Thunder River Rapids Incident Coronial Inquest

[Jdude95]

Alright everyone, here's todays roundup in a neat, easier to read format as usual. 

https://docs.google.com/document/d/1efAbeRV7gRoXRkHVhrUkhFAcRe9fpiBlUIFXO3gJnJs/edit?usp=sharing

I shall see you all tomorrow for the final day of the first part of the inquest. Then we will pick things back up in October where I'll be back live posting updates from the next chapter in the Dreamworld Inquest. 

[New display name]

2 minutes ago, dbo121 said:

On the turntable there would of been a block at some point to make sure two rafts did not go through at same time?

Repeat in English please.

[dbo121]

4 minutes ago, Skeeta said:

Repeat in English please.

 

Post edited. I was feeling Chinese this morning 

[DaptoFunlandGuy]

1 hour ago, dbo121 said:

During the days of the  turntable was there a blocking point somewhere on the ride to create a distance between rafts?

There was no need. The turntable speed versus the water speed ensured spacing. Rafts could be almost touching in the station, but the speed at which the turntable turned governed how regularly a raft would be 'released' at the end of the turntable.

As the water speed was faster than the turntable, as each raft cleared the station they would pick up speed. The time delay until the next raft made its way clear of the station was enough to ensure distance was maintained.

Rafts could bump prior to the conveyor if the conveyor was backed up, but as the water was less turbulent, and the course was flat leading up to the conveyor, bumping would be just that - a bump. Provided guests in those rafts remained seated, it was unlikely to be more jolt than a bumper car at that point in the ride.

[Jdude95]

Sorry, I got caught up and got to court a little late 

Peter Gardner 

Engineering Supervisor

Mr Gardner confirmed the ride was built in-house and that if there are any rides with an issue, it should be referred back to the manufacturer but as the ride was built in-house there’s no one to refer back to. 

Mr Gardner confirmed that e-stops should be labelled. 

Mr Gardner wasn’t involved with the sensors that was installed at the base of the conveyor. 

Prior to Mr Gardner’s employment, he believes the motors for the pumps on TRR were upgraded. 

Mr Gardner is now bringer asked about annual maintenance for TRR. 

The ride is completely shut down and assessed for any works that need to be complete. If required external contractors could be bought in to ensure the ride meets legislative requirements. 

An assessment of what is required to bring the ride up to standards is complete prior and during annual maintenance. 

Preventative maintenance is performed on rides as per requirements from the manufacturer. These assessments and maintenance are completed to assist maintenance staff with figuring out the scope of work required during the annual maintenance. 

If during annual maintenance, a maintenance team member notices any issues that occur, they will raise that with their supervisor. 

Mr Gardner confirms spending was available to his department to address safety issues. 

When a ride is built in-house, all of the components of the ride should have manuals and be referred back to the manufacturer if there are issues. 

 

TRR was shut down and de-commissioning began after QPS had commenced their testing in the days after the incident. 

All the rides and slides were inspected by Pitt and Sherry, an external company, prior to the park reopening after the incident. When the park re-opened, some rides were opened progressively as the external checking and any works required were completed. 

The checks that were completed inspected every aspect of the ride including the aspheric components. 

WHS inspectors were regularly onsite to assist and oversee this process along with the maintenance staff and external team. 

Once these checks were completed by the external company, an international company was then brought in to double check the external companies audits the rides couldn’t be reopened until the external international company had signed off on them. 

Mr Gardner confirmed that if safety concerns were raised within the maintenance department, it would be send to the supervisors and then sent up the chain from there. 

Mr Gardner did not assist with previous safety audits prior to the incident, he only acted upon recommendations from those audits.

Mr Gardner confirmed that rides should be in line with Australian standards in regards to individual components.

The south pump had tripped previously within the week before the incident. Those dates are 19, 22, 23 of October and then twice on the 25th with the third time on the 25th being the time the incident occurred. 

Mr Gardner confirmed the ride should not have been in service after the second breakdown on the day of the incident. 

Mr Gardner is unaware if TRR was inspected as part of the Pitt and Sherry review that took place after the incident.

