Courtroom 17 in Southport Courthouse is packed with emotional family members, robed barristers and their instructing solicitors as the much-anticipated inquest into the Dreamworld disaster gets underway.

Usually a District Court where serious offenders get their last glimpse of sunshine through the large windows before being sent to the cells, it has been designated as the Southport Coroners Court for the duration of the six-week inquest.

There are lawyers representing the families, almost 40 Dreamworld staff, theme park owners Ardent Leisure, and the Queensland Department of Industrial Relations.

Such is the intense interest that an entire courtroom on the same floor has been set aside for the media and members of the public.

Presiding over the inquest from a Bench usually occupied by District Court judges is South-Eastern Coroner James McDougall, who has spent months preparing for this momentous day – poring over police and expert reports and even visiting Dreamworld soon after the disaster to see the doomed Thunder River Rapids ride for himself.

At 10.07am, counsel assisting the inquest, Ken Fleming, QC, begins his opening address.

The baritone-voiced veteran silk tells the court that it was about 2pm when the Thunder River Rapids ride had a “significant mechanical breakdown”, causing the four deaths.

Deaths, he says, that were “sadly … both violent and unnatural”.

“The tragedy of this event has been felt Australia-wide,” Fleming says.

He says the inquest is about sifting facts: “It is not adversarial” but about finding out “what caused the person to die”.

The coronial hearing, Fleming says, is in the public interest and designed to draw attention to the event and “prevent further such events”.

He says there have “sadly” been past incidents on the Thunder River Rapids ride which will be explored during the inquest,including one 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 hears.

The first witness to take the stand is Detective Sergeant Nicola Brown, the tenacious Coomera cop who led the police investigation into the tragedy.

Browns tells the hearing about the multiple pump failures and how water levels on the ride dropped “significantly and quite quickly”.

She says 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,” Brown says.

She also says there was no emergency drill training in place for Dreamworld staff, and a recommendation for CCTV cameras at the Thunder River Rapids ride unload area was never actioned.

Brown tells how Courtney Williams was in the unload area when she realised the water level had dropped

“Once the incident had unfolded, (Courtney) went into emergency mode and assisted everyone she could, including Kieran out of the ride,” Brown says.

The inquest hears more startling evidence from Brown.

That the Thunder River Rapids ride was modified to include shorter planks on the conveyor sometime in the 1980s or ’90s, but police were unable to obtain documentation relating to the modification.

That there was no way to measure the water levels on the ride except by a water “scumline”, and no switch to automatically shut it down if the water level dropped.

That the main emergency stop button on the ride was “totally unmarked” and was positioned on a “confusing” control panel .

That staff were sent a memo the week before the tragedy discouraging them from using a second e-stop button which could have shut down the ride in two seconds.

That Courtney Williams had been told: “Not to worry about that button, no-one uses it.”

Day 1 of the inquest concludes with police Forensic Crash Unit investigator Senior-Constable Steven Cornish telling how the tragedy was preventable and not totally unforeseen.

The potential for a fatal accident was “always there”, Cornish tells the hearing.

“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 says.

Barrister Steven Whybrow, representing Kate Goodchild’s partner Dave Turner and her father Shayne, asks Cornish if the tragedy could have been prevented had the two-second emergency stop button been pressed before the rafts collided.

Cornish: “Yes.”

The first week of the inquest also hears from Courtney Williams, who tells how she felt ‘pressured’ by one of her bosses not to speak with police after the tragedy.

She says she “didn’t know” the emergency button would stop the conveyor from moving.

“It was my first day, I wasn’t confident operating the control panel,” Williams says, adding that she had not had “sufficient training on parts I know I should have”.

After the first five days of explosive evidence, Shane Goodchild and Dave Turner issue a statement through their lawyers,dripping with anger and anguish.

“We are tired and ­devastated and horrified by the evidence that has come out this week,” Goodchild and Turner said.

“It has throttled our family. We hold Dreamworld totally responsible for this tragic event that could have so easily been avoided.”

Then-Dreamworld CEO Craig Davidson responds with his own heartfelt statement, saying his thoughts are with the families.

“We understand that this has been a harrowing week for them and that they are devastated and horrified,” he says.

“We share those feelings. We are truly sorry this happened.

“It is our aim to assist the Coroner as best we can to help understand how this tragedy occurred, and what we can do to ensure it never happens again.”

The coronial hearings run for a total of 31 days in June, October, November and December of 2018, with bombshell after bombshell revelation emerging in witness testimony.

Evidence includes that Dreamworld dithered for three years on recommendations to introduce a single emergency stop button on the Thunder River Rapids ride.

The inquest also hears that theme park bosses allegedly scrimped on safety training and even minor repairs such as blown light-bulbs and chipped concrete.

They also dismissed as “nil” the chances of rafts capsizing on the ride after similar incident in 2001.

And it’s revealed that a mechanical inspector certified the Thunder River Rapids ride “safe to use” just weeks before the tragedy.

Amid the litany of alleged failings, Dreamworld’s engineering supervisor conceded that the ride proved to be “completely unsafe” and there had been a “total failure by everybody”.

Some Dreamworld staff even made emotional apologies to the families from the witness box.

“I would like to offer the families of victims a genuine and heartfelt apology of the indescribable suffering you have experienced,” former safety officer Angus Hutchings told the court.

“I am dreadfully sorry for your loss.”

McDougall is expected to deliver his findings in early 2019 but the inquest is plagued by a series of delays which only prolong the agony for the victims’ families.

Within months of the disaster, Ardent is hit with massive lawsuits from families of the victims and first responders.

While many have since settled, legal experts estimate the compensation payouts could top $20 million.

But no amount of money can bring Kate, Luke, Roozi and Cindy back.

The grief “never really goes away”, Mathew Low will later confide in an emotional TV interview.

“It’s a massive hole that’s left when Cindy left,’ he says.

“It was a huge shock to lose Cindy and the way that we now approach it is sort of what would Cindy do is how I get through some challenging decisions that I have to make.

Mathew says while he doesn’t blame the ride operators – “they were just doing their jobs as they’d been trained” – there seemed to be a “lack of information” among staff in relation to “why you should push a certain button or not push a certain button”.

In October 2017, on the eve of the first anniversary of the Thunder River Rapids ride tragedy, Kim Dorsett broke her silence to reveal her unbearable heartache at the loss of three members of her family.

Telling of her ongoing struggle in an open letter to The Courier-Mail, she wrote: “At times, it has been difficult to face this tragedy and getting out of bed can be a major achievement.”

Kim paid tribute to her “perfect” children and Roozi, who she considered a member of her family.

“Katie was the perfect mummy to her two beautiful girls, and Luke and Roozi the perfect uncles,” she wrote.

“Kate’s girls will never have those hugs and kisses from their mum that every child should have. The baby (Evie), of course,will have no memory of her beautiful mum, but we will forever tell her how much she was loved.

“The boys (Luke and Roozi) loved their nieces, spoiling them at every opportunity with gifts, concerts and birthday parties.”

Kim said while she could not speak for other families of the victims, she believed her children would want Dreamworld to go on.

“They would never want people to miss out on the enjoyment and thrills of Dreamworld and the theme parks because of this accident.”

OTHER CHAPTERS:

Part 1: The sliding doors moment that ended in tragedy

Part 2: When happiness turned to horror