Thunder River Rapids Incident Coronial Inquest Findings

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https://www.courts.qld.gov.au/__data/assets/pdf_file/0004/641830/10545784-final-dreamworld-draft-6-for-upload.pdf

[Jamberoo Fan]

@webslave How did you find that? 

 

Below are the findings in their separate parts in case the PDF file ever goes offline. References are removed for simplicity:

CORONERS COURT OF QUEENSLAND

Inquest into the deaths of Kate Goodchild, Luke Dorsett, Cindy Low & Roozbeh Araghi at Dreamworld, October 2016

Findings and Recommendations

February 2020

CORONERS COURT OF QUEENSLAND

INQUEST INTO THE DEATHS OF KATE LOUISE GOODCHILD, LUKE JONATHAN DORSETT, CINDY TONI LOW, & ROOZBEH ARAGHI

Coroner, Southern Region

Credit for the above photograph is given to Mr. Richard Gosling, Newspix

COVER PAGE

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CORONERS COURT OF QUEENSLAND

FINDINGS OF INQUEST

CITATION: Inquest into the deaths of Kate Louise GOODCHILD, Luke Jonathan DORSETT, Cindy Toni LOW, & Roozbeh ARAGHI

TITLE OF COURT: Coroners Court

JURISDICTION: SOUTHPORT

FILE NO(s): 2016/4486, 2016/4485, 2016/4480, 2016/4482

DELIVERED ON: 24 February 2020

DELIVERED AT: BRISBANE

HEARING DATE(s): 18 June 2018 to 29 June 2018 8 October to 19 October 2018 12 November to 22 November 2019 6 & 7 December 2018

FINDINGS OF: James McDougall, Coroner

CATCHWORDS: Coroners: inquest, Dreamworld, amusement device, Theme Park, safety management systems, ride maintenance, training, amusement device regulation, amusement device designer, amusement device modification, external safety audits.

REPRESENTATION: Counsel Assisting - Mr Ken Fleming, QC Ms Rhiannon Helsen, CCoQ; Family of Cindy Low - Mr Matthew Hickey, Counsel instructed by Clayton Utz; Families of Kate Goodchild & Luke Dorsett - Mr Steven Wybrow, Counsel instructed by Aulich Civil Law; Family of Roozbeh Araghi - Mr Toby Nielsen, Counsel instructed by Gordon & Barry Law; Mrs Kim Dorsett (mother, Kate & Luke) - Mr Robert Davis, Counsel instructed by Sneddon, Hall & Gallop Lawyers; Office of Industrial Relations (Workplace Health & Safety Queensland) Mr Stephen Gray, Counsel instructed by Crown Law; Ms Courtney Williams Mr Peter Callaghan SC, instructed by Gilshennan & Luton; Ms Chloe Brix, Ms Sarah Cotter, Mr Wayne Cox, Ms Amy Crisp, Mr Generic Cruz, Mr Francoire De Villiers, Mr Christopher Deaves, Mr Quentin Dennis, Mr Andrew Fyfe, Mr Peter Gardner, Mr Mark Gordon, Ms Nichola Horton, Mr Jason Johns, Ms Jennie Knight, Mr John Lossie, Mr Troy Margetts, Mr Steven Murphy, Mr Grant Naumann, Mr Peter Nemeth, Mr Kamlesh Prasad, Mr Scott Ritchie, Mr Matthew Robertson, Mr Michael Stead, Mr Mark Watkins, Mr Timothy Williams, Mr Jacob Wilson - Mr Ralph Devlin QC & Mr Liam Dollar, Counsel instructed by K & L Gates LLP; Ardent Leisure Ltd trading as Dreamworld Mr Bruce Hodkinson QC & Mr James Bell QC, instructed by Baker McKenzie Lawyers & DWF (Australia); CEO, Dreamworld, Craig Davidson - Mr Gavin Handran, Counsel instructed by Quinn, Emanuel, Urquhardt & Sullivan LLP; Queensland Police Service - Mr Adrian Braithwaite, Counsel instructed by QPU Legal Group; DANFOSS Australia (Mr Eduardo Gie) - Mr Sean Farrell, Counsel instructed by Mills Oakley; Mr John Clark, Mr Shane Green, Mr Benjamin Hicks, Mr Nigel Irwin, Ms Rebecca Ramsay, Mr Mark Thompson - Mr Anthony Harding, Counsel instructed by Rankin & Co Lawyers; Mr Angus Hutchings - Mr Craig Eberhardt, Counsel instructed by Robertson O’Gorman Solicitors; Mr Tom Polley (Danski Pty Ltd) - Ms Polina Kinchina, Counsel instructed by Colin, Biggers, Paisley Lawyers; Mr Bob Tan - Mr John Bremhorst, Counsel instructed by Australian Business Lawyers & Advisors

INTRODUCTION

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1. At around 2:05 pm on 25 October 2016, a tragic incident occurred on the Thunder River Rapids Ride (TRRR) at Dreamworld Theme Park, Coomera, which claimed the lives of Ms. Kate Goodchild, Mr. Luke Dorsett, Ms. Cindy Low and Mr. Roozbeh Araghi. A joint inquest into the circumstances of this tragedy was convened over a six-week period at various dates in June, October, November and December 2018, in the Coroners Court of Queensland at Southport.

2. The gravity, complexity and scope of this tragedy at Australia’s largest Theme Park was reflected in the comprehensive and professional investigations conducted by the Queensland Police Service (QPS) and the Office of Industrial Relations, formerly Workplace Health and Safety Queensland (OIR), as well as the voluminous documentary, photographic and video exhibits obtained during the course of the inquiry. During the hearing, oral evidence was taken from 59 witnesses, with an expert engineering conclave convened to provide evidence concurrently.

3. The impact of this tragedy on the community, whilst paling in comparison to that on the loved ones of those who lost their lives, has been undeniably significant. Accordingly, the in-depth nature of this inquiry was intended to ensure that such a tragic event does not happen again.