[Jdude95]

John Lossie

Senior maintenance team leader

Maintenance Electrician. 

Employees at the park since 2008

Often worked on special projects such as TV’s throughout the park, speakers, wireless receivers. 

Mr Lossie wasn’t required to train staff but was often called to assist due to his experience. 

Mr Lossie was often called to assist when his supervisor wasn’t available. 

Mr Lossie was familiar with park policies and the breakdown procedure. 

Mr Lossie is retrained in CPR every 12 months. 

Mr Lossie didn’t have any power to make decisions or changes. 

Gates were installed at the beginning of the station to prevent further rafts from dispatching if the conveyor has stopped.

[Jdude95]

Mark Gordon 

Maintenance fitter/welder 

Employed at the park since 2011

Mr Gordon isn’t aware of any risk assessments that has been completed on TRR. 

Mr Gordon is also aware of the unload e-stop button. 

Mr Gordon isn’t aware of whether the unload e-stop was ever checked. 

Mr Gordon advised he didn’t check the air pressure in the rafts as the air pressure gauge wasn’t available. 

Mr Gordon stated that he would check the air pressure by stepping on the raft tube to get a rough estimate. 

Pit and Sherry auditors were in the park on the day of the incident. Mr Gordon believes they were inspecting the wipeout on that day. 

Me Gordon was shown a photo of the control panel and explained that the e-stop button above the control panel would turn off both pumps and shut the station gates to prevent rafts being dispatched. 

Mr Gordon doesn’t remember this button being tested. 

Mr Gordon states the e-stop on the unload station shuts off the pumps, conveyors and every component of the ride. Mr Gordon doesn’t believe this button was tested either. 

Mr Gordon can’t remember any of the e-stop buttons ever being altered to do a different thing.

That was the final witness for this part of the inquest. The inquest shall resume for 2 weeks on October 8th and run to the 19th. 

The inquest will then resume again for another 2 weeks from the 12th-23rd of November.

Thank you for joining me for the liveposting. I shall resume when the inquest resumes in October. 

[New display name]

Dreamworld has issued a statement after adjournment of Thunder River Rapids ride inquest.

 

Zoomed in so people can read it.

[DaptoFunlandGuy]

Thanks @Jdude95 for your efforts this week. It was good to get your summary without the media spin.

 

really hope you can make it for the next segment in october!

[RossL]

That press release is barely acceptable.

Where is the statement saying that every ride has a working e-stop that is tested daily, that every operator and maintenance staff member knows how to use???

[pushbutton]

I'm a firm believer that accidents are nobodies fault  (by definition), and therefore obviously nobody should be blamed or penalised regardless of the consequences of the accident. 

The problem is that in a situation like this, if there were things Dreamworld could have and should have done which would have prevented the tragedy, and they knew or ought to have known this,  then it's not an accident. In that case, those responsible should absolutely be identified and severely punished.

Sadly from the inquest so far it seems very clear there were numerous things that should have been done, which would have prevented the horrific outcome. 

I'm stating the obvious really, but those are my thoughts. 

[dbo121]

17 minutes ago, RossL said:

That press release is barely acceptable.

Where is the statement saying that every ride has a working e-stop that is tested daily, that every operator and maintenance staff member knows how to use???

Not the time or place as it would sound defensive. 

Im suprised such strong words as shocking was used.

Yes I agree some of what we heard was extremely poor practice but would not expect that language directly from ardent. At least they recognise it?

 

Edited June 29, 2018 by dbo121

[MacPark]

46 minutes ago, pushbutton said:

I'm a firm believer that accidents are nobodies fault  (by definition), and therefore obviously nobody should be blamed or penalised regardless of the consequences of the accident. 

 

I guess it depends if you consider it an accident or an incident ;)?

 

Either way I feel Dreamworld will be a housing block in 10 years. I wont be going on any of their rides as long as current park management are involved. I just cant trust them now after seeing all this. It would be a shame to see the park go but how can we trust ardent? Someone else to buy the parks maybe?

