of ride operators was "understandable" because of how stressful the event was, also that Courtney Williams had only been trained that day. He says 30 checks that had to be done on the ride was "excessive".
– Alexandria Utting and Tanya French
The emergency stop button ...
We are now hearing the emergency stop procedure was inadequate and a recommendation to put an emergency stop button was not done but we don't know why.
It made the ride contrary to Australian Standards.
Ride operator Peter Nemeth did a shut down on the ride when he saw the water level was low on the ride, but we don't know when he pressed the conveyor stop. He says he pressed it multiple times but it didn't work, but testing found no issue with the button.
CCTV shows the conveyor slowed to a stop 11 seconds after the rafts collided.
Mr McDougall says the responsibilities placed on staff to operate the stressful ride and supervise others were "clearly unreasonable and excessive". The ride was "complex, confusing and lacked required labelling".
The Coroner says discrepancies in the recollections of ride operators was "understandable" because of how stressful the event was, also that Courtney Williams had only been trained that day. He says 30 checks that had to be done on the ride was "excessive".
– Alexandria Utting and Tanya French
Cindy Low's brother has made a bombshell statement to the court, calling Dreamworld 'cowboys' who failed to pay for counselling for the heartbroken families and instead marketing the theme park.
He also took aim at the rest of Cindy's family, saying the tragedy has forced him to be around family he doesn't want to be around and revealing he has suffered anger and alcohol issues.
He said he heard about the news in NZ about what happened to Ms Low and raced to be with his mother. He says he remembered telling himself just to do the speed limit because he wouldnt be "any good" to his mother in jail.
"There is not a moment when we don't wish they hadn't set foot on that ride," Mr Goodchild said. "Such tragedies do not happen by accident, they do not happen out of nowhere."
Coroner James McDougall is now setting the scene for how the tragedy unfolded. He has 300 pages of findings but says he will not read them all out, instead giving an overview
We are hearing Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi and two children boarded the ride about 2pm. "It was designed to simulate white water rafting". He says: "Statistically it was the most popular ride at the theme park".
– Alexandria Utting
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