‘Systemic failure’: Coroner delivers inquest findings into fatal Dreamworld tragedy
A coroner says criminal charges could be laid against Dreamworld’s owner after its “total failure” to identify safety risks before four holidaymakers died.
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Dreamworld’s handling of safety risks at the time of a horrific fatal ride tragedy was a “total failure” and the theme park’s “shoddy record keeping was a significant contributing factor”, a coroner has found.
Coroner James McDougall today handed down his long-awaited findings, totalling 300 pages, from the inquest into the deaths of four people on a ride more than three years ago.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the Thunder River Rapids malfunctioned.
Mr McDougall referred Ardent Leisure, the owner and operator of the Gold Coast theme park, to the Office of Industrial Relations to consider whether there is sufficient evidence to show it committed breaches under workplace laws.
He said there was a “systemic failure” by Dreamworld in relation to “all aspects of safety”.
In Brisbane Magistrates Court today, the coroner said it was clear from expert evidence – which emerged over six weeks in 2018 – the design and construction of the ride “posed significant risk” to patrons.
He said maintenance and safety records for the ride were scant and ad hoc.
He found there is no evidence Dreamworld conducted a thorough engineering risk assessment of the ride in the three decades it was open to the public.
“I find that shoddy record keeping was a significant contributor to this incident,” he said.
“Failure to record the changes have contributed to the masking of the real risk of the (ride).”
He said the ride was completely unsafe when the tragedy occurred, with safety procedures described as “unsophisticated” and “rudimentary at best”.
“It was simply a matter of time. That time came on October 25 (2016),” Mr McDougall said.
RELATED: Families of Dreamworld victims tell coroner of heartbreak
In addition, Mr McDougall said the responsibilities placed on staff to operate the stressful ride and supervise others were “clearly unreasonable and excessive”.
He described the ride as “complex, confusing” and lacking “required labelling”.
Ardent Leisure Theme Parks chief executive John Osborne responded to the findings on Monday afternoon.
“First and foremost, we express our deepest sympathies to the families and friends of Roozbeh Araghi, Luke Dorsett, Kate Goodchild and Cindy Low,” he said in a statement.
“Our thoughts are also with the first responders, emergency services personnel, investigators, counsellors and Dreamworld team members affected by this tragedy.
“We would like to acknowledge the attendance and involvement of the families, witnesses and all other participants in the inquest process, as well as the Coroner and his team. We will now review the Coroner’s report in detail before providing a further response tomorrow.”
Queensland Premier Annastacia Palaszczuk has all but confirmed the state government will adopt every coronial recommendation.
Police recommended no criminal charges against Dreamworld staff over the fatal incident.
“Let me make it very clear today that the recommendations that the coroner makes, we will have to implement, regardless of what they say,” Ms Palaszczuk told Seven’s Sunrise today.
She was asked if she was “guaranteeing” they would adopt every coronial recommendation.
“Well I’d like to say yes, of course we’ll have to look at them all, but I can’t see why we wouldn’t, honestly,” Ms Palaszczuk said.
“This is so important to everyone out there.
“At the end of the day, everyone wants to know that they are going to a theme park or an amusement park and that the rides are safe.”
She said the families of the victims and the public all want closure.
“We want the answers,” Ms Palaszczuk said.
Three of the four victims were flung instantly into a mechanised conveyor when their raft collided with another and partially flipped on October 25. A crucial delay in manually stopping the ride caused the jammed raft to shake, plunging a fourth person into the machinery.
The inquest heard the malfunction was the third that day and the fifth in a week.
Inexperienced staff panicked, sending out a radio call stating there was a “raft in the conveyor” — the first indication something disastrous had happened, the inquest heard last year.
Despite the efforts of paramedics, the four had no chance of survival. Ms Goodchild’s 12-year-old daughter and Ms Low’s 10-year-old son survived the incident.
The wide-ranging inquest, which opened in June 2018, revealed a “litany of problems” with some experts declaring the tragedy was an “accident waiting to happen”.
