Thunder River Rapids Incident Coronial Inquest

[webslave]

Great write-up JDude.  In terms of updates, any chance you could just post a link to your Google Doc and then a summary at the end of the day?

[dbo121]

Jdude end of day would be good. Having names on does not matter at a public inquest. 

[Slick]

Given this is a public hearing, any and all information that's been presented is open for the media and the country at large to do so as they wish (like publish names). Ultimately that means individuals can include whatever details they think are appropriate.

@Jdude95 i'd love to see some live updates, wall of text be damned - having one consolidated source instead of having to check Twitter and a bunch of news sites would be an incredible asset for many like myself who want to keep in the loop as the day unfolds. It'll also mean the information presented will be easily found and filterable by members using the forum search and guests coming to the site via Google.

Edited June 26, 2018 by Roachie

[rappa]

Yeah I vote for clog the shit out of this thread with info. More the merrier. 

 

I cant believe there is still the vibe of defending Dreamworld on here. They have literally done everything not to do, much all tied back go saving a buck. Gaol is where much of the management should be, which is still a lot better than Dead! Which let's not forget us where 4 innocent people are because this park cut corners, went against industry practices and tried to save money as a priority over YOUR safety!

[DaptoFunlandGuy]

Yeah - post here. google drive docs and so on can be lost to the ether. the Parkz forums go back 14 years, and if its posted in the thread, will last...

there's only one person that'd be unhappy about it being posted in here....

[pushbutton]

As much as I like being able to visit Dreamworld for 18cents per day (obviously assuming I choose to visit every day, which I don't), I have to seriously question the wisdom of offering annual passes so ridiculously cheap when they are saying profits are down, so much they see fit to cut maintenance spending! 

I have experience in large complex organisationss, so I do understand how such crazy decisions are made. Just saying it doesn't make sense. 

[New display name]

7 minutes ago, pushbutton said:

As much as I like being able to visit Dreamworld for 18cents per day (obviously assuming I choose to visit every day, which I don't), I have to seriously question the wisdom of offering annual passes so ridiculously cheap when they are saying profits are down, so much they see fit to cut maintenance spending! 

I have experience in large complex organisationss, so I do understand how such crazy decisions are made. Just saying it doesn't make sense. 

The people who continue to buy tickets when they know DW are cutting corners are giving DW permission to continue.

[Jdude95]

Sarah Cotter 

She was shown images of the control panel and asked to describe the functions of all the buttons. She then described that there’s only 1 e-stop button on the control panel that doesn’t shut everything off. 

The alarms were removed due to it accidentally triggering an emergency response for a non emergency situation. She isn’t 100% sure when it was removed. 

Ms Cotter confirmed that the ride ops on the day didn’t hit the emergency alarm button which would sound the alarm alerting all staff of an emergency situation. 

Ms Cotter personally doesn’t understand why the secondary conveyor e-stop hadn’t been pressed. 

Ms Cotter confirmed that she only knew the function of that button due to testing it out of curiosity. 

Ms Cotters personal opinion of the event was that upon arrival, the conveyor was still operating and she’s unsure if they conveyor was stopped due to an e-stop or due to it getting jammed with a raft. 

Unload ride ops are trained to be constantly monitoring the conveyor. Unload ops should be facing the direction of the conveyor at all times. 

Ms Cotter had heard gossip that a staff member was terminated in 2014 due to shutting off the conveyor without good reason. 

Ms Cotter mentioned that the ride wasn’t stressful for her but she’s never been presented with an emergency situation. 

Pre opening checklists included whether the first aid kit was stocked. The report that was shown was for a week during October 2016 and it was shown that the first aid kit had not been restocked in the whole week and the ride continued to operate without issue. 

 

Ms cotter confirms that she has only ever pressed the e-stop to check its function and never while there were guests on the ride. She believes she first did this in 2014. 

Ms cotter had heard rumours of the e-stop being pressed by another ride op in 2015 after a raft slipped down the conveyor. 

When supervisors are trained to be a trainer, they will be retrained on the smaller rides and slowly work up to being taught how to train new staff on the larger rides. 

 

[razza1987]

21 hours ago, MacPark said:

Im gonna be honest, This isnt looking good for Dreamworld. Im starting to think they wont recover from this..

l agree with you. This is a nightmare for them. I don’t see how they are ever going to recover after all the information that is coming out at the inquest 

[Jdude95]

Any time there is a fault with the ride, the operators must stop the ride and contact the supervisory team. 

Ms Cotter does not remember any instance of a ride op raising any safety concerns about the ride with her. 

Ms Cotter trained any new unload 

staff that if there was any concerns or issues to just hit the e-stop as first point of call. 

Ms Cotter was not aware of the 2014 incident where rafts bumped and was not aware of the 2001 incident. 

In the event of an emergency, one of the other ride ops could also access the e-stop on the unload platform. 

Ms Cotter confirmed that there was ample time to shut down the ride upon the water level dropping and the rafts colliding during the 2016 incident. 

