Dreamworld nightmare

The churning water that had been splashing into their faces hid the danger. Only now are we seeing the full, horrifying picture.

Police inspect the raft after the Dreamworld tragedy.

On that sunny October Tuesday in 2016, just about everything that could go wrong did go wrong on the Thunder River Rapids ride at Dreamworld. In the space of a few horrifying minutes, what seemed to be a minor annoyance for the people on it, and those at the controls, turned into an all-too-real nightmare that claimed four lives.

Finally, the answers sought by the bereaved families began to emerge this week at the coronial inquiry that has been deconstructing the tragedy to uncover exactly what happened and what can be done to ensure it is never repeated.

The costs have piled up since the 30-year-old ride failed catastrophically, endangering all six occupants of raft five when it up-ended. The churning water that had been splashing into their faces hid the danger: there were gaps between the wooden slats laid over the drive mechanism that trapped the victims.

Canberra mother Kate Goodchild, 32, her brother Luke Dorsett, 35, his partner Roozi Araghi, 38, and a stranger to them, Cindy Low, 42, were crushed to death. Somehow, Goodchild’s 12-year-old daughter, Ebony, and Low’s 10-year-old son, Kieran, survived by what police said was “the providence of God”.

For the bewildered families, the struggle to comprehend how a day of fun and laugher in the supposedly expert hands of the Gold Coast amusement park’s staff could end so terribly compounded their shock and grief.

“Our lives were turned upside down … by the loss of Cindy, we have spent each week and month comforting each other and learning how to live without her,” the Lows said in a statement ahead of the court proceedings.

For the workers on duty at Dreamworld, especially the two operating the popular Thunder River Rapids attraction, the impact also has been deeply traumatic. Ride attendant Courtney Williams, then 21, was so distressed giving evidence on Thursday that coroner James McDougall excused her from watching video footage of the malfunction. Her emotional state was “not good”, her barrister said.

Dreamworld’s owner, the Ardent Leisure Group, has burned through two chief executives in one-time women’s magazine editor Deborah Thomas and former Nine Entertainment finance boss Simon Kelly, reporting a $62.6 million loss in the wake of the tragedy after its share price plunged. The park was closed for 45 days.

This week’s evidence to the inquest amounts to more bad news for the embattled company. A litany of errors, missteps and laxness suggests the accident was not only preventable but also readily foreseeable given what had transpired with the ride. The timeline sketched out by the investigating police reached back the late 1980s or early 90s when the first fateful decision was taken: the planked cover of the conveyor belt drive mechanism was changed, opening up the gaps that would prove lethal.

In what should have been a telltale warning, the same accident very nearly happened in 2001, when an empty raft flipped, causing staff to email each other that they “shuddered to think” what would have happened were people in it. The recommended safety changes were not acted on.

When, on October 7, 2004, two rafts collided, throwing a patron into the water, the problematic system remained unchanged. Two years later, the recommendation of a safety audit for a clearly labelled kill switch was left to gather more dust. In 2014, a ride operator was fired over an incident that saw a raft carrying a group of guests hit another on the same conveyor.

A park-wide safety audit ahead of the disastrous events of October 25, 2016, gave Dreamworld a rating of 41.7 per cent, well short of the pass mark of 75.

Dreamworld was busy that day, basking in glorious 24C spring weather. The Thunder River Rapids ride replicated a mild, whitewater experience, a favourite with families and groups because it allowed them to stay together in parties of six, facing inward on each raft. These were pulled along the main chute by the unseen conveyor mechanism.

At 11.50am there was a problem. One of the pumps that maintained the water level failed and had to be reset by maintenance engineers, the second such “earth failure” in a week. The pump failed again at 1.09pm and was brought back on line.

The victims had just boarded raft five when the south pump malfunctioned for a third time at 2.03pm, which should have triggered a shutdown of the ride under Dreamworld procedures. Instead, they and the children who would survive sat pat under the gaze of senior operator Peter Nemeth, who was at the control panel. The raft set off.

But a minute later, nearing the end of the run, the raft ahead of them became stuck as the water level dropped. Williams was at the unloading point of the ride, new to the job of operating it. She signalled there was a problem. “I turned back around to see what they were saying, and that’s when I saw the raft coming over,” she told the inquest. “The second raft was at the top of the conveyor — it had reached the peak before it had come down.