Dreamworld’s training systems were heavily criticised, with revelations staff operating the ride on the day of the disaster were given just 90 minutes of training.
A memo sent to staff days before the tragedy warned the emergency stop button should not be pushed.
To cut costs, Dreamworld also stopped spending money on repairs and maintenance in the months before the fatal accident.
Kate and Luke’s mother, Kim Dorsett, spoke to Nine’s Today on Monday morning.
“The biggest thing from the inquest was that if someone were to push that (emergency stop) button, Luke would still be alive today,” she said.
“I think that no parent should ever bury a child, and I buried three of them.”
In a dramatic conclusion to the first week of the inquest, relatives of two victims spoke of how the event has “throttled” their family.
“We are tired and devastated and horrified by the evidence that has come out this week,” they said in a statement in 2018.
“We hold Dreamworld totally responsible for this tragic event that could have so easily been avoided. It has throttled our family.”
Staff admitted there had been a “total failure” to identify risks with the ride and a series of equipment failures before the accident should have been investigated.
The ride was also heavily criticised as “unsafe” with no proper maintenance schedules, extensive cracking and corrosion, with parts of the structure “propped up with timber”.
Theme park staff removed slats from the conveyor belt and made unapproved structural alterations to the attraction that had been installed more than 30 years ago.
The Queensland government pre-empted the inquest findings, introducing new safety regulations for amusement rides including mandatory major inspections of rides by qualified engineers every 10 years and improved training for ride operators.
The state also tightened workplace health and safety prosecution laws, including the introduction of industrial manslaughter as a charge.
Individuals guilty of industrial manslaughter will face up to 20 years behind bars while corporate offenders are liable for fines of up to $10 million.
Ms Palaszczuk on Monday also said she believes there “really needs to be a good look” at the age of operators used to run the rides.
“You need the experience of an engineer, not the experience of someone who has just started work,” she said.
Ardent Leisure was among the worst performers on the ASX/300 index on Monday, its shares plunging by as much as 18.1 per cent to a near two-month low of $1.155 in morning trade.
The company was still trading 15.6 per cent lower at $1.19 at 1pm.
THE VICTIMS
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi were killed when Dreamworld’s Thunder River Rapids ride malfunctioned on October 25, 2016
WHAT HAPPENED
• Two rafts collided on a conveyor when a water pump failed and caused water levels to drop dramatically
• The malfunction was the third that day, and fifth in a week
• The victims’ raft was pushed into a vertical position and the victims plunged into the ride machinery causing fatal injuries
RIDE HISTORY
• Police uncovered multiple previous incidents with the ride, including a guest being thrown into the trough in 2004 when rafts collided
• Despite recommendations for a single emergency stop, no single shutdown function was installed
STAFF TESTIMONY
• Dreamworld electricians described the control panel wiring as a “rat’s nest”
• Staff insisted the ride was one of the most complex to operate
• The operator in charge on the day was given only 90 minutes of training
• A supervisor said pump failures were frequent in the week preceding the tragedy
• Staff were unaware of the theme park’s policy to shut down an attraction after two failures in 24 hours, believing a third was needed for a supervisor to be notified
• Engineering general manager admitted the ride “should never have opened” after the malfunctions
OTHER EVIDENCE
• Government registration of Thunder River Rapids and other rides at the park were more than nine months overdue
• Dreamworld executives announced cutbacks to maintenance and repair spending in 2016 due to falling profits
• Workplace Health and Safety inspectors identified a “litany of concerns’ on the ride’s maintenance including missing slats on the conveyor belt, excessive corrosion, crumbling concrete and unidentified controls
• Modifications made to the attraction had never been approved by WPHS
WHAT THE VICTIMS’ FAMILIES HAVE SAID
• Relatives of two victims said in a statement they held Dreamworld “totally responsible” for the deaths.
Originally published as ‘Systemic failure’: Coroner delivers inquest findings into fatal Dreamworld tragedy