Thunder River Rapids Incident Coronial Inquest Findings

[Jamberoo Fan]

The official details that were revealed back on the 3rd of February:

Quote

As at 03 February 2020

Name of deceased: Dreamworld River Rapids Fatalities ; Araghi, Roozbeh; Dorsett, Luke Jonathon; Goodchild, Kate Louise; and Low, Cindy.

Inquest date and location: Findings scheduled for 24 Feb 2020 at 10:00am in Court 17 at BRISBANE

Coroner: James McDougall

Issues to be considered:

• The findings required by s.45 (2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how they died and what caused the death.
• The circumstances and cause of the fatal incident on the Thunder River Rapids Ride at the Dreamworld Theme Park, which occurred on 25th October 2016.
• Examination of the Thunder River Rapids Ride at the Dreamworld Theme Park, including but not limited to, the construction, maintenance, safety measures, staffing, history and modifications.
• Examination of the sufficiency of the training provided to staff in operating the Thunder River Rapids Ride.
• Consideration of the regulatory environment and applicable standards by which Amusement Park rides operate in Queensland and Australia, and whether changes need to be made to ensure a similar incident does not happen in the future.
• What further actions and safety measures could be introduced to prevent a similar future incident from occurring?

NPO: Yes

Disclaimer – Non-publication (suppression) orders (NPO) or statutory provisions publication may have been applied to some of the information contained within this list. The onus remains on any person using this information or material from court files to ensure that the intended use of that information or material does not breach any such order or provision. Should you need to seek assistance about the existence or content of any orders or provisions – contact the Manager, Business Support Team on 3738 705

And from the Australian Broadcasting Corporation:

Quote

Dreamworld ride tragedy families invited to speak when inquest findings are delivered

ABC Gold CoastBy Tom Forbes  

  Posted 7:30am

PHOTO: Queensland Emergency service personnel are seen at Thunder River Rapids ride in 2016. (AAP: Dan Peled)

The families of the four people killed in the 2016 Dreamworld tragedy have been invited to speak when Coroner James McDougall hands down his findings in a Brisbane court on Monday morning.

Key points

• Coroner to deliver findings into Dreamworld ride deaths more than three years after tragedy
• Families left in limbo after inquest was delayed by six months
• Dreamworld owners Ardent Leisure could face prosecution by World Place Health and Safety Queensland

It will be three years, three months and 30 days since Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi climbed into a raft on the popular Thunder River Rapids ride at the Gold Coast theme park.

Their raft was nearing the end of the ride when it struck another raft that was stuck at the base of a conveyor.

The collision caused the raft containing the victims to flip up, throwing them into the conveyor.

The date was October 25, 2016, and the repercussions were not only devasting for the victims' families and friends, but for those who witnessed the tragedy and the theme park's staff and owners.

While the front entrance of the Coomera theme park became a makeshift memorial for a grieving public, the Queensland Government announced a statewide audit of all rides and attractions.

Dreamworld shut its doors for more than six weeks while police investigated the industrial accident on the 30-year-old ride, which never reopened and has since been decommissioned.

PHOTO: (LtoR) Roozbeh Araghi, Luke Dorsett, Kate Goodchild, and Cindy Low. (Facebook)

The park operators called in ride experts and reviewed all their safety procedures, but when the doors reopened on December 10, 2016, the crowds did not return in the same numbers.

On the first day of the inquest on June 18, 2018, the victims' families heard a young park employee Courtney Williams had only been trained on the ride that morning and she did not know, that as the tragedy unfolded, there was an emergency stop button with her reach.

It was during the first weeks of the inquest in a Southport court that Dreamworld employees outlined evidence that they were ordered to cut back on repairs and maintenance spending, while another witness said the Thunder River Rapids ride should not have been in service when it malfunctioned.

The inquest examined the circumstances and cause of the fatal incident, which included the Thunder River Rapids ride and its construction, maintenance and safety measures.

Mr McDougall has also considered the regulatory environment and the standards by which amusement park rides operate and whether changes need to be made to ensure a similar incident does not happen in the future.

Inquest delays

After 31 sitting days, the inquest finished hearing evidence on December 7, 2018.

Final submissions from the involved parties were due to be submitted in March 2019, but due to delays within the Coroner's office the submissions were delivered six months later in August 2019.

Mr McDougall is not permitted to make findings of guilt, but he can make recommendations which may include referring Ardent Leisure (Dreamworld's owner) to the Work Place Health and Safety regulator for prosecution.

The findings are due to be handed down at 10:00am on Monday.

 

[Brad2912]

Say what?

[Jay Jay The Jet Plane]

*incoming news story*

[Jamberoo Fan]

Quote

Disclaimer – Non-publication (suppression) orders (NPO) or statutory provisions publication may have been applied to some of the information contained within this list. The onus remains on any person using this information or material from court files to ensure that the intended use of that information or material does not breach any such order or provision. Should you need to seek assistance about the existence or content of any orders or provisions – contact the Manager, Business Support Team on 3738 705

Correction: The phone number is 3738 7050.