I worked for ardent in another division in a supervisory role for a  few years and I left the company due to rampant cost cutting making my job almost impossible to do properly and leaving me with too much on shift stress. I wasn't in an area that could have caused harm to people so to think they have done this on their parks division is a real worry. Im going to assume its all across the parks now this is coming to light. Its a shame people had to die for it to become public.

[Jdude95]

2 hours ago, pushbutton said:

I'm a firm believer that accidents are nobodies fault  (by definition), and therefore obviously nobody should be blamed or penalised regardless of the consequences of the accident. 

The problem is that in a situation like this, if there were things Dreamworld could have and should have done which would have prevented the tragedy, and they knew or ought to have known this,  then it's not an accident. In that case, those responsible should absolutely be identified and severely punished.

Sadly from the inquest so far it seems very clear there were numerous things that should have been done, which would have prevented the horrific outcome. 

I'm stating the obvious really, but those are my thoughts. 

This is why the bill was introduced to bring in the industrial manslaughter laws. Yes they aren't able to come into play here as it's retrospective but it does ensure the right people are held responsible if something like this were to happen again.

[RobMac]

"We acknowledge that shocking and deeply concerning evidence has been presented at the Coronial Inquest," the theme park said in a statement on Friday afternoon. [Brisbane Times]

The tragic news in recent days from the inquest has matter-of-factly  [and finally] publicly revealed, what keen theme-park observers have known of DW for well over a decade - it isn't what it once was!

I hope it can survive as a major tourist attraction, but it will need both financially and socially new owners and this time, a professional theme-park operator.

Until this occurs, frankly few people [particularly families], will be inclined to click through its turnstiles.

Edited June 29, 2018 by RobMac

[red dragin]

12 hours ago, Jdude95 said:

This is why the bill was introduced to bring in the industrial manslaughter laws. Yes they aren't able to come into play here as it's retrospective but it does ensure the right people are held responsible if something like this were to happen again.

Those laws wouldn't apply anyway, as they do not cover guests, only employees. Was discussed on TV or radio (can't remember which) the other morning 

[Levithian]

On 28/06/2018 at 8:30 AM, AlexB said:

It's not like they were left alone though... they were still under the supervision and direction of a more senior ride operator whilst they consolidated their training...

It doesn't mean they are competent though. You have to demonstrate competency even with someone overseeing them, in fact, thats the point of the buddy system. You literally have someone shadowing you to make sure you are doing ok. A person in a booth with their own responsibilities isn't really providing enough guidance with so many potential distractions going on. Especially in this case where the unloader probably shares equal responsibility for guest safety. If they had a functioning block system that queued the rafts so they arrived and were restrained at the station one at a time so the unloader really didn't need to worry what was happening behind them, then it might be a bit different. In this case, it really sounds like you have to monitor a few things at once, so it's probably a position you should have someone literally standing next to you to help out on your first shift.

Edited June 30, 2018 by Levithian

[pushbutton]

Brief summary of the inquest so far in todays Courier Mail. 

 

[Levithian]

4 hours ago, red dragin said:

Those laws wouldn't apply anyway, as they do not cover guests, only employees. Was discussed on TV or radio (can't remember which) the other morning 

With regards to the industrial manslaughter laws, yup it applies to employees. The brisbane accident at the racecourse where people were crushed under concrete tilt panels is probably more applicable to the laws than the dreamworld deaths, both happened in october and were in the news a lot, which forced the government to look at the laws and add something to make people personally responsible. There are other laws regarding workplace safety and injury to the public though.

As ive said before, it all depends on the word negligence. It's kind of like the difference between manslaughter and murder. You can kill someone without planning or direct intent. You may not have meant to do it, but you still killed someone, so its not murder, it becomes manslaughter. However if you planned or intended to kill someone, that becomes murder. They basically have to establish you set out, planned or intended to kill someone, that kicks it up a grade to murder. It's sometimes hard to establish a person calculated and planned out the killing.

