Hard Lessons Nigel Benton looks at the implications of the Coroner’s report into the deaths of four guests on Dreamworld’s Thunder River Rapids ride in 2016
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ith the impact and implications of the deaths of four guests on Dreamworld’s Thunder River Rapids ride in 2016 having been hanging over the Australian theme park sector for more than three years, the release of Queensland Coroner James McDougall’s report into the cause of the fatalities at last ends speculation about the causes of the incident. With the Coronial inquest having been the source of a series of revelations during 2018, Coroner McDougall’s report has firmly set out what caused the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi when riding ‘raft five’ of the Thunder River Rapids ride 25th October 2016. Coroner McDougall’s report hits hard, finding that Australia’s largest theme park and its management had “a culpable culture” from the board down that was “careless in terms of safety” and that he reasonably suspected Dreamworld owner, Ardent Leisure, had committed a workplace offence. He advised that the design and construction of the ride posed a “significant risk” to patrons’ safety, noting that Dreamworld’s systems were “frighteningly unsophisticated” and that the theme park had a “systemic failure” in all safety aspects. Coroner McDougall told a Brisbane court that while Dreamworld had a reputation as a “modern, world-class theme park”, its safety and maintenance systems were “rudimentary at best” and that the occurrence of a serious accident “was simply a matter of time”. Systems and assessments Commenting on the ride, which had been designed and constructed by an in-house team at Dreamworld, Coroner 58 Australasian Leisure Management Issue 137
McDougall said there was no proper engineering oversight, nor were there any holistic risk assessments ever conducted on the ride. The ride, while resembling rides built by international manufacturers and installed at theme parks around the world, was built by Dreamworld and had been modified since its opening in 1986. Referring to the inquest, Coroner McDougall stated “it is clear from the expert evidence that at the time of the incident the construction of the ride posed a risk.” Identifying hazards including the wide spacing of slats, pump failure and the fact that there was no emergency stop button, Coroner McDougall noted “Dreamworld could, and should, have identified the safety issues connected to the ride (but) there was no evidence that Dreamworld ever conducted a proper engineering risk assessment on the ride during its 30 years of commission.” The 2018 inquest had heard that the ride’s fatal malfunction was the third malfunction that day and the fifth in just one week. This prompted Coroner McDougall to comment “why safety action was not taken earlier that day I find very difficult to understand.” He also said that the training provided to staff in operating the Thunder River Rapids Ride was inadequate, adding “there was evidence of an 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.” Risk responsibilities Coroner McDougall went on to say “owners should be riskaverse. That was not the case with respect of (this ride). “Dreamworld placed significant reliance on ride operators to identify risks of issues.” “It is unfathomable that this serious and important task fell to staff … who didn’t have the requisite qualifications or skill sets to identify such risks.” Coroner McDougall said “shoddy record-keeping was a significant contributor to this incident and contributed to the masking of the real risk of the ride” and that it was unclear why basic engineer controls - such as a water level monitor - were not installed on the ride. Legal action Coroner McDougall’s report is expected to open the door to multiple prosecutions under Queensland’s Workplace Health and Safety Laws, with Coroner McDougall advising that he will be referring Ardent Leisure, to the Queensland Office of Industrial Relations. He said Ardent Leisure “may have committed an offence under workplace laws”, adding “whether there is sufficient evidence to proceed to prosecution is (a matter for them).” Ardent Leisure could face up to $3 million in fines if a prosecution is successful. He said he would also pass his findings to the board of Professional Engineers Queensland to whom he would also refer the engineer who was hired by Dreamworld to inspect the ride, stating that his failure to properly inspect the ride fell below industry standards. No corporate manslaughter prosecutions will be available because the relevant laws are limited to employee deaths. Queensland Police advised in October 2017 that no criminal charges would be laid against Dreamworld staff over the fatal incident. Moving forward Coroner McDougall noted “significant changes” in ride audit and inspection systems at Dreamworld since 2016. He said while this was positive, it also highlighted the