4. I would like to commend the work of all of those involved in the investigation of this tragic incident. The investigation was conducted to an exceptionally high standard, with a great deal of compassion, expertise and dedication by the Queensland Police Service and Office of Industrial Relation (OIR) officers involved. The gravity, scope and complexity of this tragedy at Australia’s largest Theme Park is unparalleled in Queensland’s history, and was carried out to a remarkable standard under great public scrutiny, with the eyes of the world watching.

5. Whilst the investigation and ongoing preparation of this inquiry was certainly collaborative, I would like to make particular commendations to the following Queensland Police Investigators for their remarkable efforts.

6. I am grateful for the tireless and outstanding work undertaken by Detective Sergeant Nicola Brown, the lead investigator for this tragic incident. Her standard of work and dedication has been exceptional, and of great assistance to my inquiry. The task of investigating such a unique and high-profile incident was immense, and undertaken by Detective Sergeant Brown in a professional, diligent, compassionate and comprehensive manner. I am thankful for all her efforts during the course of these proceedings.

7. The skillful and detailed analysis conducted by Senior Constable Steven Cornish, the lead Forensic Crash Unit Investigator, with respect to the mechanical and technical aspects of this tragedy was pivotal to this inquiry. His dedication and attention to detail ensured that this unique and catastrophic incident was properly, and with the requisite expertise, investigated and considered. I am grateful for all his tireless work and commitment.

ISSUES FOR INQUEST

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8. On 3 April 2018 and 25 May 2018, at pre-inquest hearings, the following issues for the inquest were determined:

• a. 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.
• b. The circumstances and cause of the fatal incident on the Thunder River Rapids Ride at the Dreamworld Theme Park, which occurred on 25 October 2016.
• c. 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.
• d. Examination of the sufficiency of the training provided to staff in operating the Thunder River Rapids Ride.
• e. 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.
• f. What further actions and safety measures could be introduced to prevent a similar future incident from occurring?

ABOUT THE DECEASED PERSONS

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9. Ms. Kate Louise Goodchild was born on 3 August 1984 in Canberra. She resided with her partner of 15 years, David Turner, and their two children, Ebony and Evie in Ngunnawal, ACT. She was a dedicated wife and mother, who had a wonderful sense of humour. She had three siblings, Luke Dorsett, Jeremy Goodchild and Peta Harrison. At the time of her death, Ms. Goodchild worked for the Department of Human Services, having previously worked in various public service and private organisations.

10. Mr. Luke Johnathan Dorsett was born on 28 March 1981 in Canberra, and is Ms. Kate Goodchild’s older brother. He resided with his adored partner of 10 years, Mr. Roozbeh Araghi in the ACT. He worked for the Department of Human Services. Like his sister Kate, Mr. Dorsett was dedicated to his role in the public service and had an immense work ethic. He was described as an extraordinary role model to those around him.

11. Mrs. Cindy Toni Low was born in Whakatane, New Zealand on 19 May 1974. She and her husband, Mr. Mathew Low travelled to Sydney and settled there in 2001. They had two children, Keiran Elijah Low and Isla Grace Low. Mrs. Low was a dedicated wife and mother, who was described by her family as vibrant, intelligent and social. She lived at East Gosford and worked as a personal assistant at a property valuation company.

12. Mr. Roozbeh Araghi was born on 7 September 1978 in Iran to parents Behrooz Araghi and Vivien Hadden Araghi. He had two siblings, Simon Sirus Araghi and Darius Araghi and was the father of Zachary Araghi Dawson and Harrison Araghi Dawson. He resided in the ACT with his loving partner of 10 years, Mr. Dorsett. He held a Bachelor of Arts (Honours) from Sydney University and worked for the Australian Bureau of Statistics. He was known amongst his friends and colleagues as a ‘tireless defender of the under privileged’.

BRIEF SUMMARY OF THE INCIDENT

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13. On Tuesday 25 October 2016, Dreamworld opened as usual at 10:00 am. The Thunder River Rapids Ride (TRRR) commenced operating with nine rafts in circulation and two Ride Operators. This is the maximum number of rafts allowed in circulation for a two Operator model.

14. At around 2:00 pm on 25 October 2016, Cindy Low and her son Kieran, Kate Goodchild and her daughter Ebony Turner, along with Kate’s brother, Luke Dorsett and his partner Roozbeh Araghi, boarded Raft 5 of the TRRR. At the time, the weather was dry and clear.

15. The TRRR, which is no longer in commission, was an aquatic based family orientated ‘moderate thrill ride’, which was suitable for patrons over the age of two. It was designed to simulate white water rafting for six patrons, with the option of having three children seated on an adult’s lap, within a circular raft. Statistically, it was the most popular ride in the Theme Park.

16. Raft 5 travelled through the water course without incident before being picked up by the conveyor at the end of the ride and moved towards the elevated unloading area. At this time, Raft 6, which was dispatched in front of Raft 5, became stranded on the steel support rails situated at the end of the conveyor near the unloading area. Raft 5 continued to travel on the conveyor where it collided with Raft 6 before being lifted and pulled vertically into the conveyor mechanism. Ebony and Kieran, who were seated at the top of Raft 5, were able to free themselves and escape to safety. Ms. Goodchild, Ms. Low, Mr. Dorsett and Mr. Araghi were caught in the mechanism of the ride, and were either trapped in the raft or ejected into the water beneath the conveyor.

17. The Ride Operators and some patrons immediately responded to the incident, attempting to assist those trapped in the raft and in the watercourse. Emergency services were contacted, and various Dreamworld staff responded to the incident. Unfortunately, all attempts to provide medical assistance to Ms. Goodchild, Mr. Dorsett, Ms. Low and Mr. Araghi were unsuccessful, and they were declared deceased at the scene.

