Dreamworld tragedy: Theme park’s rudimentary safety and “systemic failures” under fire

A damning coronial report has found Dreamworld parent company Ardent Leisure breached breaching Workplace Health and Safety laws in the lead up to the Thunder River Rapids Ride tragedy.

DREAMWORLD parent company Ardent Leisure could be prosecuted for breaching Workplace Health and Safety laws in the lead up to the Thunder River Rapids Ride tragedy, a damning coronial report has found.

The referral to the Office of Industrial Relations was made yesterday when Coroner James McDougall handed down his findings in a scathing report into the October 25, 2016 disaster which killed four people.

In the 274-page report he found “systemic” safety failures and described the theme park’s safety systems as “rudimentary”, the record keeping “shoddy”, communication between departments as “dire” and the fact there had not been an injury on the ride in 30 years as “good luck more than good management”.

THE SLIDING DOORS MOMENT THAT ENDED IN TRAGEDY

Queensland Emergency service personnel are seen at Dreamworld after the Thunder River Rapids Ride disaster. Picture: AAP

“It is reasonably suspected that Ardent Leisure may have committed an offence under Workplace Health and Safety law,” Mr McDougall said.

“I refer my findings and the evidence gathered in the course of inquest for further consideration as to these matters.

“Whether there is sufficient evidence to proceed to prosecution of is matter for the Office of Industrial Relations.”

Four people – Kate Goodchild, Luke Dorsett, Roozbeh Araghi and Cindy Low – lost their lives when a pump stopped working on the Thunder River Rapids Ride just after 2pm on October 25, 2016. The water levels dropped and a raft became stuck on a conveyor belt.

That raft was hit by another carrying Mr Dorsett, his sister Ms Goodchild, her daughter Ebony, 12, Mr Araghi, Ms Low and her son, Kieran, 10. The raft flipped and the four adults were killed.

The two children remained strapped in the raft until onlookers were able to free them.

It was found the pump had failed two times earlier that day and three more times in the week preceding the incident.

DREAM WORLD SHOCK: WHEN HAPPINESS TURNED TO HORROR

Coroner James McDougall arrives at Dreamworld on the day of the disaster. Picture: Marc Robertson

Mr McDougall said the park should have shut down the ride when the pump originally failed.

“Why safety action was not taken earlier that day I find very difficult to understand,” he said.

The report said it was an attitude which came from the top down.

“Such a culpable culture can exist only when leadership from the board (of directors) down are careless in respect of safety. That cannot be allowed,” he said.

Ardent Leisure Chairman, Gary Weiss and Theme Parks Division Chief Executive Officer, John Osborne refused to answer questions from journalist yesterday despite calling a press conference.

In the statements, Dr Weiss and Mr Osborne both offered their “deepest sympathies” to the four people who died at the park almost four years ago.

VILLAINS BOTCH JOBS AND SCANDAL

Ardent Leisure CEO John Osborne (left) and Chairman Gary Weiss leave the Magistrates Court in Brisbane yesterday. Picture: AAP

“We are committed to implementing the Coroner’s recommendations,” Dr Weiss said, adding that safety was the number one priority at the park.

He earlier said: “No one will ever forget the events of that terrible day and reaffirm our commitment to safety and to strive for global best practice in theme park operation.

“We are also profoundly sorry for those who have been impacted by this tragedy.”

Mr McDougall also recommended the regulator develop an industry wide Code of Practice for all businesses which had amusement rides.

He also recommended comprehensive changes to the regulations to ensure rides are fully inspected annually, safety systems were in place, all rides comply with Australian Standards, qualified external engineers regularly certify rides, regular maintenance conducted and full audits completed regularly.

Police next to a ride similar to the one in which four people died in an accident at Dreamworld, Gold Coast. Photo: Regi Varghese

It took little more than two and a half hours for Mr McDougall to outline his findings – more than 18 months after the inquest first started in June 2018.

Before he started to speak, family members filed into the courtroom, sitting stoically, in the front three rows alongside Dreamworld’s representatives and the principal investigators of the disaster.

The families and friends were quiet and only spoke when asked and could be occasionally heard fighting back tears or taking deep breaths.

Mr McDougall was damning in his assessment of Dreamworld’s safety management, record keeping, the design of the ride and training.

He described the ride as posing a “significant risk to health and safety of patrons”.

Risks included “wide spacing of slats (on the conveyor), nip points at the head of the conveyor, the effect of a pump failure on water levels and the absence of an emergency stop button at the main conveyor”.

“Each of these would have been easily identifiable to a competent person had one ever been engaged to conduct a risk assessment of the ride,” he said.

It was noted there four previous incidents were rafts had collided, including at least one which flipped the rafts.

“It is indeed fortunate, to quote (Dreamworld engineer) Mr (Bob) Tan, that no lives were lost,” Mr McDougall said.

It was noted that in 30 years of operation no injuries had been sustained on the Thunder River Rapids Ride.

“This suggests good luck more than good management,” he said.

Mr McDougall also slammed Dreamworld for their “shoddy” paperwork and record keeping which he labelled as “significant contributor” to the fatal tragedy.

He also found the lack of an emergency stop button at the main control panel was contrary to Australian standards.

Mr McDougall also found a water level monitor should have been installed to stop rafts from getting stuck.

“A basic detection would have been inexpensive and may have prevented the incident from occurring,” he said.

The incident occurred after pump shut down and water levels began to drop.

He said the ride had also gone under a number of modifications but the changes in the design never lodged with the regulator.

DREAMWORLD BOSSES’ SHOCK SNUB AFTER INQUEST

Mr McDougall said changes were made without thought to the impact it would have on other parts of the ride.

Industrial Relations Minister Grace Grace said the state government accepted the coroner’s findings and some of the recommendations had already been introduced.

“We have a new regulatory framework in place which fundamentally improves the approach and safety standard for amusement rides and theme parks in Queensland – laws which are nothing short of world class,” she said.

Ms Grace said the changes included more stringent record keeping, comprehensive safety case and licensing regimen for all rides at theme parks and mandatory inspection of all rides by qualified engineers every 10 years.

“We have employed 33 additional inspectors, including three engineers to oversee the new safety requirements for major amusement parks,” she said.

Ms Grace said if more action was needed the stage government would “act swiftly”.