Thunder River Rapids Incident Coronial Inquest

[Brad2912]

And then he would have blamed the ride op from Oct 2016 for him needing to excuse himself to go to the bathroom in Oct 2018...

[New display name]

 

DW did nothing to eliminate human error. 

[Jessicajealousy]

Any updates from today? Or were there no sessions today?

[New display name]

10 minutes ago, Jessicajealousy said:

Any updates from today? Or were there no sessions today?

@Jdude95Is currently having a diarrhea apocalypse but the good news is you can now trust him because he's no longer full of shit.

 

@Jessicajealousynothing new came out today and it will now resume on November 12.

Edited October 19, 2018 by Skeeta

[Jdude95]

I can confirm, in a rare twist of events, everything Skeet just said is true.

[pitul22]

When does the enquiry start again?  Is it any closer to finishing? 

 

[Cryptic Hatter]

11 hours ago, pitul22 said:

When does the enquiry start again?  Is it any closer to finishing? 

 

@pitul22 The November sittings are expected to focus on the role of the state safety regulators.

[pitul22]

Thanks @cryptichatter.  Not sure too much more will come from the state regulators. 

[Levithian]

All the external companies tasked with inspections or compliancing having been called yet though have they?

Theres plenty for government inspectors/agencies to answer for. Things like why, over years of operation and inspection, did the registration for all rides and plant equipment, and lodging of those documents slip through the cracks? Why was it allowed to continue and why werent the lapses investigated which probably would have shown some pretty big discrepancies in their documentation and policies, which should have snowballed into a full blown investigation. Where there's smoke, there's fire, etc.

Might not have saved lives and stopped an incident like this happening, but on the other hand, after being thoroughly investigated and being taken to task for such poor attitudes towards operation and documentation of their rides, the apparent lack of policies and proceedures when it comes to safety; It may have caused them to make safety upgrades a priority to appease the assessors which would have saved these people. 

Its all very open ended, lots of what if's, but inquests by nature are looking at all parties for anything thats overlooked, or basically failure to do the job they are tasked with (usually in the interest of the general public). Includes government departments, even responders like medical people and police who attended. Even if they did nothing wrong, by nature of this basically being a first in the state, the coroner often makes recommendations how to better improve how the services respond in this situation too. 

[Brad2912]

That’s who will be called upon in this next 2 week sitting @Levithian - all the regulators and industry bodies 

[Levithian]

Yes, which is why i was replying to the person above me who said nothing much more will come from regulators.

They have plenty to answer for as well, as they dont just work within the theme parks, but industry as a whole. So it could call into question hundreds or thousands of investigations or cases they are ultimately responsible for, which probably has greater impact than establishing the liability of dreamworld.

Especially if the coroner passes down recommedations of some sort of licence or registration scheme. You cant task the same regulators who ultimately overlooked so much with the responsibility of overseeing a new standard. Might mean quite a bit for safety compliancing in general if they are critical of the government workplace inspectors. 

[Thrill Seeker]

Today now marks two years 

[Gary86]

This old sign advertising the sales people that were at the River Rapids entry. 

A look at former Gold Rush / River Rapids 25/10/18

[Jamberoo Fan]

The coronial inquest into the Thunder River Rapids incident resumes in Southport on Monday the 12th of November. It will be held everyday (presumably excluding weekends), starting at 10am, until Friday the 23rd of November where it will presumably adjourn again until the 17th of December, when an extra, originally unscheduled 5 days of coronial inquest hearings will be held due to Ardent Leisure delivering requested documents late earlier in the coronial inquest.

Edited November 10, 2018 by Jamberoo Fan

[Jamberoo Fan]

According to the Gold Coast Bulletin (subscriber-only article), Dreamworld's lawyers have submitted about 500 more documents towards the Thunder River Rapids coronial inquest. This could potentially drag the inquest into next year, something the Coroner was trying to avoid by scheduling the 5 extra days of hearings between the 17th & 21st of December, which only happened because Ardent Leisure submitted 1000 extra documents exactly 1 month ago. All this despite all documents being requested 2 years ago, shortly after the Thunder River Rapids incident occurred.

It is also rumoured Ardent Leisure's & Dreamworld's former safety manager, Angus Hutchings, will be one of the first to take the stand tomorrow morning.

[joz]

Its a pretty dumb move to delay handing over docs. They might've stood a chance of having it almost over now but now it'll drag on into and affect peak trading. No one is going to plan a theme park trip or buy theme park tickets before Christmas now. That shit doesn't just affect them either, that's a drag on the industry, so good going there.

[DaptoFunlandGuy]

The article I read this morning (no idea of source) stated that additional documents were requested at the last hearing block. They may not have been within the original scope but were requested after certain evidence raised additional questions or issues...

[New display name]

That's not what I'm reading @AlexB                                                                                                                                                                                  " Inquest slams delays in Dreamworld owner providing documents to the inquest. Says they should have been provided almost 2 years ago and fears it could delay inquest".

[Jdude95]

Angus Hutchins 

Former Ardent Safety Manager

No longer working at the park. 

Mr Hutchins states that when he started in the company, there was only 1 safety system in place to keep track of all safety related documents. 

Me Hutchins states that historical safety data wasn’t uploaded to safety systems, only new safety data would go into the database. 