“I turned back to Peter to say what do we do? And he didn’t react at all, and then looked back and saw the incident unfold.”

The raft carrying the victims ploughed into the stalled capsule and was pushed vertical, tipping them out. The adults died almost instantly, the inquest heard. Nemeth pressed what he thought was the stop override on the control panel — as he had been taught. What he did not know was it was a “slow stop” action taking about eight seconds. The machinery kept grinding.

“I saw the second raft coming over the top of the conveyor, so it would have been … about five to 10m between them,” Nemeth said in his evidence. “There’s a conveyor stop button that needs to be pressed every time there’s a shutdown procedure, to stop the conveyor moving. I turned around and I pressed it more than once, to make sure the raft stops before it collides with the other one.”

To his horror, nothing happened, “even though I pressed it … two or three times”. The emer­gency stop button was actually less than 1m to the right of Williams’s work station, on a yellow box. It had been pointed out by the safety officer that very morning who took her through the required 90 minutes of training for a level two ride operator. The trouble was that Williams had been told not to worry about the stop button because it was never used. “She pointed out from a distance … she said, ‘do you see Tim’s water bottle on the yellow box?’ — and I said yes,” Williams said, recounting what she had been told by the female training officer. “And she said, ‘don’t worry about it, no one ever uses it’.”

To her immense credit, Wil­liams put her own life on the line to save the surviving children. She managed to grab little Kieran Low and drag him to safety. “Once the incident had unfolded, she went into emergency mode and assisted everyone she could,” Detective Sergeant Nicola Brown told the inquest. Barrister Steven Whybrow, for the Dorsett and Goodchild families, made a point of telling both Williams and Nemeth that they did not hold them in the least responsible for what had happened.

In the wash-up, police were left to ask why an emergency stop button that could have averted the tragedy wasn’t labelled, how there was no automated shutdown when the ride’s componentry ­failed and why there was not a ­single override to stop all of its ­machinery.

Under Dreamworld protocols, responsibility for activating the emergency stop lay with Nemeth, the senior attendant, even though his position was more than 10m from the button near Williams. Not that it would have done any good. He too admitted he had no idea until this week that it was the best way to freeze the conveyor in an emergency. He said he had not been trained in CPR, nor had he received instruction on what to do during “catastrophic” incidents.

Questioned by Matthew Hickey, for the Low family, Nemeth said he had 36 duties and checks to carry out during each ride cycle, which lasted barely a minute.

“Can I suggest to you, Mr Nemeth, it is impossible for a human being to do all of those things in less than a minute. Do you agree?” the barrister asked him.

“Yes, I agree,” Nemeth said.

Hickey: “Wouldn’t it have made sense if you had been assisted at the very least in doing that very, very difficult job by being provided with another level three ride operator, rather than a level two?

Nemeth: “Yes. It would have made it easier for me.”

Speaking to CCTV footage played to the inquest, Brown said the rafts had lost buoyancy from the moment the south pump failed for the third time. “As soon as it stops, you can really see a significant change in the water movement. When the pump failed, which means there’s not enough buoyancy around the unload and load areas to keep the rafts buoyant … they were kind of stuck on the raft support rails … And then it’s been caught in that mechanism,” she said.

Asked by Whybrow whether the tragedy could have been averted, the police investigator said: “There were a lot of different factors that might have minimised or prevented (it).”

Among those was the absence of a label to show an emergency stop button; the fact the button was so far from Nemeth, the operator authorised to push it; training deficiencies with the operators who were taught the order in which to push buttons but not what the buttons actually did; and the lack of sensors to measure water levels.

“There’s issues such as the gaps in the slats (on the conveyor) and those sorts of things, all of which, any one, had they been identified and addressed, might well have prevented this tragedy?” Whybrow asked. Brown replied: “Correct.”

Senior Dreamworld officials have yet to appear at the inquest to respond to this week’s explosive opening evidence by the police and the two ride attendants.

One issue likely to be revisited is a conversation Williams remembers having with a Dreamworld manager named Troy soon after the tragedy. She told police that this executive — “one under the CEO” — had told her “not to say anything to anyone, don’t give any statements and just to wait over to the side”.

When a police officer subsequently approached her to take a statement, Williams said she had looked to Troy for “permission”, though he made no attempt to stop her. Asked at the inquest if she felt she was under any pressure not to speak to the police, the young woman replied: “Yes.”

The inquest continues next week.