DaptoFunlandGuy

Any monkey can build an effect that triggers when the beam is broken. Effects triggers don't need to be built into the ride's PLC. Which is why it's perfectly acceptable to let effects triggers rot on WWF - they don't compromise safety. I'm still reading the report in parts. its going to take a while, but from what i'm reading, it sounds like the despatch control system they had installed was a simple timer that would only open the despatch gate every XX seconds (whether or not there was a raft present), rather than a block control system. This makes sense because of the stoppage procedures requiring the raft at the despatch gate to be tied to the dock and the emergency gate to be shut. This was a measure put in place to space out the rafts, to prevent stacking in unload, the cause of the older (2001?) incident. If, rather than a simple timed gate, they'd have implemented a block safety system (a very well established method of maintaining separation on an amusement ride) at that point, none of this would have happened.

Nice try of what exactly? Exactly - all I said was disney paints things in 'go away green' when they want guests to ignore it rather than trying to elaborately theme and cover them up with something else.

It was actually 15 years ago... almost to the day.

Ok, I think this is as good as I can get - this pic is near the end of the conveyor (the wonderland conveyor completely submerged before returning). The support rails on each side of the conveyor have uprights that are level with the channelboards. The indicated upright (and the upright opposite it) are the only uprights that are higher than the channel boards. Additionally, near the tip of the arrow is a white circle, and a white line leading up to it from the bottom. This is most likely a conduit and J-box containing the wiring for the infra-red beam. And when it rains it pours - here's a second look - this is a still from a maintenance video taken standing in the unload zone trough (dry, obviously) showing the same (far side) upright with the sensor on it: lol. Ok, I guess I got carried away 'in wonderland' but the point is, these automated systems weren't new. or modern. they just weren't reliant on operators to maintain total control over every safety aspect on the ride. On quiet days, Wonderland could operate Snowy with ONE staff member, who was capable of parking the raft, supervising guests as they self loaded, despatching the raft, monitoring it throughout the watercourse, receiving it up the conveyor and parking it for unloading. I'm sure given recent events, if Snowy were still operating, a full review of operations procedures would probably have occurred... (There is even a video of maintenance workers riding it - without anyone at the operator controls, although for obvious reasons I don't suggest this is a wise move)

I'm really taking this to the ludicrous extreme here, and don't seriously believe it (although i don't really know what to believe anymore) but if you had seen so many 'safety' issues brushed under the rug, why would you bother, when you know 'save 30% on our power bill' would be a slam dunk win? Honestly though - 'more modern' is the wrong term for this. The technology for this to be a safe system existed in the 90s. Intamin's rapids ride (and i'm using Wonderland as an example here) had continuous load stations just like TRRR did when it was first built. Wonderland's turntable was also switched off, I believe sometime in the late 80s or early 90s, and airjacks were installed to physically hold the rafts in position for load, unload and despatch. A series of infra-red beams were installed from the bottom of the conveyor to the top, at unload, load, and despatch, and the PLC was capable of monitoring the position of the rafts. Operators had manual control of raft release at load and unload, but the PLC controlled the conveyor, and wouldn't release a raft into the unload zone while it was occupied. Further, A despatch jack would hold a raft from despatching too closely after a raft had already been despatched. Picture below: Airjacks (metal frame with timber planking) to the right of the raft, and the despatch sensor beam (bottom left) mounted on the steel railings immediately below the loaded raft. I know for certain that the conveyor had a beam across it to track rafts nearing the unload point, but try as I might, I simply cannot locate a picture of it. Tales from the Wonderland Maintenance Bay: As I mentioned earlier, the coroner made a point of stating right at the start that he found no fault with the ride operators. I agree totally disgusting, but very glad to hear they weren't faulted.

Nah, he doesn't have a ladder.

I really hope I don't have to explain the history and story of the scooby fire eyes to you gentlemen... i'm starting to feel like you think i'm serious...

Just on this monetary argument - I feel like a person working at the park, knowing that very little gets done unless it makes money, wouldn't you be inclined to push the cost saving factor as a way to get it approved?

needs to cover all angles because they're in a fixed position, whereas the ones on scooby doo, being mounted on the front of the ride vehicles, are capable of moving around the entire ride envelope...

...or maybe they took it down to paint that particular spot... i mean... its not like village would ever listen to guest feedback, right?

The ride operators manual considered pump failure to be the most serious issue - code 6 "operation ASAP". And the procedures for pump failure included initiating a shutdown of the ride including the conveyor. around 1 minute passed between pump stoppage, until impact. Even if the PLC initiated a slow stop at the time of pump failure, it would still have been fast enough to prevent this, even based on the minimum 30 second despatch times. I get what you're saying - nowhere is it spelled out bluntly that that is what it was for, and you can't take anything for granted given the gross negligence and ignorance, but there's enough there that even if water level was a cost factor first and a safety factor second, it'd still have been within scope and therefore under the PLC control in the pump interlocks.

No. Because the investigation showed that they brought a company in to upgrade PLC and sensors, and eventually a touch screen control system. That company installed the chain break and raft sensor, and wired it into the PLC, and quoted for the water level sensor but were told not to proceed. So it IS an easy assumption to say, that if they installed the water sensor, they'd have wired it to the PLC. A one button stop was also discussed, and not proceeded with. These were some of the coroner's first words - he essentially cleared the ride operators of any fault.

