Thunder River Rapids Incident Coronial Inquest

[Jdude95]

39 minutes ago, webslave said:

Surely this isn't @Bussy?

Nah, I doubt it. But he did used to operate Snowy River Rapids at Wonderland so there's probably some irony there somewhere.

[Jdude95]

Also, the same as last time, here is each day compiled and neatened up a bit and in one google doc instead of 14 different posts. 
Heres yesterday: https://tinyurl.com/Monday-inquest
And here's today: https://tinyurl.com/Tuesday-inquest

[DaptoFunlandGuy]

In about 5 months time, @Bussy will log in and answer that question, but I think no.

[Jdude95]

Parking was a nightmare on the coast so I got here a little late. It seems I didn’t miss much though. 

 

Stephen Buss

Began at Dreamworld in 2006 as a ride operator, was terminated in 2014 after an incident where  he stopped the thunder river rapids ride  which caused two rafts to collide. 

Mr Buss wasn’t involved in the Dreamworld operations team. Mr Buss states that he personally didn’t find pressing 4 buttons to shut down the ride, difficult. It may have been difficult but he didn’t have any issues. 

During an interview with WHS, Mr Buss states that a single e-stop would be helpful but the ride needs to be completely restarted for a number of reasons which is why there were 4 different buttons. 

TRR would generally only run with 3 operators if it was during peak period. Outside of that, it was 2 operators that would run it. Mr Buss states that always having a 3rd person (deckhand) would be of an advantage because it would make the number 1 operators job easier as the deckhand generally takes some of the responsibilities off the number 1 operator. 

Mr Buss doesn’t believe the rides were ever under staffed, he only issues were during holidays where the park was busier than usual. 

Mr Buss noticed on many occasions that the the personal culture was very good and that the trainers would regularly check up on operators to see how they are doing. 

Mr Buss mentioned in his WHS interview that he can’t understand how the 2016 incident happened as it’s drilled into operators to stop the ride if anything happens. Me Buss states that if you failed any emergency shut down procedure, you would be taken off the ride and retrained before you can operate it again.  

When asked what button Mr Buss would press first in a situation like this and his answer was “the conveyor e-stop” “the conveyor stop is the primary button they drill into you” 

Me Buss states that the unload operators were given instructions to use the conveyor e-stop if they noticed anything wrong but he personally never used it. 

Mr Buss states that stopping the conveyor is fundamental training. 

Mr Buss isn’t happy with the decision to terminate his contract but he accepted it as he couldn’t fight it. Mr Buss has been the level 1 operator on many occasions and stopped the conveyor on many occasions. When asked if Mr Buss ever had any problems using it, he replied “no”. 

Mr Buss also agreed that it can be confusing in a panic situation. 

Mr Buss never had any discussions about the issues with the conveyor and rafts after his incident as it was never fathomed that such an incident could occur. 

 

Mr Buss believed the training provided for rapids was great. His incident and termination was due to him restarting the conveyor while there were still guests at the bottom near the reservoir, not because the rafts bumped into eachother on the top of the conveyor. 

Mr Buss states that there was never emergency drills. The training auditors would sometimes quickly yell out an issue to the operators just to see what their reaction would be. But that was the closest to an emergency drill that Mr Buss has ever been to participating in at Dreamworld. 

Mr Buss states that operators generally aren’t stressed when a code 6 is called because it is a common occurrence. When Mr Buss saw the incident on TV, the first thing he thought was “why didn’t they stop the conveyor, they just needed to stop the conveyor” 

Mr Buss had previously been told that if rafts collided around the course of the ride, there was a risk of “capsizing” 

Mr Buss was never aware of any previous incidents on TRR. 

Mr Buss has just finished giving evidence.

John Clark 

Employed at DW 3 years before the incident as a safety officer. Prior to working at Dreamworld, Mr Clark worked for Queensland Ambulance as an advanced paramedic level 2. This permits Mr Clark to administer IV drugs and declare life extinct, along with other advanced patient care. Mr Clark states that he has been a paramedic for 22 years and was a first aid officer at Dreamworld. Mr Clark mostly organised safety meetings and hadn’t spent much time in the safety officer role. Mr Clark never performed risk assessments. 

