Thunder River Rapids Incident Coronial Inquest

[TomiJ]

10 hours ago, Skeeta said:

Another day of the inquest, another day of WTF.

DW top engineer says "he did not know it took multiple buttons on main control panel to stop Thunder River Rapids ride before the 2016 tragedy".

According to the ABC report below it states "he cannot operate any of the parks 36 rides" (58 sec into the video). I just want to be sure this is the same person @Skeetamentioned in the post above or is it a different person. Ethier way it is not good. 

Also thoughts on the report? 

Edited November 14, 2018 by TomiJ
Had poor gramma, should be asleep

[joz]

This is probably the testimony I've been most interested in reading about, and all I can say is wow. Now we see the real cause of the issue, not $25 an hour ride ops not pressing a button, what he have here is a fundamental failure of a person overseeing the park's rides.

 

The head of engineering doesn't know how the rides work but is in the position to make judgment calls about them? If he doesn't know how the rides work then why on Earth would anyone have told him that there's a problem? Not like he can do anything with that info. He'd been at the park for 4 years, the fact he didn't know how to run the rides is either a lie to cover up the fact he knew it was fucked, or he is terrible at his job.

 

What amazes me the most is he's still there. He's still not a qualified engineer. He still hasn't taken any steps to mitigate the fact he's not a qualified engineer. He seems like he thinks not knowing how to operate the rides is OK. Elsewhere in his testimony he says he wasn't sure who had the job of making sure the rides are safe. I'll give you a clue, Head of Engineering; its you. It's your department, you set the agenda. Your agenda didn't see you making the effort to get to know the rides you were managing. Had you have taken the smallest bit of interest you would have known the ride's control system was a mess. I have zero confidence in the safety of any rides he's in charge of, and to be honest I wouldn't trust him to change a tire on my car. He doesn't need to go because of PR, he needs to go because he's a danger to the community in his current role.

 

I know on this forum we can get hung up on trivial stuff like 'the wall is ugly now the tree has been cut down' or 'drinks should be in meal deals' so important points can get lost. But here's the thing, this person was allowed to continue to be in a position of authority while having no idea about his area of responsibility and feeling no need the change that. Other staff have had problems with the computer systems and encountered 'push back' from Ardent about safety issues, but they were all people who legitimately tried to make it better before something happened. Right here is someone who straight up was the problem, and continues to be the problem. A bubble of pure incompetence at the top of the engineering food chain. I don't care who you are, you cannot fail that badly at a job and be given a second go at it.

Edited November 14, 2018 by joz

[New display name]

And now DW have a CEO who has never worked in a theme park.   Ardent are incapable of learning from past failures.   

[webslave]

I guess this begs the question - why was this guy in the job?  How did he get hired, and why was he kept?  Was there some other primary skill-set that he had that kept him in the job and the title just wasn't a good fit?

[New display name]

31 minutes ago, webslave said:

 job and the title just wasn't a good fit?

If this was the case, why wouldn't he had clarified his position yesterday.    The Coroner James McDougall even stopped the the questioning and said " I am puzzled to know why you didn’t know these things seeing you are general manager of engineering,” 

Mr Deaves said,  

“You don’t get out to drive them and operate them quite often, you rely on feedback for that".

“If you were to ask me these questions on any device I would be giving a similar answer.”

I understand Mr Deaves was only an administrator but, but, but & but how can an administrator make the correct calls if he doesn’t know what is required?

How does Mr Deaves know the the feedback his getting is correct or google gaga?

 

Edited November 15, 2018 by Skeeta

[red dragin]

I'm a property manager (residential rentals). These days it's 90% administration rather than being out on the road.

I don't know how to fix a toilet, or replace a light fitting, or service an air conditioner. But I have a moderate understanding of how these things work and enough knowledge to quiz my tenants on the symptoms, to help the tradesperson determine the issue.

My point is I am earning below the national average wage, but I have some understanding of what I am dealing with. If he had no understanding, and would be earning much more than I do, how did he even get hired to start with?

[rappa]

By contrast I'm pretty sure that Movie World's previous General Manager Greg was signed off to operate every ride at the park... if A GM isn't more of an Administrative role than Head of Engineering then I don't know what is...

