Thunder River Rapids Incident Coronial Inquest

[Jamberoo Fan]

The Courier-Mail is reporting (subscriber-only article) that the coronial inquest will begin on Tuesday the 3rd of April.

 

Edited March 5, 2018 by Jamberoo Fan

[Jdude95]

Here's the article for anyone who can't get past the paywall

Edited March 5, 2018 by Jdude95

[Tim Pearson]

There's some pretty unsafe equipment been used there. That's what reading up on the incident led me to believe. In most industries, a piece of machinery will have something like a rollbar, to prevent it injuring its occupants. And then you look at that conveyer belt and its not a conveyer belt at all, its some industrial chain with planks of wood bolted to it. Its a deathtrap. All conveyer belts I've seen are continuous multi ply rubber and they have exit platforms, like you see at airports. You don't engineer a conveyer belt that way just cos its cheaper and easier to implement. A ride running 1000s of times a day has this statistical probability that makes it super dangerous.

[DaptoFunlandGuy]

3 hours ago, Tim Pearson said:

All conveyer belts I've seen are continuous multi ply rubber and they have exit platforms, like you see at airports. You don't engineer a conveyer belt that way just cos its cheaper and easier to implement.

Welcome to the forums @Tim Pearson.

Although you may have only seen a rubber-belted conveyor, there are several different types out there - continuous rollers, for example.

The style of conveyor used on Thunder River is fairly standard for this type of ride, and has been in use for decades. As has been discussed ad nauseum, it is not the type of conveyor that is in issue here, but rather the modifications made to it that are suggested to have been the cause.

Take these images - from a river rapids ride at Disney's California Adventure:

In comparison, you can see the slats at dreamworld are not as closely spaced:

There are of course examples of river rapids rides that do use a rubberised belt:

 

As for a rollbar, most river rapids don't feature this - however, from what I understand of this accident, a rollbar likely wouldn't have prevented what occurred. the raft did not flip completely over.

There's quite a discussion on Parkz about the incident, with loads of speculation - it's worth a read if you're interested, as much of what you've pointed out has been discussed at length with good examples and arguments both for and against.

[Jamberoo Fan]

Day 1 and already a lot of stories in the media. Here's the most interesting quotes I could find:

From Yahoo!7:

Quote

The Brisbane Coroners Court on heard on Tuesday the theme park visitors had boarded raft five on the ride, which had been designed for families with children and had been a key attraction at the park since December 1986.

Ms Low's family is hoping for answers from the inquest and that it will prevent others from suffering "such enormous heartbreak".

On Tuesday it was proposed the inquest be held in two parts.

The first...will investigate the construction, maintenance, safety, history and modifications made to the ride.

It will also examine the emergency services response and the training of Dreamworld staff.

The second part of the inquest will look at laws around theme park operations and whether changes need to be made and further safety measures introduced.

From The Australian:

Quote

In the Coroners Court in Brisbane this morning, counsel assisting the inquest, Ken Fleming QC, outlined the October 2016 tragedy in which Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi, along with Sydney woman Cindy Low.

Nine rafts were in circulation at the time.

“Raft 5 travelled through the course without incident before being picked up by the conveyor at the end of the ride and moved towards the elevated unloading area,” Mr Fleming said. “At this time, Raft 6, which was dispatched in front of Raft 5, became stranded on the steel railings situated at the end of the conveyor near the unloading area.

“It appears from CCTV footage from the incident that around 15 seconds beforehand, the south pump had stopped working, causing water to rapidly flow back into the pump outlet which resulted in a drop of the ride’s water level. As the water flowed back into the pump outlet, it simply was allowed to return to the reservoir, thus allowing the water level to drop.

“Raft 5 continued to travel on the conveyor where it collided with Raft 6, before being lifted and pulled vertically into the conveyor mechanism.”

He said the conveyor stopped “a number of seconds” later.

“Ebony and Kieran, who were seated at the top of Raft 5, were able to free themselves and escape to safety,” he said. “Ms Goodchild, Ms Low, Mr Dorsett and Mr Araghi were caught in the mechanism of the ride and were either trapped in the raft or ejected into the water beneath the conveyor. 

From the Australian Broadcasting Corporation's Radio Australia:

Quote

"Each died almost instantly as a result of compressive or crushing injuries as a result of coming into contact with the mechanism of the conveyor," Mr Fleming said.

The first half of the inquest will likely be heard in June and July, with proposed dates for the second portion slated for October, November and December.

The dates are yet to be formalised.

Lawyers for Ardent Leisure, Dreamworld's parent company, said they would cooperate with the inquest.

Mr Fleming said the inquest would not result in blame being laid on any parties, but acknowledged the Director of Public Prosecutions and Workplace Health and Safety Queensland could take their own legal action.

