Dreamworld inquest: Coroner James McDougall delivers his findings on Thunder River Rapids disaster

Coroner James McDougall has referred Dreamworld owner Ardent Leisure to the regulator to consider whether it broke laws after handing down a damning verdict on the Thunder River Rapids tragedy.

DREAMWORLD owner Ardent Leisure have been referred to the regulator to consider if the theme park breached Workplace Health and Safety laws.

Coroner James McDougall this morning handed down his findings in to the Thunder River Rides Tragedy after a more than 18 months inquest process.

“It is reasonably suspected that Ardent Leisure may have committed an offence under Workplace Health and Safety Law,” he 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.”

Mr McDougall also recommended the regulator developed an industry ride 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 and regular maintenance conducted.

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 for the third time on October 25, 2016 just after 2pm. 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.

FAMILIES REVEAL GRIEF IN HEARTBREAKING STATEMENTS

Coroner James McDougall. Picture: Jason O’Brien.

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Delivering his findings, Mr McDougall outlined a number of failures at the park.

Mr McDougall said “shoddy record keeping was a significant contributor” to the tragedy.

Mr McDougall said different departments were unable to access information and the information available was limited.

He has also criticised the design of the ride, which he refers to as the TRRR.

“TRRR operated fatality free for about 30 years, at the time of the fatal incident, it was clear the design and construction of conveyor unload area consisted a risk to the health and safety of patrons,” he said.

Mr McDougall said the lack of an emergency stop button at the main control panel was contrary to Australian standards.

He also said a water level monitor could have been installed.

“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.

Mr McDougall said two previous incidents on the ride should have alerted Dreamworld to the risks.

He said the risks included: “Wide spacing of slats, nip point at heat of conveyor, effect of pump failure on water level and an absence of emergency stop button at the main conveyor panel.”

Mr McDougall said if Dreamworld had a competent person conduct a risk assessment would have identified those issues.

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

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