I guarantee Movie World's Head of Engineering knows a hell of a lot about how their rides operate.

Edited November 15, 2018 by djrappa

[Spotty]

1 hour ago, djrappa said:

By contrast I'm pretty sure that Movie World's previous General Manager Greg was signed off to operate every ride at the park... if A GM isn't more of an Administrative role than Head of Engineering then I don't know what is...

I guarantee Movie World's Head of Engineering knows a hell of a lot about how their rides operate.

From personally seeing Greg operate DC Rivals and Doomsday, I would be fairly sure he would be. Or at the very least he would have someone supervising him while he operated it (who was trained). At least he had a somewhat hands on approach to operations in the park and it was something I always noticed at Village when working there. Even the park supervisors occasionally did shifts operating the rides to keep their knowledge up on them. 

Wish I could say the same here...

[Jdude95]

Unrelated fun fact but Greg was the first person trained on Rivals so that he could also assist with staff training.
It's a completely different ball game just down the road at DW.
Also, update for everyone. I've been in and out of meetings this week so I haven't been able to make it much to the inquest but my week next week is looking more free so i'm hoping to be there for as much of it as I can.

[joz]

You definitely need to get back there, the twitter updates from the press aren't doing it at the moment.

[Brad2912]

Officially sacking @Jdude95 as our Official Court Reporter....

David Randall, the managing director of DRA Safety Specialists, told an inquest in to the disaster Dreamworld’s safety systems were not reassuring when he was first engaged by the business in 2013.

He said he told the Ardent Leisure Board three years before the 2016 disaster that the company would be on perilous ground in the case of a tragedy.

“As I said to the board at the time, if we had an accident we would not have had the body of evidence to demonstrate we had carried out due diligence,” he said.

“There was a (safety) system in place but it wasn’t great.

“There was a system but you could run a steamroller through it at that particular time.”

He said there was a resistance to change, very poor safety system ideals and staff were concerned primarily with watching each other’s backs.

He said many theme park rides had the same level of risk as commercial aircraft.

“If we make a mistake there could be just as many fatalities as with an aircraft,” he said.

UPDATE 11.15am: A SAFETY auditor engaged by Dreamworld three years before the Thunder River Rapids tragedy has told an inquest safety systems were so bad prior to his arrival he would not have let his own children go on the park’s rides.

David Randall, the managing director of safety specialists DRA, told the inquest he had major concerns with Dreamworld’s systems when he first started working with the park on a safety audit in 2013 – three years before the 2016 disaster that claimed four lives.

“Even though staff were competent … the rides weren’t maintained to a standard where I would place my own children on them – and I love my children,” he said.

After initially receiving a score of just 41 per cent on a safety audit, Mr Randall said Dreamworld was making progress and was ‘committed to the process’ of improvement.

UPDATE 10.50am: A SAFETY audit carried out at Dreamworld three years before the Thunder River Rapids tragedy found the park severely wanting.

In the audit, carried out by leading firm DRA Safety Specialists, Dreamworld scored just 41.7 per cent.

A ‘fully compliant’ business would require a score of 75 per cent.

The audit concluded there was no evidence the rides had been inspected to comply with manufacturer’s requirements and there had been no formal risk management process applied.

It also found little evidence of ride induction and several other forms of staff training including work at height and confined space training, while some records had been lost or thrown in the bin.

The audit measured Dreamworld’s systems and procedures rather than physical inspections of actual rides.

[New display name]

28 minutes ago, Brad2912 said:

Officially sacking @Jdude95 as our Official Court Reporter....

You don't have that authority. 

[Brad2912]

6 minutes ago, Skeeta said:

You don't have that authority. 

 

 

[Jdude95]

Hahaha! Well, if I'm fired, I guess I don't have to go next week then?

The twitter updates have been sparse because a lot of the journos don't understand a lot of what is being said as it's very technical heavy so it takes them a while to break to down to a level that is understandable by the GP. Unfortunately that also means a lot of it just isn't reported on.
But yes, DRI are the company that audited their processes and systems. JAK used to do the structural and mechanical audits but were recommended to be removed in early 2016 after they weren't auditing to Aussie standards. I'm hoping JAK get called up to give evidence because not only were they a dodgy audit company but Ardent also knew that they were a dodgy audit company.