18. A major investigation code named ‘Operation Oscar Holocene’ was immediately commenced by QPS, which included support from various internal specialty units, including the Forensic Crash Unit, who carried out testing and an expert analysis of the scene and circumstances of the incident. Given the scale of the investigation and nature of the incident, support was also provided by the State Crime and Intelligence, Counter-Terrorism and Major Events Command.

19. The scope of the QPS investigation was twofold. Firstly, to determine whether there was any criminal negligence or criminal responsibility under the Criminal Code 1899, and also to identify, report and obtain evidence, which could assist the South Eastern Coroner in his investigation of the incident, establish a cause of death, make the requisite findings under the Coroners Act 2003 and identify any possible preventative recommendations. In addition to undertaking an expert forensic examination and search of the incident scene, a multitude of witnesses were interviewed, including eye witnesses, Ride Operators, Dreamworld management staff, maintenance workers, current and former Dreamworld employees, Queensland Ambulance Service (QAS) officers, and Dreamworld patrons. Relevant evidence from the scene was seized, extensive photographs of the incident site taken, and various external and internal subject matter experts were engaged in order to comprehensively canvas all of the pertinent issues associated with the tragedy, and to ensure a thorough and expert analysis was conducted of the incident and scene.

20. Due to the nature of the coronial investigation, its gravity and scope, OIR, whilst undertaking their own separate statutory investigation, assisted QPS in examining the incident. Various interviews and evidence was obtained pursuant to s.171 of the Work Health and Safety Act 2011, for an array of potential witnesses, who refused to provide voluntary statements to QPS, however, were highly relevant to provide context, evidence, information regarding training, maintenance, safety and the history of the TRRR.

21. The OIR investigation into the circumstances of the tragedy was also extensive, and various professionals and experts were employed to provide comment as to components of the incident, the ride and regulatory history. OIR officers attended site immediately following the incident and continued to work concurrently with QPS investigators throughout the course of the inquiry.

22. Extensive documentary evidence was also sought from Ardent Leisure, as well as other external parties, by way of numerous coronial directions. As a result, voluminous records pertaining to a myriad of issues, including the TRRR, modifications made, training, maintenance, job descriptions, operations at Dreamworld, certifications, workplace health and safety related issues, meeting minutes, safety decisions, policies and procedures, directions and complaints, were obtained.

23. Ultimately, comprehensive coronial reports with extensive annexures, including statements, interviews and documentary exhibits, were furnished by Detective Sergeant Nicola Brown, Gold Coast Criminal Investigation Branch and Senior Constable Steven Cornish, Forensic Crash Unit (FCU), Coomera.

24. As Coroner I attended the scene of the tragedy and was briefed by officers approximately two hours after the event and before the forensic pathologists attended. I also attended the day of testing and reconstruction, in company with my Counsel Assisting, Ms. Rhiannon Helsen and my Investigations Officer, Mr. Mark Ozolins.

POST MORTEM FINDINGS

Kate Goodchild

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25. An external and full internal post-mortem examination was carried out on 26 October 2016 by Pathologist, Dr Dianne Little. A CT scan and toxicological testing was also conducted.

26. The post-mortem examination revealed the presence of severe chest and abdominal injuries. A band of abrasions and bruising were found across the upper and mid trunk, as well as the corresponding area across the left upper arm. Internal injuries found included multiple rib fractures, fragmentation of the liver, transection of the duodenum and torn blood vessels to the right kidney. These injuries were the direct cause of death and suggestive of a crushing blow to this area of the body. There was no evidence of drowning.

Luke Dorsett

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27. An external and full internal post-mortem examination was carried out on 26 October 2016 by Pathologist, A/Professor Alex Olumbe. A CT scan and toxicological testing was also conducted. 

28. The external examination revealed extensive bruising and abrasions over the entire body. Multiple severe contusions and crushing injuries to the neck, spine and ribs, as well as the liver, were found following the internal examination. These injuries were consistent with having been caused by multiple compressive impacts, particularly to the cervical area, and upper section of the thoracic spinal column, resulting in severing of the brain stem, as well as other injuries. Death would have been rapid. There was no evidence of drowning.

Cindy Low

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29. An external and full internal post-mortem examination was carried out on 25 October 2016 by Pathologist, Dr Dianne Little. A CT scan and toxicological testing was also conducted.

30. Extensive multiple injuries were observed to the head, chest, abdomen, pelvis and limbs, the combined effect of which was found to be the cause of death.

Roozbeh Araghi

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31. An external and full internal post-mortem examination was carried out on 25 October 2016 by Pathologist, A/Professor Alex Olumbe. A CT scan and toxicological testing was also conducted.

32. The cause of death was extensive disruptive chest injuries evidence of which was evident internally and externally. The mechanism of death was found to be a single disruptive compressive impact to the middle section of the chest due to a rapid movement by an implement. Death would have been rapid. There was no evidence of drowning.

 

Edited February 24, 2020 by Jamberoo Fan
It's now on the findings page of the Queensland Coroners' Court

[Jamberoo Fan]

DREAMWORLD STRUCTURE & OVERVIEW

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33. The Dreamworld Theme Park is located on the Gold Coast at 1 Dreamworld Parkway, Coomera. It was developed by John Longhurst and was officially opened to patrons on 15 December 1981. Over the years, Dreamworld has expanded, and is now Australia’s largest Theme Park comprised of various themed rides, wildlife and television branded attractions. Ardent Leisure Group, an Australian based leisure company, currently owns and operates Dreamworld, having acquired the park in 1998 from the Macquarie Leisure Trust. Ardent Leisure operates Dreamworld along with the adjacent Whitewater World, Skypoint, AMF Bowling, Kingpin Bowling, and Good Life Health Clubs throughout Australia, New Zealand and the United States of America. Ardent Leisure Limited was incorporated on 28 April 2003 and took over the ownership, management and responsibility of the Dreamworld assets from that date. The TRRR had long been in operation at that time. The documentation Ardent inherited in 2003 could well be described as “scant”. They commenced their own record keeping from that date.