Edited February 23, 2020 by Jamberoo Fan

[DaptoFunlandGuy]

Court has convened. @Jdude95 and I will be covering updates.

All counsel have made their appearances and the court has invited the family members to make a statement.

[Brad2912]

Thanks Gents for making the effort to be there and keeping us informed 

[webslave]

Social media reports indicate that the brother of Cindy Low criticized Dreamworld as 'money-driven cowboys' who were more concerned with damage control.  He goes on to say that DW isn't interested in paying for his counselling and would rather spend the money on marketing the park.

[DaptoFunlandGuy]

@webslave can confirm.

[webslave]

(because I know you guys are busy I'll try and aggregate social snippets here for people - by all means fix me up if I get it wrong)

[Jdude95]

Matt Low began with a statement on behalf of his family. Including a statement from their kid. Thanked the coroners team. 

 

Kim Dorsett has provided a statement about her family. 

 

Cindy Low’s brother has made a statement. Disappointed with how Dreamworld has handled the incident and how the media and public have handled the incident. 

 

Lawyer for Shane Goodchild has made a statement on his behalf. Gave thanks to the coronial team. 

 

Lawyer for Low Family is providing a statement on behalf of The mother of Cindy Low 

 

Proceedings have begun

[DaptoFunlandGuy]

Family has concluded their statements.

Coroner has advised his findings are some 300 pages, and so will be making a summary only.

[Brad2912]

Does anyone know if the full findings are made publicly available ? 

[webslave]

 

[Jamberoo Fan]

ABC News 24 will also be providing updates throughout the day (Note: Federal Parliament is on between 1:40pm & 3:15pm). ABC reported at 11am that findings may take a few hours:

 

Edited February 24, 2020 by Jamberoo Fan

[DaptoFunlandGuy]

The coroner is now reading the series of events that lead to the accident.

[Jamberoo Fan]

3 minutes ago, Brad2912 said:

Does anyone know if the full findings are made publicly available ? 

They are. I'm planning to publish them in full here once available.

[webslave]

 

Edited February 24, 2020 by webslave

[DaptoFunlandGuy]

The coroner is now outlining the police investigation and steps taken by investigators 

[Jay Jay The Jet Plane]

8 minutes ago, Brad2912 said:

Does anyone know if the full findings are made publicly available ? 

9News confirmed on Twitter the hard copy of the 300 page report will be made publicly today

[DaptoFunlandGuy]

The coroner is now outlining the issues he considered during the inquiry including construction, maintenance, staffing and training.

Slats, underwater rails, pump failure and e-stop issues all cited as key issues.

coroner states these hazards would “all have been evident to a competent person, had one inspected the ride”

#oof

[webslave]

Wuh-oh:

 

 

[DaptoFunlandGuy]

“It is evident that TRRR was apparently modified ...without a designer”

“It appears the modifications were somewhat random and in response to acute issues without consideration of the other issues and hazards that resulted...”

“There were a number of missed opportunities where dreamworld could and should have addressed issues with the ride...”

”inspections were not based on Australian Standards...”

”dreamworld knew of this significant limitation in its safety audits but failed to take steps to address this...”

 

 

[New display name]

@AlexB @Jdude95 Who is at the inquest from DW/Ardent?

[webslave]

 

[Jdude95]

Full findings are a 300 page report that will be available upon the completion of today. 

Coroner commended all people involved in the coronial investigation. Gave special thanks to Queensland Police investigator Nicola Brown. Also gave thanks to Steven Cornish from the Queensland Police Service. 

 

Coroner is providing a timeline and overview of the investigation. 

 

Coroner believes the unload/load area posed significant risk. The spacing of the slats, the pinch point at the head of the conveyor and the rails under the ride all posted significant risk too. 

There was ample evidence that a disaster like this would happen. Believes there was ample documentation of prior incidents that should have been picked up on. 

The modifications to the ride were made without a designer. Bob Tan and other Dreamworld Engineers were never tasked with completing a risk assessment on the ride. 

They also never provided any documentation to the regulator. Modifications made to the ride are seemingly random and don’t take into account other risks or hazards that could occur due to modifications. 

Maintenance was untaken regularly but was based on historical checklists and never updated. 

External Auditing that was completed by JAK engineering was not done to the Australian Standard. 

Previous incidents in 2014 and 2001 that were near identical, should have prompted changes to the ride. 

Problems with the ride were not identified as no risk assessments took place.

Just now, Skeeta said:

@AlexB @Jdude95 Who is at the inquest from DW/Ardent?

Gary Weiss and The CEO, John Osborne