A risk assessment on the ride operation was never completed in 30 years. Individual hazards were assessed for risk, but not a wholesome view - each hazard was assessed in isolation. The coroner also mentioned in his findings, that controls (mainly administrative ones) were put in place to mitigate risks (reactionary) without considering what other hazards those controls caused, which is why a whole-of-ride assessment (that was never done) should have been. The section of the report that covers the new sensors installed - which is also the section that discusses whether a water level sensor should also be installed - does mention that the rollback and chain break sensors weren't just alarms - they were wired into the PLC systems to stop the ride \ ride components when the sensors indicated a fault. So if the additional water level sensor HAD been isntalled, one can assume, based on the operation and programming of the other sensors, that the water level sensor would also have been wired into the PLC, and programmed to stop the ride. You're reaching here mate. they fucked up. And any competent person responsible for safety and risk management in the park should have seen that coming. The trouble is - Dreamworld didn't have one.

Agree - the coroner mentioned this and I'm pretty sure it was in one of my rapid fire updates - they argued 'hindsight bias' as influencing the views that something so cheap and simple could have fixed it. (For those who don't know what that means, here's a copypasta slab complete with wiki references: This was Dreamworld's argument before the coroner - that everyone can see how predictable the events were in hindsight. The coroner emphatically rejected this claim of hindsight bias, and used the examples of the MULTIPLE previous historic incidents over more than a decade as justification that the incident was VERY predictable. Further, the coroner stated it was more a case of good luck than good management that nobody had been injured previously. The coroner also stated that a risk assessment had NEVER been completed on the ride operation in 30 years. And that any competent person could see the risks.

Have you been there to see it for yourself? Disney paints a lot of plain buildings 'go away green' and leaves them in plain sight. So it must be fine. Ask @TheChad - he's worked at DisneyWorld you know...

Nah, they're the fire sensors.

That’s a lot of stuff to stick to my fridge @Jamberoo Fan! Monster effort! mod team - is there anyway JF’s posts can be consolidated or kept together? The random replies and multiple posts are a bit hard to read through.

The findings are being uploaded to the coroners court website NOW

Regular ongoing and adequate auditing to be undertaken by the regulator is essential in the industry. Significant changes at Dreamworld since the incident including inspections, emergency drills, training and safety management systems. village roadshow SMS cited also. it is without question more direct oversight and auditing of the industry is necessary. The coroner has now turned to the findings: He has named the deceased to formally identify them. At 2:05, the deceased collided with an empty raft at the unload, causing their raft to lift and be pulled into the conveyor. cause of death was sever internal and external injuries as a result of multiple compressive impacts. Recommendations: change regulatory framework for inspection and licensing. require amusement owners use effective safety management system owner must comply with updated Aus standards. annual risk assessments must be completed by competent persons. operators must be assessed as competent regulator must conduct audits on a regular basis by suitably qualified and trained inspectors. major parks in QLD required to implement effective procedures and processes to ensure safe operation aligned with the new regulations and inspection requirements. new code of practice to establish a minimum standard must be developed. Directions: the coroner has directed the matter to be referred to the office of industrial relations for consideration of whether there is a case for prosecution of Ardent for breaches of WH&S Act. Dreamworld engineer has also been referred to the engineering authority. The inquest is closed.

The coroner rejects the suggestion of “hindsight bias” due to the numerous prior incidents. dreamworlds experts are rejected by the coroner as experts on hindsight bias. “Mr Tan had numerous responsibilities and was moved to multiple different positions within the park, but no one was ever charged with conducting risk assessments in the park” ”such hazards would have been obvious to someone suitably qualified” That no one was injured “was more good luck than good management” Burden on ride operators was significant and unfair.

Operating manuals were drafted by ops department without input from maintenance or safety departments. 5 breakdowns of TRRR in the prior 7 days due to the failure of the south pump. Ride was reset without investigation. no specific training provided to staff on how to manage a ride with multiple failures. “Regardless of training provided, it would never have been sufficient to overcome the design and engineering faults...”

It was only 20 seconds from when the water began to drop until raft 6 became stranded Approximately 50 seconds after when raft 5 collided. It is not clear when the operator initiated the shutdown from CCTV, or if in fact he did. Testing found no issue with the controls. CCTV shows conveyor began a slow stop 11 seconds after the collision. It is clear that the 38 signals and checks to be undertaken by the ride operators were excessive.

The coroner is now reading the technical circumstances of the accident. failure of the south pump, drop in water level, conveyor belt not stopped. Dreamworld was aware the pump failure was an issue to ride operation, but no audible alarm to indicate the pump failure. The gap between the rails and the conveyor created a significant “nip point” large enough to grab raft 5. TRRR was “severely lacking in automation” A basic automated detection system for the water level would have been inexpensive and may have prevented the accident. a one button shutdown was recommended, and was unfortunately not undertaken. it is unclear why this action was never taken.

Total failure by everybody at Dreamworld to identify the hazards on TRRR. Safety systems rudimentary at best. departments operated in silos record keeping was ad-hoc. safety systems were frighteningly unsophisticated. ”it was simply a matter of time” Maintenance and inspection was “reactionary” “Widespread lack of record keeping and document management” It is significant that the GM of engineering had no knowledge of the previous raft crashes “Shoddy recordkeeping” was a significant contributor to this accident.