34. Within Dreamworld, under the command of the Chief Executive Officer (CEO), are the following Departments: 

• Operations;
• Engineering and Technical (E&T);
• Life Sciences;
• Retail;
• Sales and Marketing;
• Food and Beverage;
• Safety;
• Finance and Administration; and
• Employee relations.

35. The CEO of Dreamworld, at the time of the tragic incident, was Mr. Craig Davidson. All General Managers of the above Departments, and the Chief Financial Officer reported directly to him. He held the ultimate decision making authority for Dreamworld, and liaised directly with the Ardent Leisure Board as to all relevant matters, including safety, expenditure and the like. In a responsibility statement for the CEO, which was signed by Mr. Davidson on 20 March 2015, it notes, inter alia, that the position is responsible for the health and safety in all areas of their control and is responsible to:

• Assist the business to develop and implement the Work Health and Safety Plan and actively support the Plan to meet the safety objectives;
• Ensure that managers under their delegation are aware of the work health and safety responsibilities;
• Ensure that relevant personnel perform risk assessments and implement controls in accordance with an relevant Regulations, Australian Standards and Codes of Practice;
• Establish an annual review of the Safety Management System to ensure it reflects the current legislation and supports the needs of the company;
• Regularly assess (at least every year), via internal auditing, how effectively operations comply with the required health and safety standards; and
• Participate in and support safety inspections – shall conduct at least one safety inspection of the Business per year.

36. The Operations Department, which is one of the largest within the Park, has a number of subsets, including Aquatics, Attractions, Entertainment, Costume, Security, Guest Services, Reception, Cleaning and Gardening. The Operations Department is responsible for the ‘smooth running of the park throughout the day’ and encompasses the Ride Operators, supervisors, relief supervisors and instructors. At the time of the tragic incident, Mr. Troy Margetts was the Operations Manager at Dreamworld. He had held this role since 2014, having commenced employment with Dreamworld in 1990. He was required to report directly to Mr. Davidson.

37. Mr. Andrew Fyfe was the Attractions and Entertainment Manager at Dreamworld, which was a subset of the Operations Department. He reported to the Operations Manager, having held this position for the past 10 years. Mr. Fyfe was responsible for the daily operations of White Water World slide attendants, Dreamworld Ride Operators and the Attractions Supervisory team, as well as the entertainment staff and Laundry and uniform operations.

38. Within the Operations Department, Ms. Nichola Horton was the Operations Systems Administrator, having worked at Dreamworld in various roles since 2002.This role, which commenced in 2016, reported directly to Mr. Margetts, and was responsible for examining systems in place across operations through audits to determine what improvements could be made. As part of this role, Ms. Horton was involved in amending and writing Ride Operator procedures for various rides within Dreamworld and ensuring these were placed onto Liferay, a new electronic document library. She also had carriage of accounts for Operations, which included ordering for the Operations Department. Ms.Horton also performed the role of Duty Manager at Dreamworld, which involved responding to guest complaints, any ride related emergencies, or any major events.

39. At the time of the incident, the Attractions Supervisors, who reported to Mr. Fyfe, included Ms. Jennie Knight, Mr. Jason Johns, Ms. Tracey McGraw and Ms. Sarah Cotter. The responsibilities of the Supervisors were to ‘ensure the safe and efficient daily operations of the Attractions Department through effective management of people resources and operational efficiencies…’ which included supervising the activities of attractions staff on a daily basis, attendance at daily operational calls, Code 6’s and breakdowns on rides. A Code 6 is the code used when a ride has ceased operation due to a technical fault. Each of the Supervisors had been Ride Operators previously and progressed to the position of Supervisor.

40. Relief Supervisors within the Attractions and Entertainment Department are responsible for supervising park operations, which includes supervising the Operators out on the rides, being called out to breakdowns, being out in the park to ensure that the operation runs smoothly and assisting to manage guest issues.

41. According to the Attractions and Aquatics Induction Handbook, Supervisors in the Operations Department were responsible for the day to day operation of the park, which included daily supervision of all team members, liaising with other Departments as necessary, attending emergency situations, hazard and incident reporting, assessing team member’s performance and assisting with guest enquiries. They were also expected to work with management and various team members to execute new ideas and initiatives.

42. Meetings were held weekly with Mr. Margetts, Mr. Fyfe and the Supervisors within the Operations Department. Financial results were discussed, as were any relevant findings from recent Executive Meetings, with Managers providing an update as to any issues associated with their area. Whilst ride down times and safety were not generally discussed during these meetings, any prolonged delay, unscheduled maintenance or ride shutdowns were canvassed.

43. The Engineering and Technical (E&T) Department within Dreamworld is ‘responsible for the servicing and maintenance of all of our rides and attractions’ and is required to attend a ride in the event of a breakdown during daily operations. Personnel in this Department include multiple technical specialties, including electricians and mechanical fitters and turners. At the time of the incident, Mr. Christopher Deaves was the General Manager of Engineering. Whilst he had no tertiary engineering qualifications, he held an Advanced Diploma in Mechanical Engineering, as well as a Diploma of Business, Health and Safety and trade qualifications. Mr. Scott Ritchie (Electrical), Mr. Mark Watkins and Mr. Wayne Cox were all Supervisors within the Department.

44. Long-term former employee, Mr. Bob Tan, who resigned from Dreamworld in January 2016, commenced working at the Park in 1987 as the Assistant Maintenance Controller. He subsequently performed a number of roles, including the Projects Manager (1992), Technical and Services Director (1995), Maintenance Controller (2003), General Manager of Engineering (2009), before taking on the role of Director of Special Projects within the Engineering Department (2014) when Mr. Deaves was promoted to the General Manager of Engineering. Mr. Tan reported directly to the CEO. During his tenure at Dreamworld, he became a qualified engineer, however, was not RPEQ certified.

