'Total failure': Dreamworld findings revealed
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.
He said there was a "systematic failure" by Dreamworld in relation to "all aspects of safety".
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 at the theme park.
Confronting evidence emerged during six weeks of evidence in 2018.
In Brisbane Magistrates Court today, the coroner said it was clear from expert evidence 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 "rudimentary" and "unsophisticated".
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".
Queensland Premier Annastacia Palaszczuk has all but confirmed the state government will adopt every coronial recommendation after an inquest into the 2016 tragedy at Dreamworld.
Confronting evidence emerged during six weeks of evidence in 2018.
Police recommended no criminal charges against Dreamworld staff over the fatal incident, but the coroner could still recommend prosecutions or substantial fines for the company and its executives.
"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 2019, 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.
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.
- 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
- 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
- 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
- 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
- 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.