Mr Clark was asked if 2 first aid officers onsite is adequate and his response was “it has been in the past, it’s never an issue unless there is an emergency” 

Mr Clark was based in the gold rush first aid office. He was called to a code 222 blue at rapids and began to head there. Upon arrival Mr Clark recalls the first thing he spotted was one of the rafts in an upright position, 90 degrees to its normal position. Mr Clark advises the ride was still running when he was arriving at the ride. Mr Clark then provided a ride operator with a lockout tag to put on the control panel. Mr Clark was asked if he had everything he needed in an emergency. Mr Clark states that he would always pack the first aid bags with as much that he could realistically fit and use. 

Mr Clark cannot think of any piece of equipment that would have made his job easier from a professional paramedic standpoint.

[Jdude95]

Mr Clark states there are times where the First Aid clinic is unattended because both the first aid officers are in the park attending with medical issues. 

Mr Clark was only aware of 2-3 patients when he arrived onsite but then realised there was also another patient. 

Mr Clark stayed at Dreamworld for about a year after the incident before leaving the company. Mr Clark stated that many things changed after the incident including more staff being hired and policies being changed. 

Mr Clark doesn’t believe there was ever an emergency drill practiced on a ride. It was all computer learning and talking about an emergency drill situation. 

Mr Clark mentioned that you can never debrief enough after an emergency situation. 

When Mr Clark arrived at the ride, he doesn’t recall seeing anyone underwater.

Mr Clark believed the First Aid Clinic was adequately stocked and prepared to deal with a medical situation including 4 beds. The primary First Aid Clinic is based in White Water World. 

When Mr Clark arrived at the ride, he didn’t talk with the ride operator, just handed them a lockout tag and requested more staff before saying “I’m going in the water”. 

By the time Mr Clark got into the water, it was still at chest height. There was a member of the public performing CPR on a woman and Mr Clark requested 3 ambulances attend. Mr Clark’s main priority was to get the guests out of the water as nothing can be done to help  in the water. Mr Clark brought a defibrillator with him to the scene. 

Mr Clark has just finished giving evidence.

[DaptoFunlandGuy]

i know there was a first aid station near the fairy shop thing, which is very close, but by the sounds of Clark's testimony, he came from the WWW clinic. Even at a dead sprint thats several minutes - especially carrying trauma kits and an AED.

For the water to still be at chest height when he hit the water (hint - the trough itself isn't that deep, so chest height is practically full strength operation) it sounds very different to some of the operator testimony about how quickly the ride was stopped.

Given the guy was level 2 paramedic, he'd have a level head. I have a lot of confidence that his testimony is reliable... which does bring into question other people's statements...

[RossL]

1 hour ago, Jdude95 said:

Mr Clark was based in the gold rush first aid office.

 

[Jdude95]

Shane Green 

First Aid Manager 

Was trained as a paramedic in 2006 and has been since then. Has been employed at Dreamworld since 2013. 

Mr Green is based in the White Water World first aid clinic and states it took around 3-5 minutes to make it to rapids after the call was made. Once Mr Green arrived onsite, he administered aid for as long as he could. Mr Green stated that there would always be 2 first aid officers on so there could be one based in each clinic. White Water World Lifeguards are also called upon to assist with first aid when required. 

When Mr Green for arrived at Dreamworld, he believed the medical equipment was seriously lacking but was provided with the correct equipment once he requested it. 

Mr Green doesn’t believe there was any medical equipment or leading surgeons in the world that would be able to assist or save the lives of the victims. 

When asked if Mr Green believes equipment could be provided to assist in getting people out of the Thunder River Rapids troughs, he responded that it is difficult because every situation is different. Mr Green also stated that the troughs are impossible to navigate due to slime buildup underwater so he was slipping and falling over while trying to help. Mr Green doesn’t recall the rapid ride alarm sounding, he only remembers hearing a “Code 222 blue” call. 

Mr Green was asked if he can think of any ways that this whole situation could have been improved. He responded saying no, in this particular case, there is very little more that we could have done. 

When asked if everything was adequate to deal with that situation, Mr Green advised that it was but there was nothing more that could be done.

We have just adjourned for lunch 

[Jessicajealousy]

Reading these last two testimonies, it is very sad to hear what they experienced

[Jdude95]

Hey guys, I left the court during lunch as the aircon wasn't working and it's expected that Mr Green will take up the rest of the afternoon. A lot of the conversations and questions with Mr Green are just a rehash of what was said earlier by Mr Clark so I took the opportunity to leave. I do still have someone at the hearing so I'll provide any major updates if anything new or big gets said.