45. At the time of the incident, the Safety Department at Dreamworld was responsible for assisting with safety compliance at the Park, and to continually improve culture/business practice in conjunction with other Departments. Mr. Mark Thompson was the Safety Manager at the time having commenced in the position in March 2016. He was responsible for delivering training on general safety matters at induction, park-wide safety matters, responding to issues raised through the incident system and implementing control measures for these hazards and investigating suspected safety breaches, as well as oversight of the First Aid Clinic. Mr. Thompson reported to Mr. Angus Hutchings, who was the Group Safety Manager for Ardent Leisure.Mr. Hutchings had held this position since 2010, and was responsible for providing advisory services with respect to safety and strategic planning to all of the Ardent Leisure business groups, including Dreamworld. From 2004 until 2010, Mr. Hutchings held the position of Dreamworld Safety Manager. In both roles, he was required to report to the CEO. Mr. Hutchings had prior experience working for the Safety Regulator, OIR, however, had not previously been involved in implementing or devising safety systems.

46. Within Dreamworld there were also a number of subset groups and teams, which met at various intervals to discuss different matters. From the records provided, the most pertinent groups relevant to the decision making within the Park seem to be as follows:

1. The Leadership Team, which consisted of General Managers of the various Departments within the Park, including Mr. Margetts, Mr. Thompson, Mr. Tan and Mr. Deaves. A wide range of issues were discussed during these meetings, including safety, financials, guest service issues, rides and upcoming events.\ The CEO would sometimes attend these meetings if needed.
2. The Executive Safety Committee consisted of the CEO and General Managers of the Departments, which at the time of the incident relevantly seems to have included Mr. Craig Davidson, Mr. Deaves, Mr. Hutchings and Mr. Margetts.\ Topics discussed at these meetings included ride modifications.
3. The Engineering Management Team, which consisted of the General Manager of Engineering and Supervisors, as well as Mr. Thompson, as the Safety Manager. Weekly meetings were conducted,46 with issues associated with rides, including down-times, being discussed.

Further specific details as to the Safety and E&T Departments at Dreamworld and their respective responsibilities and staffing, commence at page 78.

THUNDER RIVER RAPIDS RIDE (TRRR)

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48. The TRRR commenced operation in December 1986, as part of the rustically themed Gold Rush Country section of the Theme Park. It was manufactured inhouse at Dreamworld between 1985 and 1986, and was based upon a 1979 Intamin Amusement Ride called ‘Rapids Ride’. Information as to the original construction and subsequent modifications to the TRRR, as provided by Ardent Leisure and OIR, are minimal. A summary of the information provided as to the various modifications and alterations made to the ride over its 30 year commission, are outlined further below commencing at page 25.

49. The TRRR was designed by consultant engineers. Mr. Len Shaw, the Engineering Services Manager for Dreamworld, oversaw the construction. The engineering drawings were provided at the time to Workplace Health and Safety (as it then was) and approved by the Chief Inspector of Machinery for the Division of Occupational Safety.

50. On 14 August 1987, the design of the TRRR was approved by the Chief Inspector of Machinery in principle, subject to safety devices and guarding being found to be to the requisite satisfaction of the District Inspector of Machinery. Supporting documentation to the design approval indicates that the ride was certified at that time by a Consulting Engineer attesting to the safe structural integrity of the design, and that it was compliant with the Australian Standards.

51. The TRRR was designed as a family orientated, aquatic based amusement ride, which consisted of a raft that seated six occupants. Riders entered a long partially indoor queue with a number of switchbacks, along with an express line for the Ride Express pass holders. Upon reaching the front of the queue, riders were guided onto a circular raft by one of two TRRR Ride Operators, before being dispatched from the loading area. The ride then proceeded to be propelled by a natural flow of water through the man-made river’s watercourse, which includes calm and turbulent rapids, with rafts reaching speeds of up to 45 kph.

52. The raft travelled a watercourse (rapids) through various troughs and tunnels, which was approximately 450 m long. A wooden conveyor transported the rafts at the end of the ride to the unload area. The duration of the ride, until the commencement of the conveyor, was approximately three minutes and 16 seconds with a 35 second delay between each raft. It took approximately 42 seconds for a raft to travel on the conveyor and arrive at the unloading area. The approximate total ride time for the TRRR was 4 minutes and 10 seconds.

53. Riders could get wet during the course of the ride, which ended when the raft was elevated and transported by a conveyor towards the unloading area, which is adjacent to where patrons are loaded onto the ride.

54. Below is an aerial view of the ride, with the path travelled by each raft through the watercourse highlighted in yellow.

FIGURE: Ex F9A(1), pg. 4

Configuration of the TRRR

Forensic Crash Unit Investigation

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55. As part of the QPS investigation, the mechanical and technical aspects of the TRRR, its operation and the tragic incident were analysed by Senior Constable Steven Cornish from the FCU at Coomera. This analysis included detailed consideration of the technical operation of the ride and its components in their entirety, relevant supporting documentation as to the ride and its history, as well as the mechanism and timeline of the incident. Extensive on-site testing of each component of the ride was carried out, in addition to various attempts to reconstruct the tragic incident.

56. Senior Constable Cornish’s findings were detailed in a supporting coronial report, with the various testing and other diagrams and exhibits annexed.

57. The findings reached by Senior Constable Cornish were accepted and reinforced by expert evidence provided by way of a conclave during the inquest hearing, and have formed the basis for the details as to the configuration of the TRRR, the timeline of the incident, and the cause.

Configuration of the TRRR at the Time of the Incident

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58. There were a number of major components of the TRRR, which whilst operating individually, also played an integral and interdependent role within the overall successful function of the ride. The central components of the ride consisted of a trough, water pumps, conveyor system, rafts, pneumatic gates, operating control system and raft support rails.