[Brad2912]

29 minutes ago, Jdude95 said:

Hahaha! Well, if I'm fired, I guess I don't have to go next week then?

Fired but I’m being nice and giving you a weeks Notice so you can report next week.

and we may need you for 2 weeks in December...

[Jdude95]

You're so generous, bossman. 

Parking in Brisbane is a pain in the ass so the week(s) in December will be fun but hopefully @Slick will also be there so he can pick up some of the slack or at least make getting there, easier.

[Brad2912]

In all honesty, you do a better job that all these apparent “court reporters” that I’m surprised the GC Bulletin don’t stalk this thread for their tweets...

[Jdude95]

I literally just take note of anything that is of interest. I honestly don't understand how they miss so much.

[webslave]

16 hours ago, Brad2912 said:

He said many theme park rides had the same level of risk as commercial aircraft.

“If we make a mistake there could be just as many fatalities as with an aircraft,” he said.

I think Dreamworld would be lucky to have anything in their park with a capacity much over that of a small business jet...

[New display name]

A US company which carried out safety audits at DW has been given ‘a final opportunity’ to co-operate with inquest into Thunder River Rapids ride tragedy. Warned it could face ‘adverse findings’

"Counsel assisting the inquest Ken Fleming QC told the hearing today repeated attempts to contact JAK, which carried out safety inspections of rides at Dreamworld before the 2016 Thunder River Rapids disaster, had been unsuccessful.

Mr Fleming said there had been attempts to contact JAK by registered mail and even LinkedIn to no avail.

He said the Coroner’s Office would write to JAK “one last time ... giving them a final opportunity to respond to us so that the rules of natural justice can be fully applied”.

Mr Fleming said JAK could face adverse findings over the way in which ride inspections were conducted ‘or the things that may have been missed".

 

 

@Jdude95I hope Brad pays well.

Edited November 16, 2018 by Skeeta

[Levithian]

You dont need to know how each ride physically works to oversee a department.

You have to UNDERSTAND how engineering principles work and UNDERSTAND control systems, so when your very experienced (with this ride, function or system) staff come to you, explaining the situation or discussing a matter with you, you know what they are talking about even if it means you can't walk over to a ride and push buttons on a console.

You can talk over to a ride with this very knowledgeable tech staff who know exactly how to operate the ride, who then can perform those very basic functions while you talk about the actual control systems and mechanics that are happening once that button is pushed. See the difference? You know what systems are actually functioning when you press that button that starts a conveyor, and how that conveyor works. The operator pushing the button only understands the function, not the process.

The department head is going to know about the engineering that goes into running a complex machine like an amusement ride, they don't have to sit down in front of a ride and run it. 

Might things change following this inquest? maybe. But it really doesn't make a lot of difference. Unless you are a chartered engineer registered with one of the few societies in the country, you aren't making judgement calls on systems anyway. So even having an engineer in the top job of the maintenance department who could replace a sick operator at a moments notice isn't going to achieve much.

What you are supposed to be is someone up on current industry standards around things like safety and operation and very adept at recognising potential issues before they happen. This is what half of your job is, the running of the department is left to supervisors. You oversee the works and are tasked with bringing in auditors and technical inspectors or 3rd party engineers for advice or to respond to outside requests, changes or incidents. You basically want a chartered engineer prepared to put a recommendation to paper, essentially putting their registration and insurances on the line. I would be surprised if there are any of these people in any theme park in the country. They are the ones that command big dollars and are ultimately singing off on projects and developments for pretty much everything you see around us. If a person has had a hand in building or maintaining it, there's a chartered engineer who has signed off on it.

So, going ahead and making changes to a control system full of buttons and complex controls isn't something someone running the department probably does either. It would be like my boss coming into the office on monday and saying he wants the bottom chords moved higher in all the trusses of this conversion we are doing so they aren't immediately visible from the big glass doors at the end of the building. No problems, i'll just change the bottom timbers out on all the engineered components that hold the roof up and tie the walls together.  It's not like it would need a complete redesign to be safe, no big deal.