[Jdude95]

Further update: When Mr Clark and Mr Green arrived at the scene and were administering first aid, they were only aware of 3 patients. There was still a 4th underwater that wasn't revealed until the water levels had completely dropped. CPR was being performed on one female patient on the unload platform by Mr Clark, two males were in the water around the conveyor area and were unable to be helped and the 4th person was trapped underwater and discovered once the water had drained from the station. Mr Clark mentioned many times that the water was very murky and that he couldn't see the bottom of the troughs. Mr Green had also mentioned many times about the slime on the troughs that made it impossible to stand or walk on without slipping.

Also, I'd like to add that Mr Clark and Mr Green are both trained paramedics so they are coping extremely well given what they have witnessed and were involved in.

Also todays google doc link: https://tinyurl.com/Wednesday-inquest

Edited October 10, 2018 by Jdude95

[joz]

Any indication of at what point the pumps were turned off and how long it takes for water to drain from that area? Seems extraordinary that 5 mins after it happened the water level hadn't dropped enough to find everyone.

[Jdude95]

Mr Clark later clarified that the conveyor was stopped when he arrived at the unload platform to jump in. He was one of the first people onsite as he was in the gold rush first aid clinic so the distance from there, down the fastpass line striaght to the unload platform is pretty quick. It isn’t clear whether the pump was still running when he jumped in but I’d say it was still in the process of draining because he wasn’t in the main trough, he was in the water area near the conveyor and station turntable. 

The water was so dirty from the nature of the incident and the natural dirtiness of the water since it isn’t exactly cleaned. I believe the 4th person was trapped under something which is why it was harder to notice in all the panic and until the water was fairly low. I can explain this in a lot more detail but I’d rather not in a public forum as those details are the ones covered by the NPO. Happy to privately gore with you though @joz  

[Whombex]

2 hours ago, Jdude95 said:

The water was so dirty from the nature of the incident and the natural dirtiness of the water since it isn’t exactly cleaned. I believe the 4th person was trapped under something which is why it was harder to notice in all the panic and until the water was fairly low. I can explain this in a lot more detail but I’d rather not in a public forum as those details are the ones covered by the NPO. Happy to privately gore with you though @joz  

Terrible to think that he entered water dirty from the nature of the incident. Yes it's the job to respond and make all attempts to save life, but that was incredibly brave. 

The testimony today includes guests assisting in first aid. Are they to be called upon to provide testimony, or will statements they've made to Police suffice?

[Cryptic Hatter]

4 hours ago, Jdude95 said:

The water was so dirty from the nature of the incident and the natural dirtiness of the water since it isn’t exactly cleaned. I believe the 4th person was trapped under something which is why it was harder to notice in all the panic and until the water was fairly low. I can explain this in a lot more detail but I’d rather not in a public forum as those details are the ones covered by the NPO. Happy to privately gore with you though @joz  

Did they go over those details today ? would like to know more if they did.  obviously not on public forum but privately @Jdude95

Edited October 10, 2018 by Cryptic Hatter

[DaptoFunlandGuy]

15 hours ago, joz said:

Any indication of at what point the pumps were turned off and how long it takes for water to drain from that area? Seems extraordinary that 5 mins after it happened the water level hadn't dropped enough to find everyone.

Speaking from Wonderland knowledge, which should, but may not be the same - the unload point at the end of the conveyor is right next to the pumps. If the pumps were given a power disconnect, water stops flowing within seconds.

As the highest point on the ride, the water level should drop RAPIDLY. Most of the pump flow is directed away from the load zone (which is why you have to walk over a bridge to get to the station - the water bypasses the station at that point), so it would be relatively safe to enter the water at the unload zone while the water level was dropping, but it should drain in less than a minute.

Based on the first aider testimony, the e-stop wasn't engaged as claimed. Even if the first aider arrived on scene 30 seconds after the radio call, from testimony so far we have in order:

• operator presses e-stop
• operator calls control to report emergency - assume 1-2 rings, and then 20 second conversation
• control sees CCTV, makes the decision to upgrade from 'BLUE' to 'GREY'
• Makes the radio call to the responding staff - assume 20 seconds radio message

We're close to a minute after the e-stop has been pressed according to the operator testimony, and allow another minute for the first aider to grab trauma kits, AED and run down the Q4U line - so two minutes to be on scene and the water is chest deep?

Here's an intamin rapids diagram:

And here's a dry station photo of the Wonderland Snowy River (during demolition)

 

It's clear to see the water level through the station. It is worth noting however that we know Thunder River had issues with stability in the station, and Dreamworld installed the guiderails under the surface. From pics we saw previously, the guiderails were about a foot or so high, so you can probably add another 300 to the above measurements - giving you a possible 1500 deep water at the station - which isn't much higher than chest deep to begin with, depending on how tall you are (average australian male height is about 175-180cm according to the ABS.

