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

With 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”. 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

Dreamworld’s Thunder River Rapids ride in operation prior to the October 2016 fatalities.

deficiency of safety management at the theme park before the tragedy, noting “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.”

He also recommended the issue of a shortfall of experienced ride engineers be addressed.

Commenting on the judgement, tourism lawyer Tony Cordato of Cordato Partners Lawyers, noted “the Coroner’s report will provide useful evidence of the failure by Dreamworld to satisfy its duty of care to ensure the safety of visitors, especially on its rides.

“It remains to be seen whether Dreamworld’s failures amount to recklessness, so as to strip Dreamworld of any protection it has under its Terms and Conditions which include ‘The Company will not be liable for any person in respect of the loss of life or personal injury to, any person, whether that loss, damage or personal injury is caused by any person’s negligence (including the negligence of The Company) or otherwise’.”

In the wake of the Coroner’s report, the Australian Amusement, Leisure and Recreation Association Inc. (AALARA) has expressed that its “sympathies are with the families and first responders involved in this tragedy.”

The Association has advised that it will address recommendations from the Coronial report and is working to establish a code of practice with the industry and Queensland Government to ensure the highest level of safety is achieved.

Following the 2016 deaths, AALARA briefed the international attractions industry and has worked proactively with the Queensland Government following a Best Practice Review into Workplace Health and Safety to develop legislative changes.

AALARA President, Shane McGrath highlighted that this is part of the sector’s continuous and ongoing efforts to achieve world leading safety management within Australia’s attractions industry.

Ardent Leisure

In reaction to the Coroner’s report, Dreamworld Chief Executive, John Osborne (who joined Ardent Leisure last year), advised “first and foremost, we express our deepest sympathies to the families and friends of (the deceased). Our thoughts are also with the first responders, emergency services personnel, investigators, counsellors and Dreamworld team members affected by this tragedy.”

Ardent Leisure Chairman Gary Weiss – who took on the role in September

2017, having just been a shareholder at the time of the fatalities - said the company was committed to implementing the Coroner’s recommendations and said safety was the number one priority for the theme park moving forward.

Dr Weiss commented “the Coroner’s report does not mark the beginning of change at Dreamworld, but rather represents a very important milestone in a continuous improvement journey for safety at Dreamworld that is ongoing.

“They are proactively focused on continuous improvements to safety across the park, in the areas of ride safety and reliability, training of ride operators, emergency management procedures, safety management systems and safety governance.”

With the Thunder River Rapids ride now dismantled and removed from the site out of respect for the victims, a memorial garden will be built at Dreamworld to honour the four victims but a timeline on its construction is yet to be finalised.

Separately, many of the families and first responders have already been compensated through private settlements.

Nigel Benton is Publisher of Australasian Leisure Management.

Coroner McDougall’s recommendations from the Dreamworld inquest: •Changes be made to the current regulatory framework in Queensland with respect to the inspection and licensing of major amusement park devices to ensure that a more structured and compliance focused regime is implemented. •That Queensland’s Office of Industry Relations (OIR) continue to develop a Code of Practice for the amusement device industry in Queensland, which will establish a minimum standard for the operation of amusement devices, in consultation with the requisite industry stakeholders, including the Amusement Device Working Group. •That efforts to harmonise the requirements of the relevant design standards, particularly the critical safety requirements on amusement devices in Australia, Europe and America continue in consultation with relevant industry stakeholders. •Steps be taken to rectify the lack of detailed knowledge of Safety Related Control Circuits held by the majority of OIR Inspectors. •That a reassessment of the Australian Standards applicable to waterborne rides (including raft rides) be undertaken to include some of the types of safety requirements associated with roller coasters, including more thorough considerations for lifts/elevators, collisions and passenger loading/unloading. •Consideration as to whether the requirement for hazard identification and risk assessment should be made mandatory, and whether any modification or alteration to the ride should require hazard identification and risk assessment to ensure that changes made do not affect safe operation and use.