Litany of failures led to Dreamworld deaths

Queensland’s coroner has delivered a withering account of Dreamworld’s role in the deaths of four people three years ago.

The coroner has handed down his findings into the deaths of Cindy Low, Roozi Araghi, Kate Goodchild and Luke Dorsett at Dreamworld in 2016.

The owners of Australia’s most popular theme park, Dreamworld, stand accused of a barefaced disregard for safety and a negligent corporate culture, after Queensland’s coroner delivered a withering account of the company’s role in the deaths of four people on its most popular ride more than three years ago.

The families of those killed spoke out before the coroner’s report, accusing Ardent Leisure of putting profits before safety in the years leading up to the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi on the Thunder River Rapids ride in October 2016.

Coroner James McDougall cited a litany of safety breaches, including the failure to do a proper risk assessment of the ride in the 30 years since it began operating. He urged the Queensland government to investigate whether the company should face prosecution over the tragedy.

Possible fines for breaching workplace laws could run into the millions of dollars. Mr McDougall said Ardent Leisure was guilty of a systemic failure in all aspects of safety and “shoddy” record keeping despite presenting Dreamworld as a modern, world-class theme park.

He said ultimate responsibility for Dreamworld’s failures lay with the company’s leaders.

Coroner James McDougall has handed down a scathing report into the four deaths at Dreamworld in 2016. Picture: AAP

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

He lashed government regulators for placing “unjustified trust” in Dreamworld’s willingness to observe proper safety and maintenance systems to ensure the safe operation of the ride, built to simulate white water rafting.

“Clearly, given the nature of this tragedy, and the surrounding circumstances, including the lack of record management, the ­absence of any meaningful hazard assessments or effective engineering oversight of these devices, this was simply not the case,” Mr McDougall said.

The four victims died after their raft collided with another raft stuck on a mechanical conveyor, causing them to fall onto the conveyor and suffer horrific injuries.

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Because of their small stature, Ms Goodchild’s daughter Ebony Turner and Ms Low’s son Kieran managed to escape the raft. The breakdown was one of several that day but no automated shutdown function was installed, despite recommendations.

In a statement he read to the coroner, Cindy Low’s brother Michael Cook, who carried with him a photograph of his sister and mother who lives in New Zealand, told of the “empty void” left by her death and the “horrible experience” of sitting through the coronial hearings. “The families have lost so much, all the while this giant company with all the money in the world is out spending millions of dollars to attract more customers,” he said.

“I’ve lost so much through these managerial cowboys.”

Ardent Leisure, which was then chaired by Neil Balnaves, initially planned to reopen Dreamworld three days after the tragedy but it remained closed for 45 days. Then Ardent chief executive Deborah Thomas stepped down in the wake of the tragedy. George Venardos, who replaced Mr Balnaves soon after the tragedy, left the following September to make way for current chairman Gary Weiss. Evidence presented during the inquest showed Dreamworld was aware its ride assessments were inadequate but did not act.

“I am satisfied that Dreamworld knew of this significant limitation with respect to the safety auditing being conducted by its advisers; however, failed to take any steps to rectify them,” Mr McDougall said. “It was agreed by the experts and became obvious during the hearing, that best practice on the Thunder River Rapids ride was not followed by Dreamworld particularly in relation to compliance with the introduced Australian standards designed to ensure the safety of devices.”

The coroner found the dangers posed by the ride’s design and the risks posed by malfunction were “obvious” and “easily identifiable to a competent person”.

In his criticism of Dreamworld’s processes, Mr McDougall said the company had failed to implement proper safety audits in the ride’s 30-year existence. He said it was due more to “good luck than good management” that the Thunder River Rapids ride had not killed people earlier and that the hazards of the ride should have been obvious to any properly qualified safety inspector.

The ride had malfunctioned in a similar manner to the 2016 incident on four previous occasions.

But the incidents were never appropriately acted on and ride operators at the time of the 2016 incident were not aware of them.

In the week before the tragedy, the ride broke down seven times.

Mr McDougall found the failure to record ride modifications, lack of designer input and lack of reporting to the regulator “contributed to masking the real risk”.

Under the coronial recommendations, Queensland’s theme park owners would be required to implement more stringent safety management systems on their rides. Mr McDougall recommended owners of amusement rides must comply with updated Australian standards, carry out detailed annual risk assessments by “competent persons”, major inspections of rides by practising engineers at mandated periods and regular auditing of rides and inspections by the Office of Industrial Relations.

He also suggested theme parks should hold “trial days” in which rides are tested under a range of circumstances to “highlight weaknesses and expose hidden features of the ride”.

The court heard that since the 2016 tragedy, Dreamworld had overhauled its safety procedures including ride auditing from qualified engineering firms, reviews in operating procedures, changes to training regimes and emergency drills. In a statement, Ardent said it was committed to implementing the coroner’s recommendations and had embarked on a safety overhaul since the incident.

Staff members gather after a private memorial was held at Dreamworld in 2016. Picture: Glenn Hunt