A second pre-inquest hearing will be held at the Southport Magistrate Court on May 25.

From The Brisbane Times:

Quote

Representatives for four victims or their families were given leave to appear, along with Dreamworld parent company Ardent Leisure and two company employees.

Counsel assisting the inquest Ken Fleming QC said one of two “large in the extreme” pumps feeding the ride had stopped working just before the incident, allowing the water level to drop significantly.

Ms Low’s family members issued a statement welcoming the beginning of the process...

“Our lives were turned upside-down that day by the loss of Cindy, we have spent each week and month comforting each other and learning how to live without her. We will not be making any further statements until the inquest is fully concluded,” they said.

Mr Fleming said it was too early to list the witnesses who would appear and stressed the inquest process forbade south-east coroner James McDougall from making any findings of guilt or similar liability.

That would be a matter for the Director of Public Prosecutions and Workplace Health and Safety Queensland at another time, he said.

Outside court, an Ardent PR representative, Jacquelynne Wilcox, said the inquest process had to be respected.

“Everyone feels for the families,” she said.

From New Idea:

Quote

Results of the inquest are expected to be released later in the year. 

From the Australian Broadcasting Corporation:

Quote

Outside court, Mr Fleming said he hoped the victims' families would get some closure from the inquest.

He said there would be a lot of evidence to come out and that he had "a terabyte" of documents relating to the case.

"There is an enormous amount of work to be done to get on top of the facts — a lot of people's interest [are] at stake here," Mr Fleming said.

 

Edited April 3, 2018 by Jamberoo Fan
Added last quote

[pushbutton]

On the face of the information in the above posts, it sounds like the incident could have been prevented if the failure of the water pump had triggered an emergency stop of all moving parts of the ride. 

If so, I think that's something that should be implemented on all similar rides worldwide without delay. 

[themeparkaddict]

7 hours ago, pushbutton said:

On the face of the information in the above posts, it sounds like the incident could have been prevented if the failure of the water pump had triggered an emergency stop of all moving parts of the ride. 

And I would have thought that this would have already been the case. Quite shocked that it isnt. 15 seconds is a long period of time. Does anyone know if the pump fail also caused the raft to become stuck, or was that also coincidental?

Edited April 3, 2018 by themeparkaddict

[liz.wis]

The tragedy of this aside, it's really bad timing for Dreamworld to have this back in the media in the run up to the Commonwealth Games, and will probably really impact on potential tourist visitors.

 

 

[pushbutton]

6 minutes ago, liz.wis said:

The tragedy of this aside, it's really bad timing for Dreamworld to have this back in the media in the run up to the Commonwealth Games, and will probably really impact on potential tourist visitors.

 

 

I doubt it was Dreamworlds choice,  but yes it's unfortunate timing. 

[Tim Dasco]

I would say it's better timing now. The coverage is a lot less than it would be as the media are already full with the Games stuff to notice it.

[Brad2912]

Can you believe this article (same one posted above) is actually being pushed onto people’s facebook timeline’s as “sponsored content”. The media are actually paying money to make sure people see it... 

[Jdude95]

One article: "Painful death"
Another article: "Killed instantly"
Surely it's not that painful if it's instant?

[iwerks]

11 hours ago, Brad2912 said:

Can you believe this article (same one posted above) is actually being pushed onto people’s facebook timeline’s as “sponsored content”. The media are actually paying money to make sure people see it... 

I keep getting sponsored ‘articles’ about theme park woes from real estate sites. It’s the same article that has appeared over the last six months.

[red dragin]

Change your google and Facebook advertising ID, then switch them to private.

Stops those ads being targeted to you, if you've ever wondered how "they know" what you are into. 

[Jamberoo Fan]

The 2nd pre-inquest hearing was held today. Again, here's the most interesting quotes I could find:

From The Brisbane Times:

Quote

The coronial inquest into the deaths of four people at theme park Dreamworld will start on the Gold Coast next month.

At a pre-conference hearing in Southport Magistrates Court on Friday, Coroner James McDougall ordered the inquest into the October 2016 tragedy to begin on June 18.

At Friday's brief conference, orders were given for the list of witnesses needed to attend the inquest to be finalised by June 1.

Final evidence submissions must be made by June 8.

Legal representatives of all four victims as well as Dreamworld chief executive Craig Davidson, Dreamworld's parent company Ardent Leisure and the Office of Industrial Relations all attended Friday's conference.

From The Courier-Mail:

Quote

A brief pre-inquest hearing was held at Southport Court today with legal representatives from Dreamworld, parent company Ardent Leisure and families of victims Kate Goodchild, Luke Dorsett, Cindy Low and Roozi Araghi in attendance to hear Coroner James McDougall set June 18 as the start date for the inquest, which is expected to run for several weeks through June and July and again later in the year.