Same thing with negligence. Being able to prove someone was negligent puts it in a higher category. It can also void some insurances and in the case of professional people, can be the difference between being held personally responsible which brings with it personal liability or even jail time. To prove negligence you have to prove that your direct actions (or inaction) was not only responsible for the incident, but you knew about the risk or underlying issues that could have prevented the incident from occurring, and either willfully ignored the risk or did nothing to address the issues.

So, in the case of something like these deaths, if the higher up managers and department heads can be proven to have known about the risk; have ignored previous reports from numerous parties (including audits and staff members) indicating faults, flaws or unsafe operating conditions that need to be addressed; and have been shown to have ignored state or federal standards or policies regarding the safe operation of equipment; of which combined together contributed to the deaths of these people; THEN it brings into the question of negligence and is no longer just a matter of a lot of people doing a bad job.

From reading the reports, it looks like the difference is going to be how long some of these people were in the position for and what happened if issues were presented to the operating officers at general meetings. Normally major issues of safety or big capital spends would require someone from the general or operations manager upwards to sign off on the proposal. So if it's true and there were numerous reports on TRR with regards to safety, how far up the chain those messages were presented, and if those people ignored them or decided against the recommendations multiple times; then there could be a few people who might actually be facing the prospect of jail time.

Big companies have big chains of authority with each progression taking on more responsibility along the way. But ultimately, often major decisions rest with one person, or a group of people with the same control, so basically someone who runs the park or a board who decide on issues of its operation. So even the managerial staff that worked in their maintenance divisions could have been fighting the same battles to have any recommendations implemented and can't rightfully be held responsible. Could they have shut the ride down? probably, but at risk to their own jobs I suspect. So it becomes a big messy area where people do what is required of them, pass the information on to their seniors to act on; who then pass it on again, and again, etc until it reaches high enough to force someone to make a decision.

It's a shit culture that becomes more about making sure you keep your own job safe by passing on the responsibility, rather than actually making sure something is done about it.

[brissy phil]

Genuine question... sorry if it has it been covered here... do we actually know what caused this? We know how it played out but all this talk of pumps and water level... was it that that caused it and if so how exactly... or did the front raft not get released when it should have to create space... or did the back raft not get stopped when it should have to allow time? I might be wrong but I think I recall being on the raft when a kid on the conveyor belt and the belt stopping when it needed to to buy time / give space? The inquest is of course identifying two dozen items that were dodgy, but what literally caused this do we know?

[pushbutton]

9 hours ago, Levithian said:

With regards to the industrial manslaughter laws, yup it applies to employees. The brisbane accident at the racecourse where people were crushed under concrete tilt panels is probably more applicable to the laws than the dreamworld deaths, both happened in october and were in the news a lot, which forced the government to look at the laws and add something to make people personally responsible. There are other laws regarding workplace safety and injury to the public though.

As ive said before, it all depends on the word negligence. It's kind of like the difference between manslaughter and murder. You can kill someone without planning or direct intent. You may not have meant to do it, but you still killed someone, so its not murder, it becomes manslaughter. However if you planned or intended to kill someone, that becomes murder. They basically have to establish you set out, planned or intended to kill someone, that kicks it up a grade to murder. It's sometimes hard to establish a person calculated and planned out the killing.

Same thing with negligence. Being able to prove someone was negligent puts it in a higher category. It can also void some insurances and in the case of professional people, can be the difference between being held personally responsible which brings with it personal liability or even jail time. To prove negligence you have to prove that your direct actions (or inaction) was not only responsible for the incident, but you knew about the risk or underlying issues that could have prevented the incident from occurring, and either willfully ignored the risk or did nothing to address the issues.

So, in the case of something like these deaths, if the higher up managers and department heads can be proven to have known about the risk; have ignored previous reports from numerous parties (including audits and staff members) indicating faults, flaws or unsafe operating conditions that need to be addressed; and have been shown to have ignored state or federal standards or policies regarding the safe operation of equipment; of which combined together contributed to the deaths of these people; THEN it brings into the question of negligence and is no longer just a matter of a lot of people doing a bad job.