It was possible to send 2 rafts together but there was process in place to prevent that. There had always been a risk of rafts bumping according to Ms Cotter 

 

Pictures from the 2001 incident were shown and the images were very similar to pictures from the 2016 incident in where the rafts ended up. One of the seat backs on the raft had also been damaged, looking similar to the raft that was removed from the conveyor during the 2016 incident. Ms Cotter confirmed that it would have been helpful if she was advised about the 2001 incident.

Michael Stead 

Maintenance/mechanical fitter 

Has been employed since 2013 

Michael is the partner of another ride op. 

 

Mr Stead said that there are scheduled maintenances and checks that take place daily, weekly, 3 monthly, 6 monthly and yearly.  He can’t recall which things are specifically checked outside of the daily maintenance. The yearly maintenance is stated as a complete pull apart and check of TRR. 

Mr Stead doesn’t recall the ride ever being fully disassembled and checked. 

Mr Stead confirmed that he was always aware of the e-stop and it’s function on the unload platform. Once it was pressed, it would send an alarm to the main control panel which would illuminate a blue light and sound an alarm. 

Mr Stead recalls that he was part of the team that installed the anti rollback devices onto TRR. 

Mr Stead is unaware if the north pump will continue to operate if the south pump fails. Also unsure if the pumps are started individually or together. 

 

Mr Stead was advised that an electrician was booked to inspect the south pump the day after the incident. 

Mr Stead stated that the rails added to the troughs had been replaced before and were checked daily. 

The slats are inspected daily for damage to check for bowing, loose fittings or damaged components. 

Mr Stead advised that the anti rollback gates were installed to prevent rafts from slipping on the conveyor but he is not aware of any previous issues to warrant this change.

[Jdude95]

Mr Stead states that every morning the maintenance supervisor should go over the breakdown policy and operation policy with the maintenance team prior to starting. 

The maintenance staff members would rotate roles between park technician and maintenance. Park technicians are allocated to be the first point of call for any technical difficulties in that day. Generally there was 2 park technicians, one electrical and one mechanical. Both park technicians must attend any faults and once it’s ascertained whether the fault was mechanical or electrical, the unneeded technician would leave the ride.

Mr Stead stated that there was no specific training provided on how to ascertain if there is any immediate danger on any rides, he relies on common sense to make this judgement. If they are unsure how to do this, they are required to call a supervisor before any further action can be taken. 

Mr Stead stated that it was a surprise to him that the south pump had broken down as the pumps don’t fail often. 

If there is a fault with a critical component such as the pump, the park technicians MUST contact their supervisor to advise how to proceed. 

New maintenance staff should be shadowed by a trainer and then a supervisor who will also ask the new staff member to explain every point on their daily checklist and what it means before they are signed off to be a technician or maintenance without supervision.

Mr Stead’s licence to perform high risk work expired in September 2015 but states that his licence is currently valid but cannot remember the date it was renewed. Mr Stead cannot confirm if it was renewed before it expired. 

Mr Stead had previously been tasked with evacuating guests off TRR while other maintenance/technicians were working on the ride but he had received no formal training on ride evacuations. 

Part of the opening checklist is that the maintenance staff will drain the ride completely and do a walkthrough of the channel, after this was done, all the lanyard stops were checked and the conveyor was inspected for damage or bowed slats. Testing e-stops weren’t part of the daily checklist. 

Mr Stead states that he has never replaced any of the conveyor slats due to bowed slats, only due to damage.

Mr Stead advised that in his opinion, the safety culture at Dreamworld was very sound. 

Mr Stead had never previously raised any safety concerns or heard of any safety concerns being raised about TRR.

[Jdude95]

Amy Crisp (partner of Michael Stead)

Training and compliance officer/relief supervisor

Ms Crisp was the staff member who trained the junior ride op (Courtney Williams) on the day of the incident from 9:30am to 11:15am

Completed a 3 hour walk through of the ride with QPS and WHS officers, 5 days after the incident.

Ms Crisp completed a “train the trainer” course to become a “Skills Coach in Operations” prior to the incident.

 

we’ve just been adjourned for lunch, I shall resume at 2:30 

[dbo121]

Great work. This is awesome 

[Brad2912]

Interesting we’ve had 2 safety people interviewed, one said he was doing the job of 5 people, the other saying DWs safety culture is sound... 

not hard to guess which one still works there...

[Jdude95]

Ms Crisp has worked at the park for 8 years. 

Upon startup It takes 7 minutes for each pump to reach full capacity. 

The rails were added to the troughs in June 2016. The rails were added to prevent rafts bottoming out in the trough and prevent rafts from floating into the reservoir. 

There is an additional control panel on the conveyor catwalk that maintenance generally use. This would mean there’s a total of 3 e-stops. The one on the main control panel, the one on a pole at the unload station and one on the conveyor catwalk. 

There’s a sensor at the bottom of the conveyor, if it notices a raft has been in that sensor for more than 10 seconds, the conveyor will automatically shut down. 