Edited May 25, 2018 by Jamberoo Fan

[Brad2912]

Dreamworld staff’s safety fears after tragedy reveals parks rollercoaster of emotion

JUNE 16, 2018

STAFF have accused Dreamworld of refusing to implement key training procedures following the Thunder River Rapids ride tragedy that killed four people.

The Bulletin has obtained internal documents and spoken to whistleblowers as part of an investigation which puts the spotlight on the theme park’s management on the eve of a coroner’s inquest.

Staff claim a manager refused requests for critical response training because “the incident was too raw to get involved”.

Experienced health and safety workers also allege:

* No formalised critical response training had occurred since the tragic events of 2016.

* When it was brought up managers responded by saying that “it is too raw” or talked about cost factors and not having the budget to cover the expense of training.

* Nothing was documented for first respondents on what to do if an incident occurred on a ride which requires guest extraction.

* If a guest sustained an injury on a ride there was no formal response, individual clinicians having to make up their own mind what to do.

* If a ride like the Buzz Saw was stopped, staff lacked formal guidelines on how to get people out.

* Inexperienced staff had been appointed to senior safety roles and some multi-hired staff have basic first aid but need more training.

* First aid staff had been excluded from some training, and safety concerns were raised in an inhouse survey.

* Some staff were refusing to operate certain rides because they had concerns about safety.

* Staff were operating rides after only four to five months working in the theme park despite previous practice requiring 18 months.

A pre-inquest hearing in April found a faulty water pump and raft were the likely trigger for the ride malfunction which killed four tourists in October 2016.

Kate Goodchild, 32, her brother Luke Dorsett, 35, and his partner Roozbeh Araghi, 38, and Gosford woman Cindy Low, 42, died in the tragedy.

The Bulletin revealed the pump malfunction as the cause, and in a special report detailed how safety concerns had surfaced four years earlier.

Fresh documents detailing notes from interviews and emails with staff show an offsite meeting chaired by Arden Leisure’s chief audit officer was held at Hope Island in late April.

Workplace Health and Safety Queensland said it had received a complaint last month about a range of alleged issues at Dreamworld, and an inspector and engineer attended the theme park to investigate.

“No contraventions of WHS legislation were identified and the investigation into the alleged issues has concluded,” the spokesperson said.

But the Bulletin has been told the investigation did not consider cultural and management issues.

Dreamworld yesterday issued a statement indicating the theme park would “continue to co-operate with the Coroner and those assisting him”.

A Dreamworld spokesman said the theme park was not in a position to provide information which may be dealt with by the inquiry.

“Every complaint relating in any way to a safety matter is fully investigated. Where appropriate external advice is sought to ensure every safety complaint is dealt with thoroughly,” the spokesperson said.

AWU acting branch secretary Steve Baker said union members were concerned about Dreamworld’s approach to safety matters. Documents were provided to police for the Coroner.

“A major concern has been a culture of secrecy in the behaviour of Dreamworld management,” Mr Baker said.

“Whenever the union sought documentation from Dreamworld regarding safety issues, these requests were refused by management. This meant the union had to pursue matters through other means including Right to Information.”

At April’s safety audit meeting, some staff said some managers were suffering from post-traumatic stress disorder

“I get asked by every second guest was I there on the day. It is referred to as ‘the incident’. The effects of this incident are still being felt among the staff,” a staffer said.

Aquatics at the park had staged incident response training in a room so as “to not be visible because of sensitivities”.

A plan for a major health and safety training day at the water park was abandoned after the Rapids Ride tragedy.

“They said it was too fresh, we shouldn’t be doing CPR, it will harm others in the park,” a Dreamworld source said. “The lifeguards needed that training. We now know these events are real and can happen.”

Despite rides being deemed safe and passing engineer testing, some staff were reluctant to be operators.

“I know people who refuse to operate,” another Dreamworld source said. “I know some who say it took me three years to get Rapids, now they (newer employees) are getting high-level rides in 18 months.”

Another theme park insider told the Bulletin: “The staff are committed, dedicated and professional. They were pushed down and out.

“A number of people who were first responders — they’re gone. They saw the clinicians being decimated and decrease with expertise.”

[westical]

I find it a little hard to believe that 1 in 2 guests are asking staff members if they were present on the day of the “incident”.

[GoGoBoy]

Sounds mostly like a beat up to me.

[Levithian]

Its a quote from a person experiencing a large amount of questions. Its exactly what you hear people say as a turn of phrase. Its not literal. 

"We had 3 different kinds of roast, but it was like every second person wanted chicken"

And yes, im thinking what roast dinner to cook tonight 🤔

[New display name]

@alexutting  from the Courier-Mail is tweeting updates from the inquest today.

