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The Coroner’s report into the fatalities of four guests riding Dreamworld's Thunder River Rapids Ride in October 2016, has advised that the design and construction of the ride posed a "significant risk" to patrons' safety.

Queensland south-eastern Coroner James McDougall today delivered his findings into the deaths of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi as a result of the popular river ride malfunctioning at the Gold Coast theme park.

Assessing material from the lengthy inquest conducted during 2018, Coroner McDougall advised 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".

He said there had been a "systemic failure by Dreamworld in relation to all aspects of safety" and that he was referring parent company Ardent Leisure for possible prosecution.

Systems and assessments
Coroner McDougall stated "(there were) frighteningly unsophisticated systems in place at Dreamworld” and that the occurrence of a serious accident “was simply a matter of time. That time came on October 25 (2016)."

Commenting on the ride, which had been designed and constructed by an in-house team at Dreamworld, Coroner 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 risk-averse. 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.

Future legal action
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 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."

His 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.

Family members react
Ahead of the Coroner's findings, family members of those who died read out victim impact statements.

Matthew Low, the husband of Cindy Low, told the court his wife had the "heart of a tiger" and was "soft, nurturing, unpredictable and confident".

"Our heart aches daily as we try to be grateful for the decades we had. There just weren't enough.”

He also read out a statement from their nine-year-old daughter, who wrote she missed her "hugs and cakes that she used to make for us".

Kim Dorsett said her son Luke had a compassionate and loving nature, and that "if you were loved by Luke you were loved 100%" and that her daughter Kate Goodchild "was the love of many people's lives" and was "the best mummy to her two girls".

She added "my huge regret is the day she needed me most I wasn't there.

"The three of them loved the theme parks on the Gold Coast - the scarier (the ride), the better."

She thanked emergency services, first responders, the coroner and "the people of Queensland who took these four souls into their hearts".

Ardent Leisure's reaction
On Friday, Ardent Leisure invited media to attend a press conference at Dreamworld on Tuesday 25th February, to hear from Ardent Leisure Chairman, Gary Weiss and Ardent Leisure Theme Parks Division Chief Executive, John Osborne in regards to the Coroner’s report.

Australasian Leisure Management will report this.

Click here to read the full report from the Queensland Coroner. The report makes the following recommendations:

• 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
• The Board of Engineers, in consultation with OIR and other industry groups, to continue efforts to address the shortfall in suitably qualified and experienced RPEQ’s with respect to the inspection of amusement devices.
• 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.

Image: The Thunder River Rapids Ride in operation at Dreamworld prior to the October 2016 fatalities.

Editor's note: This news item was first published as 'Coroner's report into Dreamworld fatalities critical of the design and construction of Thunder River Rapids Ride'.

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