FIGURE EX. F9A(1), PG. 7: OVERVIEW OF TRRR WITH LOCATION OF LOADING & UNLOADING AREA, PUMPS, CONVEYOR & RAILS

Operating Control System

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59. The main operating control panel was located at the designated loading area of the ride. It had the capability of operating all of the independent components of the ride, and was the only panel to have this access. The CCTV from five cameras located around the ride were displayed on a monitor within a partitioned wooden area. The position of this panel allowed the Ride Operator to oversee the trough area as the rafts departed, as well as the conveyor system and unload area.

MAIN CONTROL PANEL AS IT APPEARED OCT 2016 - EX B2, PG. 30

60. There is an approximate distance of 12 metres between the Main Ride Operator and the Unload Operator. Due to the distance from the conveyor and unload area, as well as the wooden structure of the control unit and exit walkway fencing, the line of sight of the end of the conveyor by the Ride Operator stationed at this panel was somewhat obstructed. There was no electronic communication between the two Operators.

Trough

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61. The trough was the channeling system, which the water flows through over a distance of 410 metres, transporting the rafts and occupants. It was generally constructed of concrete with a depth of 1.3 metres and a width measuring between three to five metres around the course of the ride.

62. Along the length of the trough, there were a series of turns, barriers and floor mounted wooden logs. These elements were designed to create a turbulent flow for the water, and to simulate a rafting experience. There were also a number of tunnels, one of which had animations and attractions related to the ride and operated by motion sensors.

63. Through the load and unload area of the ride there were outer metal guide rails and wooden barge planks on the trough, which were designed to assist with the loading and unloading of guests from the rafts.

Raft Supporting Rails

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64. Mounted throughout the trough system in the load and unload areas of the ride were steel raft support rails, which were primarily intended to prevent the rafts from heeling (tipping) or flipping whilst occupants were embarking or disembarking. The rails also prevented the rafts from dropping to the bottom of the trough in the event that the water level reduced or completely dissipated.

65. The steel railings were a dual system constructed of 100 mm wide right angle steel, spaced 1450 mm apart (outer to outer) and bolted to the concrete floor of the trough.Within the level area of the trough between the load and unload areas, the railings were positioned a minimum of 700mm above ground level and remained level for the complete length of the construction.

DEPICTS THE RAILING SYSTEM THROUGH ENTRY/EXIT AREA - EX B2, PG. 12

66. Additionally, there were a series of support railings in the trough prior to the beginning of the conveyor (bottom), which were installed in 2015.68

67. In the area of the incident at the end of the conveyor (top), there was no variation in the level, with the support rails having been adapted to suit the sloping nature of the flooring leading back to the area beneath the conveyor, known as the ‘pit’.69 This area is where the water for the ride was gravity drained back into the storage reservoir.

EX B2, PG. 14

Conveyor System

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68. The conveyor on the TRRR was a mechanical device, which was chain driven by an electric motor. The conveyor belt was constructed of a series of wooden planks of two variations in size and evenly spaced along the belt. The conveyor was located towards the end of the ride, and was used to carry rafts from the end of the trough system up to the unloading area.

69. The drive axle and two cogs were fixed to the western end of the conveyor where the electric motor was attached. There was a dual chain system, which the planks were attached to, that was pulled along from the drive axle. The conveyor was driven by its own dedicated, power source and control system, which was not linked to any other of the ride’s components.

70. The main control system for the conveyor was located at the Main Control Panel, with a further control box, primarily used for maintenance purposes, located next to the conveyor away from public access. At the Operator control panel, there was a start and stop button, as well as a reset button, which could be used to restart the conveyor in the event that it was stopped under the Emergency Stop procedures. Upon depressing the start button, it became illuminated to show it was operating whilst the red button flashed. The red button initiates the slow shut down of the conveyor. There was no Emergency stop for the conveyor available at the Main Control Panel.

71. During testing of the conveyor and Main Control Panel, Investigators found that depressing the stop button for the conveyor was sufficient to initiate a slow stop. A slow stop of the conveyor took 8 seconds for the conveyor to come to a complete stop. Activation of the E-Stops were found to stop the conveyor in two seconds.

72. Given the location of the incident and mechanism involved, extensive examination of the conveyor was undertaken by Senior Constable Cornish and other officers, which included intricate manual measurements. Video recordings of the conveyor’s movements also assisted to calculate speeds, as well as the interaction with the rafts, supporting railings and water flow.

73. The measurements of the conveyor planks, including the spacing and configuration, are as follows:

74. The speed of the conveyor was found to be 2.7 kph.

75. An open air gap was found between the end of the conveyor closest to the unload station and the beginning of the raft supporting rails. This interface area, which was significant during the incident as it was into this gap that Raft 5 was pulled down once inverted, was extensively examined and measured. The gap of the interface between the conveyor’s long planks at their furthest point, and the leading edge of the support rail was found to be 430 mm, with a 760 mm gap between the leading edge of the support rails and the drive axle (when exposed).

DEPICTS SIDE PROFILE OF INTERFACE, Ex. B2, pg. 21

76. Further details as to the modifications made to the conveyor over the duration of the ride’s 30 year commission commence at page 25.

 

THUNDER RIVER RAPIDS RIDE (TRRR)

Configuration of the TRRR

Water Pumps

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77. There were two Danfoss VLT Aqua VLT 8502 Drives, which operated the two induction motors (water pumps) utilised by the ride. The drives were installed in 2006. The pumps were referred to as the North and South pumps due to their positioning. The pumps were located under the conveyor belt, in a separate confined enclosure.

78. The controls for both the pumps (stop and start) were located at the Main Control Panel by way of separate buttons. A display on the panel also showed the amps for the respective pumps. This was a predetermined figure, which took into account the condition of the pump and the operating hertz of the motor in the main electrical room. For the TRRR pumps, the reading was to be below 500 amp, and was generally between 430-460 amps. The control panel had no mechanism to allow for a variation of the power of the pump, which would subsequently vary the water flow. The variation in the amp usage was determined by the water level in the reservoir. The lower the water level, the higher the amp output to maintain the constant flow through the outlet.

