Dreamworld Coroner finds leadership culpable

On 25 October 2016, a tragic incident occurred on the Thunder River Rapids Ride (TRRR) at Dreamworld Theme Park, claiming four lives.

The 30-year-old TRRR ride was a water based family orientated ˜moderate thrill ride’ where patrons simulated white water rafting in a circular raft, suitable for patrons over the age of two, with the option of having children seated on an adult’s lap.

On that day Raft 5 became stranded on steel support rails situated at the end of the rides’ conveyor belt and it continued to travel where it collided with another raft before being lifted and pulled vertically into the conveyor mechanism. However, Kate Goodchild, Luke Dorsett, Cindy Low and Roozbeh Araghi were caught in the mechanism of the ride, and were either trapped in the raft or ejected into the water beneath the conveyor. Although ride operators and some patrons immediately responded, the four were declared deceased at the scene. Two children, aged 10 and 12, seated at the top of Raft 5 were able to free themselves and escape to safety.

Beginning 2018,  Coroner James McDougall ‘s inquest examined the circumstances that caused the fatalities, including:

• The construction, maintenance, safety measures, staffing, history and modifications of the ride.
• The sufficiency of the training provided to staff in operating the ride.
• The regulatory environment and applicable standards by which amusement park rides operate in Queensland and Australia.
• What further actions and safety measures could be introduced to prevent a similar future incident from occurring.

Coroner James McDougall handed down his findings on Feb 24 2020 telling the Queensland court that there was a œtotal and œsystemic failure by Dreamworld to ensure all aspects of safety and referred parent company Ardent Leisure for possible prosecution.

The findings included:

• That the design and construction of the TTTR ride œposed significant risk to patrons.
• œDreamworld could, and should, have identified the safety issues but there was no evidence of an engineering assessment on the TTTR ride in 30 years.
• There were œfrighteningly unsophisticated systems in place, that “shoddy record-keeping was a significant contributor to this incident and contributed to the masking of the real risk of the ride and that the likelihood of a serious accident œwas simply a matter of time.
• The responsibilities placed on operational staff was stressful and œclearly unreasonable and excessive which included monitoring of the pumps, CCTV, air pressure of the gates and queue lines. Operating the ride was œcomplex, confusing and the ride lacked the œrequired labelling, with ride operators having to perform more than a dozen tasks in the space of a single minute.
• Each of the trained ride operators, noted that a requirement the role was to watch the water level, done by looking at an informal ˜scum’ mark around the trough of the ride, as well as the buoyancy of the rafts at the load and unload station, and whether they were sitting on the rails.
• There was also evidence of œan inherent lack of proper training and process in place at Dreamworld to ensure the training provided to new Ride Operators and Instructors was suitable for the roles and responsibilities to be undertaken.

Following the Dreamworld tragedy and the in the wake of the deaths of two workers at the Eagle Farm racecourse, Queensland introduced the charge of industrial manslaughter in 2017. Under those laws Ardent Leisure, Dreamworld’s parent company, would faces fines of up to $3 million, with individual executives facing up to $600,000 and five years’ jail.

However, this law does apply retrospectively and the industrial manslaughter provisions only apply to the deaths of workers, not visitors to a workplace.

Coroner McDougall said he œreasonably suspected Ardent Leisure had committed an offence under the Work Health and Safety Act 2011 and advised he would be referring the company to the Queensland Office of Industrial Relations to consider prosecutions. In 2017 Queensland Police advised that no criminal charges would be laid against Dreamworld staff over the fatalities.

Coroner McDougall stated in his remarks that “such a culpable culture can exist only when leadership from the board (of Dreamworld’s parent company, Ardent Leisure) down are careless in respect of safety ¦ that cannot be allowed.”

Download the complete Coroner’s report:

https://www.awu.net.au/wp-content/uploads/2020/02/10545784-final-dreamworld-draft-6-for-upload_compressed.pdf