What seems to have happened at dreamworld though is they have had good, 3rd party, professional advice on many issues of safety, control and operation of their rides, and little to none of it has been implemented. This may not be just an issue with the department head though as they would have budgets to work within, but further up the management chain where the money decisions are really made. Especially when it seems clear they had been told to put a hold on any spending that wasn't already a capital works project.

Really, jail time needs to be an outcome of this. Who gets jailed should ultimately come down to who made the yes or no decisions that placed ALL of us in jeopardy. Not just the people who lost their lives, BUT EVERY PERSON WHO VISITED THE PARK IN RECENT HISTORY.

If there is a long suffering maintenance department burried under the lack of funding decided upon by people like the financial officers, park general manager or even the chief operations officer, then no matter how inept some people in the department were, it's not ultimately their responsibility alone.

In this specific case;

Yes - allowing the ride to return to operation that many times following faults should see you jailed. You ignored even your very poor control methods/standards and people died because of it. The ride should never have been running, and if you advised park management of this and they put pressure on you to keep it open, you should have grown a spine and told them it's an issue of safety and you weren't prepared to open the ride until the electrician arrives to inspect the problems with the pumps.

and

Yes - Not approving a MAJOR safety upgrade to your ride that would have made its operation easier and implemented a control system that no longer required the input or judgement of operators, which would have meant these people would not have been killed, you go to jail.

You, or they (together) sat there in front of a bunch of numbers and discussed the works and ultimately decided an amount worth less than your monthly salary was too great to ensure that your guests will be afforded with at least a basic level of safety that should have been (and was previously recommended) performed long ago. You put a price on each of those people's heads that amounted to a few thousand dollars each.

You all should go to jail. And if they bring in a new law that requires every amusement operator in the country to register for a licence to operate amusement rides, you should be struck off the register to make sure you are NEVER in the position to weigh up the cost of human life again. You were supposed to weigh up the cost of upgrading the ride vs shutting it down, you weren't supposed to weigh up the cost of safety vs the cost of human life. I hope it comes out in the inquest if these same methods were applied to any other rides too, because it's these people that need to be turned out for all the media and the general public to see.

There needs to be a clear message sent out that it's not OK to judge who lives and who dies. If you cannot afford to maintain, upgrade and operate a complex, dangerous machine within the grounds of what the safety industry, and hell, members of the public consider an acceptable risk; then you don't get to open the chain links or gates to that ride until you come up with the funding to do so. When it starts becoming a business of making profit for shareholders, you start killing people and that should never be acceptable. The board members who stepped down should have necked the lot of them and turfed them all out as they were out the door themselves.

Edited November 16, 2018 by Levithian

[webslave]

Personally, I think the test should be whether you knew - or should have known - that the decision you made materially increased the risk of serious injury or death occurring.

Ergo;

• If you were denied the funding to complete an upgrade to safety/control components then the decision was not yours, therefore you are not culpable.
• Allowing a ride to return to operation several times following an intermittent fault may not make you culpable if you could demonstrate that you were unaware that doing so materially increased the risk of serious injury or death occurring (which would be a fairly high bar, but how many of us before now would have linked a pump failure with an accident like this? After all, as far as we were aware it's never happened in all the years of operation)
• If you knew the state of the safety infrastructure on a ride was deficient and knew this deficiency increased the risk of serious injury or death but either neglected to report it or down-played the risk when reporting it you are culpable.

[joz]

Another Dreamworld executive has taken to the stand and blamed the ride op. Such a disgraceful attitude. Anyone blaming the ops needs to get out if the industry pronto. You can't have a dangerous ride and that requires intervention to make it safe and then blame the staff member for not intervening, particularly a new staff member, particularly when intervention was not straight forward.

[Brad2912]

Isn’t that the general rule of good upper Manangement? It should be a fairly thankless role as when things are great you praise the team on the ground for making it so, but a process or system are wrong you take responsibility for the failure yourself and fix it.

blaiming the ride ops is scum imo and anyone doing it doesn’t deserve to have a role in management ever again. 

[webslave]

Stuff like this is rarely the fault of one person or group, be it management nor the ride ops.