79. The amp display, red and green lights, were the only visible aspect on the panel, which showed that the pump was functioning. Each pump functioned independently of the other, and could be started and stopped separately. An emergency stop at the panel also deactivated the North pump only. There was no emergency stop for the South pump, or one that stopped both pumps simultaneously.

80. The North and South pumps were gravity fed from the storage reservoir, before being pumped out through the two outlets positioned under the conveyor belt. The pumps had the ability to pump up to 4000 litres per second.  This large water flow created the initial current around the load and unload areas, before it naturally flowed down through the trough system around the ride. The two outlets were 1.6m in diameter and approximately 3 metres from the bottom of the pit. They were also utilised in a reverse flow manner when water was being drained from the ride area, which caused the water level to drop quickly and considerably.

81. Under the instruction of Electrical General Manager, Scott Ritchie, Senior Constable Cornish was shown the start-up procedures for the pumps. It was observed that the North pump was activated first, and took approximately 7 minutes to get to operating capacity and its full ampere. Once this was achieved, the South pump was then activated and the same process followed. Once the amp reading had stabilised and the pumps’ respective green lights were at a solid illumination, the pumps were deemed to be operating at full capacity. A final visual check was then to be undertaken by the Ride Operator of the water level in the trough. The same process could then be utilised to manually shut down the pumps, pressing the red button to stop each pump. A key start and shut down process is stipulated in the Operators Procedure Manual, which involves the use of a key start, which commences the auto sequence.

PUMP OUTLETS IN PIT, EX. B2, PG. 15

Edited February 24, 2020 by Jamberoo Fan

[Jamberoo Fan]

Rafts

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82. The rafts consisted of a fibreglass constructed tub, inserted into a large custom built rubber tube, known as a floatation collar. The floatation collar was internally separated into eight air chambers, which could hold a maximum of 2 PSI. Each raft had six allocated seats. They were inspected on a daily basis by E&T staff, and often drained each morning as they would take on water during the day.

83. Neither the intended lifespan of the rafts or floatation collars in use at the time of the incident nor how long they had in fact been in use by this date is known.

84. It should be noted that Raft 6, which was the stationary raft involved in the tragic incident, had various notes recorded in recent daily checklists (6, 11, 15 & 20 October) with respect to air pressure in the floatation collar.

85. On 31 October 2016, all rafts in service on the TRRR were weighed. It was found by Senior Constable Cornish that there was a variation of up to 100kgs between all of the rafts. Possible reasons offered for this variation were the rafts being unable to be completely drained due to blockages in internal construction, an amount of water soaking into the fibreglass, ropes or other materials within the raft, or water within the collar.

Pneumatic Gates

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86. A series of pneumatic gates, referred to as ‘jacks’ were positioned within the loading and unloading zones. There were a series of two jacks at each of the load and unloading areas. The primary function of the jacks was to restrict the flow of the rafts through the trough system.When operated, the jack protruded into the canal stopping the raft from traveling further forward.

87. The primary operating system for the jacks was located at the main operating panel. At the loading area, the jacks were used to hold the raft in place to allow patrons safe access. There was a timing alarm integrated into the dispatch jack’s release, which was designed to ensure that there was a safe gap between each of the rafts leaving the area and commencing the water course. The timing was approximately 35 seconds. The Ride Operator at the Main Control Panel was able to control the loading and dispatch jacks, as well as the final unload jack.

88. On the Main Control Panel, the load button operated the two jacks at the loading area. Depressing the button caused both gates to open, moving the loaded raft to the dispatch jack, whilst an empty raft moved forward to be loaded with further patrons. Once the time delay alarm had sounded, the Ride Operator could depress the load 2 button on the control panel, which then released the raft onto the water course. The load and load 2 buttons were operated completely independently of each other.

DEPICTS LOADING JACKS, Ex. B2, pg. 30

89. Within the unload area, there were two jacks with operating buttons on poles. The first was used to stop and secure the rafts, which allowed the patrons to disembark safely. The second jack was closer to the conveyor, and was designed to prevent any approaching rafts from colliding with the stationary raft in the unload area. The jack near the conveyor was installed in 2004, following an incident where an approaching raft collided with another in the unload area, causing a patron to fall into the watercourse.

90. Further details as to the modifications made to the ride over its 30 year commission and previous incidents are detailed below.

Safety Features of the TRRR

Emergency Stops (E-Stops)

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91. There are a series of Emergency Stops, ‘E-Stops’, that were installed to activate a near instantaneous stop of the conveyor.They were located at the unload area, the conveyor control panel box, and a lanyard emergency stop, which was positioned either side of the conveyor.

92. The E-stop at the unload area was the only mechanism, which could stop the conveyor, that was accessible by an employee or member of the public. It was housed in a yellow box with a red button in the centre.

Ex. B4 (5), pg. 25

93. Testing by Investigators confirmed that there was not a single control button which would initiate a complete shutdown of all of the ride’s mechanism.

Raft Safety Stop

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94. Infra-red switches were positioned at the beginning of the conveyor (bottom), which identified when a raft was stationary at that point for a period of at least 15 seconds. If this occurred, an audible alarm sounded, the conveyor stopped and the release jacks were closed to prevent further rafts from entering the trough system.

95. Further details as to these upgrades to the conveyor, which took place in 2016, are set out below.

Chain Break Safety

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96. A second series of sensors were located at the beginning of the conveyor, which were designed to monitor the conveyor chain cadence at a certain rate. If the sensor was not tripped for a period of five seconds there, it triggered a shutdown of the conveyor as it assumed that there was a break in the chain.