From reading the reports, it looks like the difference is going to be how long some of these people were in the position for and what happened if issues were presented to the operating officers at general meetings. Normally major issues of safety or big capital spends would require someone from the general or operations manager upwards to sign off on the proposal. So if it's true and there were numerous reports on TRR with regards to safety, how far up the chain those messages were presented, and if those people ignored them or decided against the recommendations multiple times; then there could be a few people who might actually be facing the prospect of jail time.

Big companies have big chains of authority with each progression taking on more responsibility along the way. But ultimately, often major decisions rest with one person, or a group of people with the same control, so basically someone who runs the park or a board who decide on issues of its operation. So even the managerial staff that worked in their maintenance divisions could have been fighting the same battles to have any recommendations implemented and can't rightfully be held responsible. Could they have shut the ride down? probably, but at risk to their own jobs I suspect. So it becomes a big messy area where people do what is required of them, pass the information on to their seniors to act on; who then pass it on again, and again, etc until it reaches high enough to force someone to make a decision.

It's a shit culture that becomes more about making sure you keep your own job safe by passing on the responsibility, rather than actually making sure something is done about it.

Unfortunately the company I used to work for was like this, and ironically they called it "Empowering our people" in their grand mission statements and board meetings!

I was in a pretty senior position and responsible for the safety of millions of dollars worth of buildings, equipment, and stock. However I had absolutely NO budget directly under my control for anything. Not even for essential maintenance of above property!

I was very much empowered to write reports, make recommendations (sometimes even to strongly recommend certain actions), and to send these by email to a long list of people, most of whom took absolutely no notice of them, and many of whom wanted to carry out my recommendations, but were restrained either by lack of funds, or by company policies prohibiting them from doing so!

That's the modern version of empowerment!

[RabbiJody]

14 minutes ago, brissy phil said:

Genuine question... sorry if it has it been covered here... do we actually know what caused this? We know how it played out but all this talk of pumps and water level... was it that that caused it and if so how exactly... or did the front raft not get released when it should have to create space... or did the back raft not get stopped when it should have to allow time? I might be wrong but I think I recall being on the raft when a kid on the conveyor belt and the belt stopping when it needed to to buy time / give space? The inquest is of course identifying two dozen items that were dodgy, but what literally caused this do we know?

Best I can put together so far: One of the two water pumps shuts down, causing the water level at the top of the ride and around the end of the conveyor to drop. This water level drop is not noticed by ride ops.

An empty raft comes off the end of the conveyor. In normal operation this raft would float a few meters until is stops at the unload station. But because the water level has dropped this empty raft stops directly after the conveyor, resting on the submerged metal frame. The stopped raft is likely not noticed by ride ops. A sensor to detect a raft stopped here either doesn’t work or is not noticed. The sensor should stop the conveyor if a raft is stuck here for ten seconds. 

The accident raft approaches the end of the conveyor. It then contacts the empty stuck raft. The moving conveyor (modified with 2/3 of its slats removed) is pushing on the accident raft making it tip.

In the court hearing there are discrepancies as to whether an e-stop was ever pressed by ride ops. A alarm to notify if a pump failed had been turned off. 

[brissy phil]

1 minute ago, RabbiJody said:

Best I can put together so far: One of the two water pumps shuts down, causing the water level at the top of the ride and around the end of the conveyor to drop. This water level drop is not noticed by ride ops.

An empty raft comes off the end of the conveyor. In normal operation this raft would float a few meters until is stops at the unload station. But because the water level has dropped this empty raft stops directly after the conveyor, resting on the submerged metal frame. The stopped raft is likely not noticed by ride ops. A sensor to detect a raft stopped here either doesn’t work or is not noticed. The sensor should stop the conveyor if a raft is stuck here for ten seconds. 

The accident raft approaches the end of the conveyor. It then contacts the empty stuck raft. The moving conveyor (modified with 2/3 of its slats removed) is pushing on the accident raft making it tip.

In the court hearing there are discrepancies as to whether an e-stop was ever pressed by ride ops. A alarm to notify if a pump failed had been turned off. 

Appreciated, thank you. So in theory every other time the pumps failed (dozens / hundreds of times)... luck / observant staff / more experienced staff intervened in time.