 

My completely uneducated viewpoint - either the e-stop didn't work, or the operator didn't press it as\when claimed.

[Jdude95]

In the first round of the hearing, Police investigators who reviewed the CCTV footage from 2016 mentioned that none of the ride ops pressed the e-stop until much after it was too late. I believe there were already people in the water before any e-stop was hit. 

The first part of discussions that took place today were mostly between the coroners council and the Ardent Legal Team in relation to the large amount of time It took for Ardent Legal to provide all of the required documents as a majority have only been provided as recently as Monday. Some documents have also been lost due to a power outage that occurred.

The first witness has just been called. 

Ben Hicks 

Attractions and aquatics manager. 

It has come out today that there was also an incident In 2014 where two rafts collided and a woman had fallen in the water. Mr Hicks wasn’t aware of the 2014 incident. Mr Hicks mentioned that he recalls the 2001 incident but because it’s been so long, it’s hard to remember details. 

Mr Hicks was never reminded of the 2001 incident days and even weeks after the 2016 tragedy, he never thought the incidents could be related. Mr Hicks didn’t personally have access to incident reports for the rides. They were available but Mr Hicks never looked at them as he was never required to. Mr Hicks isn’t aware of any staff members who’s role it is to investigate pst incidents and learn from them. Today is the first time that Mr Hicks has seen the incident report from 2001. A lot of the information being talked about is the same as previous safety officers and ride trainers so there isn’t much new information so far.

[Jdude95]

Mr Hicks states that he never had any troubles shutting down the ride and that it was a fairly simple process. Mr Hicks also confirmed there was no water level indicator, just a scum line. Mr Hicks has never shut down the ride due to a loss of water or a pump. Mr Hicks agreed that safety on a ride is dependant on not only the safety redundancies in place, but also on how operators, operate the ride. 

Mr Hicks feels that newly trained staff felt confident to speak with senior staff if they had any questions or concerns. Mr Hickey states that as far as he is aware, there have never been any major injuries on any rides at Dreamworld. Mr Hicks also wasn’t aware of the details of the 2014 incident and how similar it was to the 2016 tragedy. Mr Hicks never imagined such a tragedy could occur, as far as he was concerned, the ride was always safe and had no potential to do this. 

Mr Hicks has just finished giving evidence.

Rebecca Ramsey 

Registered nurse currently studying at university. Was registered as a nurse in 2010. Previously employed at Dreamworld, began in 2004 and stayed working at the park until the 2016 tragedy. Ms Ramsey was employed as a registered nurse and first aid officer. Ms Ramsey is one of the staff members involved in the civil action that has recently been launched against Dreamworld by former staff members. Ms Ramsey spent about 60% of her time in White Water World and the other 40% in Dreamworld. Ms Ramsey became aware of the situation when she got a radio call for a code 222 blue at the rapids ride. Ms Ramsey states that she arrived at TRR moments after Mr Clark had arrived. Ms Ramsey believes she had sufficient equipment to handle the situation. Ms Ramsey doesn’t believe there would have been any easier way to retrieve someone if they fell into the water. Ms Ramsey was questioned whether the response times or equipment could have been more efficient. The only recommendation that Ms Ramsey can make is that if the thunder river rapids alarm had sounded, more staff would have attended the situation much sooner.

Ms Ramsey states that the TRR shut down sequence in a code 6 breakdown costs of 3 actions, sounding the rapids alarm, hitting the conveyor stop button and hitting the e-stop button. Ms Ramsey can’t recall any specific training drills that she was involved in on thunder river rapids but occasionally a training auditor would come around and test operator knowledge on shutdown procedure. It has been stated before that the monitors on the ride are far too small for the operator to manage. There were 9 cctv feeds on the one monitor and it was recommended that there should be a second monitor to help monitor the ride envelope. Ms Ramsey was working part time at Dreamworld while she was studying as she was also working at a local hospital as part of her course.

[Jdude95]

Ms Ramsey states that there was resistance from management about bringing in staff early for training as that would increase budget. These issues were consist and persistent throughout the length of Ms Ramsey’s employment. Ms Ramsey began at the park as a ride op and gradually moved up to first aid and safety officer. Safety officers weren’t informed about previous documents relating to ride incidents, safety incidents and outcomes from incidents. Ms Ramsey believes it would have been an advantage if safety officers had access to these documents.