Mr Hutchins only became aware of the 2001 incident on TRR when his solicitor showed him the incident report, in late 2017. 

Mr Hutchins states that annual holistic maintenance was thrown between the safety and maintenance departments as both departments thought the other was in charge of it. JAK an external auditing company was then approached to complete this maintenance. 

Mr Hutchins states that there was a lot confusion about which departments were responsible for what. Departments would often assume other departments would be in charge of something that they weren’t. 

Mr Hutchins mentioned that when Bob Tan (head of engineering) came into his role, he often wouldn’t be questioned when he made decisions as he was known as the “yoda” of that role. 

 

Also, in regards to Dreamworld and the documents issue. It was requested during the last hearing that those documents be provided well before this hearing started after the delays caused with the last hearing. DW ignored that and submitted all the documents at the very last minute again. 

Mr Hutchins was well aware of the issue where Dreamworld safety teams were working reactively no proactively and were heavily under resourced. Mr Hutchins had brought it to the attention of previous CEO’s including Craig Davidson. Mr Davidson agreed with Mr Hutchins but no extra resources were provided. 

After the incident, 4 new staff members were brought in to help with the workload in that role. 

After Mr Tan finished his role within the park, all of his duties were handed to the safety department. Mr Tan’s duties included registering, inspecting and paying for the registration of plant equipment. Prior to this, Mr Tan undertook all plant inspections and registrations. 

After Mr Tan finished at the park, Chris Deaves then started looking for a replacement for that role, it took months before the role was filled. 

Mr Hutchins states that it took so long to find a replacement as they were looking for a suitably qualified and insured engineer. Mr Hutchins was aware that the ride was not registered from January 2016  until the incident in August 2016 but allowed the ride to continue to operate. 

Mr Hutchins believed that the systems in place would take care of maintenance instead of sending out a maintenance staff member to check what maintenance was needed. 

[Jdude95]

Mr Hutchins was of the understanding that JAK undertook structural inspections while DRI, another company would handle the systems inspections. Mr Hutchins recommended In early 2016 that JAK be removed from completing audits as they have “proven unwilling to audit to Australian standards”. Mr Hutchins recommended a new auditor review the the park every 2 years and each intervening year to be inspected by a local third party company. The company slated to replace JAK was LTC, a United Kingdom based company. By late 2016 when LTC was approached, that issue had “fallen off the radar” because the priority was on re-registering the ride as “theoretically if the ride isn’t compliant, WHS would have shut the ride to the public. “Theoretically” as this was the actual situation for the 9 months prior to the 2016 incident.

Representatives from all QLD theme parks will regularly gather to discuss any incidents or major updates that could be relevant to all parties. A meeting was held to discuss the outcome of the rocky hollow log ride incident as SeaWorld also had a flume ride and knowledge will  be shared across parks when it comes to safety incidents. Mr Hutchins had never enquired as far back as the 80’s about manuals or documents relating to the TRRR as Mr Hutchins was never aware of any incidents so as far as he was concerned, the ride was safe. Mr Hutchins agreed that no realistic emergency drills were ever conducted for TRR. When asked how he feels the problem could be prevented from ever occurring again, Mr Hutchins replied: 

“In terms of what happened on the day I feel that some kind of engineering control was needed to prevent the conveyor from operating when a raft was in the unload station. The roles and responsibilities for particular tasks was not defined and neither was the reporting of risks. The document control systems were inadequate, funding was inadequate. In order to prevent that from re-occurring, the safety department instead of reviewing policies, need to be I between the park and the CEO, having the power of accepting or declining policies that relate to safety.”

[Jdude95]

Alright guys, that has been explosive so far but it still mostly just the same questions being asked again in a different way by the various barristers. The media has been stuck in a small kitchenette because there was no room and it’s cramped with no seats so I’m gonna head off for today and pick this back up tomorrow where Mr Hutchins should still be giving evidence. 

[Jamberoo Fan]

5 hours ago, AlexB said:

The article I read this morning (no idea of source) stated that additional documents were requested at the last hearing block. They may not have been within the original scope but were requested after certain evidence raised additional questions or issues...

You may be correct meaning it was a sensationalised article. As it was a subscriber-only article, I only read the limited information I could see without subscribing. Given Ardent Leisure already delivered documents late once, I thought it was worthy of posting on the Parkz forums.  I do recall the Coroner requested proof of certification of all of DW's rides in the October hearings but I thought they wouldn't have been part of those 500 documents.

Update: Just read @Jdude95's information about it in the middle of one of their posts above - there was a delay but at least it wasn't a 2 year delay. Still, hopefully it doesn't add an extra month (or any time) to the coronial inquest though.

Edited November 12, 2018 by Jamberoo Fan
Added 'update'

[New display name]

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".

[auspicious]

This "top engineer" guy is also not actually a qualified engineer.

[New display name]

At the time of the incident only 2 engineers worked at DW,   "I believe".

Junior Dreamworld engineer Gen Cruz and DW was his first job out of university.

Supervisor Peter Gardner, who was qualified in Britain and he had not received Australian qualifications.

 

EDIT:

Dreamworld's head of engineering will retake the stand at an inquest after admitting a series of equipment failures in the lead up to the tragic accident should have been investigated.

 

Edited November 14, 2018 by Skeeta