The conveyor had a lanyard e-stop that ran the length of it, alone the catwalk. 

Only 2 cctv monitors at the control booth for through the ride.

[dbo121]

What is meant by the conveyor had a lanyard e stop for the length ?

[Jdude95]

Ms Crisp advised there was no pressure put on the ride ops to have the ride open and operating at 10. The priority was having the ride safe and ready to go. 

Ms Crisp confirmed that the unload operator should be facing the conveyor at all times and during training of Ms Williams, she stressed the importance of maintaining line of site with the conveyor. There had previously been an incident 

where a unload ride op had lost her footing due to a slippery floor and damaged her ankle but that was put down to human error. 

There was an occasion where a control panel ride op had shut the ride down due to there being ducklings in the trough and they didn’t wanna squish the ducks in front of guests. The ride op wasn’t reprimanded in anyway as this was considered as following normal procedure. 

There is an e-stop on a pole next to the control booth that would shut off the pump and conveyor. There was an e-stop button above the control panel that only shut down the pumps. 

Ms Crisp stated that the memo regarding not using the secondary e-stop had been at the ride for at least a month before the date that’s on the memo. 

Important memos relating to the operation of rides need to be signed off on by staff members.

6 minutes ago, dbo121 said:

What is meant by the conveyor had a lanyard e stop for the length ?

It ran the length of the conveyor. A lanyard e-stop is essentially a red rope that you can pull on to shut the ride down. 

[DaptoFunlandGuy]

44 minutes ago, Jdude95 said:

There is an additional control panel on the conveyor catwalk that maintenance generally use. This would mean there’s a total of 3 e-stops. The one on the main control panel, the one on a pole at the unload station and one on the conveyor catwalk.

But Joel said 2? And Joel is right! Because Joel!

21 minutes ago, dbo121 said:

What is meant by the conveyor had a lanyard e stop for the length ?

I was going to give the description of the old 'bus stop' cord on buses - but kids these days probably wouldn't understand what that is!

 

But a lanyard e-stop would be similar. Here's a great image explanation:

 

 

 

[Jdude95]

The training of Ms Williams was supposed to finish at 11am but it was extended an extra 15 minutes to 11:15am. It’s common for training to be extended as the supervisor/trainer will not leave until they are confident that the trainee is competent and confident in operating the ride. 

During 2016, the process was changed so that ride ops wouldn’t spend a whole day at a time operating a ride, it was common that they would switch out with another employee and then go to another ride after their lunch break. 

Ms Crisp states that she may have trained Mr Nameth but he would have been re-trained since then as the process has changed since he was first trained. 

Any training that is done is achieved by observing other trainers and recommendations from the training coordinator. There are no external teams that train the trainers. 

Ms Crisp isn’t aware whether the WHS Officer or WHS department had any input on how training was done. 

Ms Crisp is unsure of whether the lanyard e-stops also shut off the pumps, she was only aware that they definitely shut off the conveyor. 

In the event of a ride stoppage or a “code 6” the level 3 senior ride operator will take control of the main control panel from the level 2 operator and the level 2 op will travel the catwalk to the bottom of the conveyor to reassure guests that everything is alright and also so that they are right next to the conveyor e-stop lanyard if a guest is acting unsafe in the stopped raft. 

Court has just adjourned for the day. Thanks for tuning in, I shall return tomorrow to continue. 

[DaptoFunlandGuy]

1 minute ago, Jdude95 said:

...and also so that they are right next to the conveyor e-stop lanyard if a guest is acting unsafe in the stopped raft.

What.... so they can stop it a second time?

[Whombex]

21 hours ago, JaggedJanine said:

But the whole thing is public. *confused* But okkkaaayyyyy.............

My apologies. I completely mistook your post as a comment made to you by a rideop at the park.

[dbo121]

Was the unload operator trained in any of this ? 

 

Thanks for the bus analogy 

Edited June 26, 2018 by dbo121

[Jdude95]

2 hours ago, AlexB said:

What.... so they can stop it a second time?

I believe the lanyard e-stop is more used for when the ride begins to move again on the off chance that the impatient guests in the raft decided to stand up or something stupid

[razza1987]

If what ms Cotter said about someone being fired for turning off the conveyer in 2014 is true I find that ridiculous on Dreamworlds part. Wouldn’t they have been grateful that there was no real emergency rather than firing someone? Anyone that would have heard that story would have been reluctant to do so themselves out of fear for also being fired

[dbo121]

Thought the person who got fired turned of pumps. Sounds like you could turnoff either or both with good reason and not get fired. In this case you could of said ducks in trough if smart enough. 

Sounds like this accident occurred due to human error but still does not account for why human input (trainer or operator) had to be so involved in the operation in theisday and age . Best practice should have avoided that. More automation should have been introduced over time in a pro active risk culture environment. At least longer training.

But most people should understand 2 buttons in 90 minutes? Did the trainer really say don’t worry about the red button and go to the senior operator?

Jdude was that asked ? 

 

 

 

 

 

Edited June 26, 2018 by dbo121