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A report into the death of an eight-year-old at the Royal Adelaide Show in 2014 by South Australia’s Deputy Coroner has called for national reform of carnival show ride regulations.

Released yesterday, the Coronial report into Adelene Leong's death called for improved regulation of 'high-energy' rides

The eight-year-old died after she was flung out of the Airmaxx 360 ride at a speed of at least 100km/h in front of her family and shocked onlookers.

Just 90 seconds into the ride she slipped out of restraints and was thrown into the air before landing on the ground headfirst in front of her mother and multiple witnesses.

She died from multiple injuries.

Deputy State Coroner Ian White said South Australia needed to be the leader in convincing other states and territories to improve the operation of high-energy rides.

He said the inquest revealed there were missed opportunities to change Adelene's fate that day, advising “the evidence of these missed opportunities is likely to produce understandable reactions of frustrations and despair to the public.

"There needs to be a meaningful response to honour Adelene's short life."

"Her death must be a cause for fundamental change in the operation and governance of high energy rides in Australia.

"South Australia must be the leader in convincing all jurisdictions to agree and implement the necessary actions that will ensure that the wishes of Adelene's mother are honoured so that 'such an event will not happen again.'"

The inquest heard the ride was purchased from Spain by amusement industry operators Jenny-Lee Sullivan and her husband Clinton Watkins, of CJ and Sons Pty Ltd and imported into Australia in April 2013. However, on arrival to Australia, engineers undertook the wrong type of inspection.

Before it was given the green light to operate, it had to get design registration and plant registration which ensures rides that operate in Australia do not have any design flaws.

However, the inquest heard it never went through the process of design registration and the registration number assigned to it belonged to a different ride.

Sullivan and Watkins, who borrowed more than a $1 million for the purchase, had found themselves under financial stress soon after making the purchase, breaching the terms of their loan multiple times.

In operation, they imposed a minimum height requirement of 120cm for unaccompanied riders despite the Spanish manufacturer recommending 140cm.

Leong was 137cm tall at the time of her death.

Deputy Coroner White found the eight-year-old’s death could have been prevented had the operators not ignored the manufacturer’s height requirement, noting “I am satisfied that the owners deliberately concealed this information from all the relevant authorities for the purpose of expanding the eligibility of patrons to ride on the Airmaxx.”

The inquest heard the Airmaxx was operating at maximum force with Leong hanging from her seat upside down by her left ankle just prior to being ejected.

Watkins had largely assembled the ride himself, seeking clarification on certain aspects in emails to the manufacturer.

The findings stated that an inspection of the ride conducted at the Show was inadequate and staff were not properly trained.”

The inquest also heard that prior to coming to the Royal Adelaide Show eight years ago, the Airmaxx 360 had been "plagued by complaints".

In three days at the 2014 Royal Melbourne Show 22 reports were made regarding minor injuries and WorkSafe Victoria lifted the minimum height restriction to 130 centimetres.

Two weeks after tragedy, Sullivan applied for the Airmaxx to operate at the Royal Sydney Show, still outlining a minimum height of 120cm.

In an application that was later withdrawn, she referred to an incident at the Adelaide show but claimed “there has been no fault on the ride or operators’ behalf”.

The Director of Public Prosecutions in 2016 opted not to pursue criminal charges regarding the death.

CJ and Sons Pty Ltd were convicted in 2017 of breaching workplace health and safety laws but were found to be unable to pay any financial penalties.

Deputy Coroner White noted in his findings "Adelene's death that day was inexcusable. It could and should have been prevented.

"The circumstances of her death must never be allowed to be repeated."

Deputy Coroner White called for a nationwide regulatory process to be established to verify and record design registration for rides and a common application procedure for plant registration.

He also called for a national database for ride registration numbers to be set up that could be accessed by regulators in all states and territories and for a nationwide panel to annually assess the skills of amusement ride inspectors and mandatory participation in a continuing education scheme for them has also been included in the Coroner's list of recommendations.

Deputy Coroner White also called for the Royal Agricultural Society of South Australia to work with other show organisers interstate to set up a database for sharing information about rides.

He called for Standards Australia to conduct a comprehensive review of its standards in relation to amusement devices and rides, adding "this review should clarify in detail what is required at an inspection of an amusement device or ride by a competent person in every jurisdiction.

"It urges all governments in the Australian jurisdiction that the Australian Standards have the same legal status in all jurisdictions as a rule of law rather than merely a code of practice."

The inquest heard the ride's operators tried to start operating the Airmaxx again in January 2015, but then abandoned their plans.

The ride was then sold to an operator in the United Kingdom in 2016 for approximately $180,000..

Deputy Coroner White went on to say "I heard brief evidence that in 2019, a woman fractured her skull at the Hull Show when she was ejected from the Airmaxx on to a patron from another ride.”

Images: The AirMaxx 360 ride (top), signage showing the ride's 120 centimetres minimum height restriction when it was at the Royal Adelaide Show in 2014 (middle: credit: SA Coroner's Court) and Adelene Leong before her death (below, credit: SA Police).

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