[Jdude95]

For clarification on the Shine Lawyers civil action suit against Dreamworld, the 4 staff members involved in that case are the two safety officers from yesterday, Mr Green and Mr Clark. Also included is today’s witness, Ms Ramsey and a witness still to be called, Mr Burke, a former engineer at the park.

When Ms Ramsey arrived onsite, she was handed a young child to get out of the station area while trying to ascertain how many people were on the ride. She wasn’t sure if the child was on the ride or not prior to being handed to her. 

Ms Ramsey doesn’t believe anything could have been done to locate the 4th person that was later found trapped under the water, any sooner. There was no single person in control of the situation, there were multiple people dealing with multiple

Different roles when they arrived onsite.

[Jdude95]

It was recommended by Ms Ramsey during the issue about the operators cctv monitor that there be 1 monitor with 4 split screens and 1 monitor dedicated to the CCTV that monitored the conveyor area but these weren’t implemented. After Ms Ramsey handed the small child to someone else, she went back to assessing the scene and patients and began questioning the ride ops about the amount of passengers still on the ride and in the flipped raft. 

 

And we have just adjourned for today. We will resume tomorrow. This is due to Ardent lawyers providing required documents so late. It’s appearing as though the inquest will be delayed further and push into next year. We’re still waiting to see if things stay on schedule but it isn’t looking promising 

[Jdude95]

Jennie Knight 

Senior Attractions supervisor and trainer. 

Still employed at Dreamworld. 

Ms Knight believes the Unload e-stop had never been pressed while the ride was operating. Only while the ride was testing. If there is a policy change or update, trainers would check back in with ride operators to make sure they were across the process. Ms Knight wasn’t involved in the 2016 incident. There had been previous conversations in regards to the 3-4 step shutdown procedure and how it should be simplified but it was never implemented. This was also discussed around the same time as the discussions about the extra CCTV monitoring abilities for TRR control panel operators. 

Ms Knight was unsure if there was anyone who completed structural inspections of rides such as rust and crack testing. Ms Knight believes that if it was done, it would be handled by the safety department. Ms Knight was never involved with training, trainers who would train ride operators. When ride maintenance was coming up, senior attractions staff were asked if there was anything they wanted added or implemented to it ride. These changes would then need to be assessed against CAPEX funding and have a full application process. 

Ms Knight was aware there were two different e-stop buttons on TRR but was not aware that they did two different things. Ms Knight also can’t confirm if she was ever at the ride when an e-stop was pressed. Ms Knight would only be informed of the e-stop being pressed, at the end of the day.

Ms Knights role focussed mainly on rides, safety and managing the Attractions team. Ms Knight has been employed at Dreamworld since 2007 and has been an attraction supervisor since 2012. Ms Knight wasn’t involved in discussing any improvements for rides. Ms Knight wasn’t involved with training or disciplinary action for any ride operators. Ms Knight would occasionally check up on trainees to see if they needed the trainer to come back. Ms Knight was asked if she was involved in safety in the park, she replied “no”. Ms Knight advises that she would write the procedures and operate the rides. Ms Knight isn’t aware of who writes and publishes staff memorandums. 

Ms Knight states that she was mostly tasked with walking around the park and making sure staff were following procedure. Ms Knight states that she wouldn’t handle memos and similar documents as she wasn’t very good with a computer.

[Jdude95]

Upcoming maintenance and Inspections requests wouldn’t be emailed to the safety team, they would go to the attractions supervisory team who did by play a part in the safety role in the park. The discussions around extra CCTV monitoring and a simplified shutdown process took place in October 2015, a full year before the incident. These changes were never implemented. Ms Knight was shown a risk assessment form and asked if she’s ever seen one. Mr Knight cannot recall ever seeing or completing any risk assessment form. Ms Knight was shown a different style of risk assessment form and asked if she had seen it before. Ms Knight replied “no”. 

After the incident, Ms Knight never thought that there could have been a training issue with the operators. Ms Knight also wasn’t aware of any issues with the ride on the days leading up to the incident.

[webslave]

53 minutes ago, Jdude95 said:

Ms Knight states that she wouldn’t handle memos and similar documents as she wasn’t very good with a computer.

When I read/hear that sort of stuff it immediately makes me think they are not suitable for the job.

Edited October 12, 2018 by webslave

[pushbutton]

So she wrote procedures, but didn't write memos "because she was not very good with computers".

What?  😕

Edited October 12, 2018 by pushbutton