[dbo121]

 The sensor was at the start of conveyor. A few things had to line up to be the cause. You could blame one thing  (ie staff not shutting down) but there are multiple failures which led to this. Read through the forum page where to educate yourself then come back if still confused.

if it’s wasn’t complicated you would assume the inquest to Be over

[themagician]

"Dreamworld's owner has promised the theme park will become among the safest in the world once safety measures, design improvements and new rides are operational."

https://www.couriermail.com.au/news/opinion/dreamworld-chief-quits-as-ardent-promises-leadership-shakeup-after-thunder-river-rapids-tragedy/news-story/aa1cdc89c7550fe39ca6e5ca638ac074

Quote

DREAMWORLD’S chief executive has been ousted and a new leadership group is to be appointed, as the owner vowed yesterday to implement “lock, stock and barrel” the recommendations from a damning coroner’s inquest into the deaths of four people on a ride at the theme park.

Ardent Leisure, which owns Dreamworld, has said it will be among the safest theme parks in the world once safety measures, design improvements and new rides are operational.

“We need to once again earn the trust of our visitors,’’ said Ardent chairman Gary Weiss.

Dreamworld chief executive Craig Davidson resigned late on Friday. He will be replaced in the short term by Nicole Noye, a senior manager at Ardent. A global search is underway for a new chief executive.

Mr Weiss was at pains to point out that nothing he said would erase the trauma for the families of those who perished. Kate Goodchild, Cindy Low, Roozi Araghi and Luke Dorsett died in October 2016 after a catastrophic failure in safety protocols at the Thunder River Rapids ride. Their families solely blame Dreamworld for the tragedy.

Over the past two weeks evidence has been heard at the inquest detailing a litany of poor safety procedures, including the extraordinary revelation that the failed water pump, the cause of the tragedy, had malfunctioned five times – including twice that day.

The exact same circumstance, in which rafts collided and were flung into the air, occurred 15 years earlier. Nobody was in the rafts at the time.

“I am deeply concerned by what has emerged (in evidence) over the past fortnight,’’ Mr Weiss said.

“To successfully rebirth Dreamworld, we have to earn trust again.

“Success now is that we have a theme park that is best of breed, anchored by a world-class safety-first environment. We want our visitors and staff to be knowingly participating in a totally safe environment.’’

Mr Weiss said Dreamworld’s senior leadership team would be “significantly restructured to continue to bolster delivery of its drive to embed global best-practice in all aspects of theme park operations’’.

He said Dreamworld was committed to continuous enhancements in ride safety and all elements of safety systems and procedures.

He also said Ardent would:

• Commit to the implementation of all coronial inquest recommendations in consultation with Workplace Health and Safety Queensland and the theme park industry;

• Continue to implement safety systems and procedures across the park, with ongoing support from external specialists;

• Appoint three highly experienced executives as it continues its drive to deliver global best practices across all aspects of its theme park operation

“We will never forget the events of that tragic day of October 25, 2016,’’ Mr Weiss said.

“I can only again say how profoundly sorry we are to the families and all those so deeply impacted by this tragedy.

“Every single member of our Ardent and Dreamworld team shares my deep sense of grief for what occurred.

“Like everyone else, I have been deeply concerned by what has emerged from the inquiry over the past fortnight, and this is why it is important that we listen to the evidence, understand all we can, and apply the lessons learned to ensure such accidents never occur at our parks.”

Mr Weiss said he visited Dreamworld earlier this year with his family.

“If it’s a case of the chef eating his own food, yes, I have been to the park, and we as a family had a great time enjoying all the rides,’’ he said.

Mr Weiss added: “I can assure the public that our focus on safety improvements and enhancements has been ongoing for some time and the new executive appointments will continue to drive that process.

“Dreamworld continues to work with Workplace Health and Safety authorities, implementing measures already recommended since 2016, and provide support to our former and current staff who are assisting the coroner to understand how this tragedy occurred,” Mr Weiss said.

“We are committed to ensuring Dreamworld becomes recognised as Australia’s global benchmark for theme park safety. The Ardent board has no greater priority.”