[New display name]

[Slick]

 

Here's what we know so far - feel free to comment and i'll make edits where possible.

 

• a similar incident occurred in 2001 with no one on-board, was put down to operator error, no modifications were made and emergency response training was instead increased
• operating the ride was difficult, noting that operators "must perform numerous tasks simultaneously, many of which are cognitively draining."
• Ride's e-stop button was "totally un-marked" and the main control panel was "confusing"
• The main e-stop button would take seven seconds to stop the ride & the second e-stop button could have shut down the ride in two seconds
• Operators were told "not to worry about that button (the second e-stop) [because] no one uses it."
• A memo was sent to staff less than a week before the incident advising only to use the second e-stop button if the "main control panel cannot be reached" to prevent "false alarms."
• "Button" on the unload platform stops conveyor belt, but staff were told not to worry about it
• Nothing beyond a scum line was used to measure water levels (no electronic indicators or a depth ruler) - rafts getting stuck were another sign
• Dreamworld's safety compliance rate in 2016 was nearly half (41.7%) of the 75% that is considered to be compliant
• The same pump that failed had an "earth fault" twice that morning that caused the pump to stop and had tripped on October 19, 2016 and was scheduled to be checked on October 27.
• Police were never able to replicate the incident with or without dummies

With thanks to journalists Lea Emery from GCB and Alexandria Utting from CM for the live coverage so far.

 

Edited June 18, 2018 by Roachie

[Brad2912]

Don’t have text to copy and paste but on the local radio news up here it was just reported:

2 staff Working - 1 junior and one senior. the junior staff member was incharge of the panel at the time of accident she admitted to police investigators that she wasn’t aware how to use the emergency stop system, and this process did form any of her training. She also admitted that the panel itself was confusing, and investigators noted this as well when trying to operate the ride. 

[DaptoFunlandGuy]

59 minutes ago, Roachie said:

• Ride's e-stop button was "totally un-marked" and the main control panel was "confusing"
• The main e-stop button would take seven seconds to stop the ride & the second e-stop button could have shut down the ride in two seconds

Thanks for the summary @Roachie - these two points have me a little intrigued.

 

I'm first wondering whether the 'confusing' label is that applied to it by investigators, or by qualified and experienced operators. Ie: were the people trained to operate it saying the panel was confusing? Or just a layperson? I'm sure many rides around the world would appear confusing to someone not trained on it... and I can't really imagine an experienced operator finding a panel confusing so i'm just trying to figure it out in my head.

 

WRT the 'two' e-stops, my understanding is the main e-stop was an 'all stop' - so cut power to pumps etc, and for that reason, seven seconds sounds like the time it takes the water levels to drop within the station area. The 'second' (although apparently not marked in this way) was only a stop button for the conveyor - water continued to flow if this was pressed.

 

If my understanding is correct, then the instructions 'not to use' and 'nobody uses that' kind of make sense. In an emergency, you would want an 'all stop' not just a 'stop the conveyor' so it does kind of make sense in most scenarios.

At the end of the day its starting to sound much worse than we had thought out at Dreamworld, and I think the best outcome here for all is for the inquest to end with an outcome, for that outcome to absolutely crucify Ardent and it's operations, and for the park to be on-sold to an operator with an exemplary record to re-start everything from scratch.

[Slick]

15 minutes ago, AlexB said:

Thanks for the summary @Roachie - these two points have me a little intrigued.

 

I'm first wondering whether the 'confusing' label is that applied to it by investigators, or by qualified and experienced operators. Ie: were the people trained to operate it saying the panel was confusing? Or just a layperson? I'm sure many rides around the world would appear confusing to someone not trained on it... and I can't really imagine an experienced operator finding a panel confusing so i'm just trying to figure it out in my head.

 

 WRT the 'two' e-stops, my understanding is the main e-stop was an 'all stop' - so cut power to pumps etc, and for that reason, seven seconds sounds like the time it takes the water levels to drop within the station area. The 'second' (although apparently not marked in this way) was only a stop button for the conveyor - water continued to flow if this was pressed.

 

If my understanding is correct, then the instructions 'not to use' and 'nobody uses that' kind of make sense. In an emergency, you would want an 'all stop' not just a 'stop the conveyor' so it does kind of make sense in most scenarios.

At the end of the day its starting to sound much worse than we had thought out at Dreamworld, and I think the best outcome here for all is for the inquest to end with an outcome, for that outcome to absolutely crucify Ardent and it's operations, and for the park to be on-sold to an operator with an exemplary record to re-start everything from scratch.

It seems confusing was applied to both operators and investigators.

Seems the newer e-stop cut everything where-as the older main panel had two buttons.

Some good thoughts here, i'll re-edit the original post shortly when i've checked on more information.