Anti-Roll Back Gates

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97. A set of four small gates were mounted to the incline component of the conveyor, and were designed to stop rafts from sliding backwards along the conveyor planks whilst traveling up the conveyor.

Water levels

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98. Ride Operators were required to monitor water levels within the trough of the ride. There was no formal water marker present in the trough of the load and unload area. Rather, Operators were required to measure the water level by reference to a scum mark on the wall of the trough, which was made from years of the ride operating.

History & Modifications to the TRRR Since 1986

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99. The TRRR opened on 11 December 1986, and at the time of the incident, had been operating for almost 30 years. During the course of its commission, the Ride had undergone a number of modifications to various components, although largely operated as it was intended to when first opened. A number of the major components of the ride were original, with only slight improvements or modifications having been made.

100. Documentation provided by Ardent Leisure relating to the history of the TRRR, including the modifications made and any associated issues, which arose on the ride, are scant at best. There is limited information as to the reasons for some of the alterations, when they were carried out, and if any formal type of risk or hazard assessment was undertaken prior to or following the modifications being made.

101. In more recent times, records suggest that ride modifications were discussed at a number of different management meetings, including the Executive Safety Committee Meetings, however, it seems proposals may have been verbally discussed with the CEO, with capital expenditure approvals submitted through a more formal process.

102. Overall, from the documentation provided, it appears that the modifications made to the TRRR include:

• Removal of the conveyor slats (1989-1990 est.);
• Removal of the turntable (1990-1991 est.);
• Changes to the Operator Controls (1991-2016);
• Pump discharge pipes repositioned (1999-2000 est.);
• Pump motors replacement (2012);
• Mesh and rails at conveyor foot (2016);
• Pump motor drives replacement (unknown
• Rails at conveyor head (unknown); and
• Removal of the rubber patches of the raft plug bases (unknown).

103. Below is a summary of some of the relevant modifications made to the TRRR based on the limited records available.

Issues with the Conveyor and Removal of Slats

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104. At the time of the tragic incident, it was evident that at some point in the history of the ride, every 2nd and 3rd conveyor slat had been removed. Whilst it is not clear when this modification was carried out, records suggest the following timeline:

1. 25 January 1988 – Rapid Ride Tail Shaft Failure

At 1:50 pm on 6 January 1988, the tail end of the TRRR conveyor started to tear the timber slats off the conveyor chain. An inspection found that the tail shaft had fractured at a point in line with a locating bush on the northern side of the idler sprocket. The break was clean and ‘unquestionably due to fatigue’ with similar damage found on the other side of the sprocket. It was thought that this was due to a design fault. This break caused the conveyor to destroy itself at the tail end on the supporting steel, smashing 25 timber slats and badly distorting both chain sections, tearing chain attachments off the links and completely destroying bearing seals.

It was noted that it was fortunate that a raft was not on the conveyor at the time of the incident.

Repairs required to be carried out included the fitting of a new shaft, new seals and new timber slats. The chain was able to be repaired.

1. 16 January 1989 – Rapid Ride (timber slat removal suggestion)

In a memorandum directed to Mr. Garth Bell from Mr. Len Shaw, Engineering Services Manager, it was reported that on 15 January 1989, damage occurred to 3 slats on the TRRR conveyor. This seems to have been a recurring issue. On this occasion, it was surmised that the issue may have been happening at the head of the conveyor due to water flow from the southern pump, which was lifting the return side at an angle sufficient for a slat to drop off the return guide track. It was thought that the slat would then run under the track until it reached the pump house wall before it jammed and then broke as it tried to pass underneath.

It was suggested at this time that every alternate timber slat should be removed in order to achieve the following:

• Reduce the overall weight of the system.
• Reduce the floatation effect of the timber.
• Reduce the number of things which can ‘get caught’.

It was suggested that a trial period of a section of the conveyor should be conducted to ensure other issues weren’t created by this modification. It was noted that something had to be done as ‘this chain is the subject of continuous repair section by section. The working environment for a steel chain is the worst possible imaginable.’

Mr. Shaw noted that ‘there is no way I can guarantee a trouble free run on the ride when there is no control by us as to what the water does’.

105. According to Mr. Bob Wood, who commenced working at Dreamworld in November 1988 as a mechanical fitter, the TRRR initially had full length planks on the conveyor. He recalls that the weight of the conveyor was causing the conveyor chain to wear, which resulted in links having to be removed to shorten it. He was aware that a decision was made to remove every second plank gradually from the conveyor to reduce the weight and the load being placed on the chain. To the best of his recollection, Mr. Wood thought this may have taken place in the early 1990s. The weight placed on the chain, however, continued to be a regular issue despite this modification.

106. The below photograph depicts the conveyor as it was initially constructed in 1985.

107. Mr. Wood stated during the inquest that by the time he left employment with Dreamworld in 2012, every 2nd and 3rd slat had been removed from the conveyor.

108. According to Mr. Tan, who was employed in various roles within the Engineering Department, including as the Manager since 1987, the removal of the wooden slats on the conveyor took place between 1988 and 1990 because it was frequently tripping. The boards were removed to reduce the weight the conveyor motors were required to drive, and to improve the chain ‘release’ from the head sprocket.

Turntable Removal

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109. Originally, the TRRR had a timber turntable at the end of the conveyor near the unload area, which moved the rafts from the conveyor onto an arm of the turntable that would then move the raft to a stationary position at the unload area. It was a large device, which spanned the end of the conveyor all the way around the load and unload areas, whilst an arm of the turntable would ramp off allowing the raft to float into the watercourse. There were no steel supporting rails near the conveyor or unload area at the time it was in use.

110. In a memorandum from Mr. Len Shaw, Engineering Services Manager, to Mr. Wes Hepburn titled, Memorandum 13 August 1987 – Rapid Ride Turntable, it was noted that there had been reoccurring issues associated with the turntable at the TRRR. Since December 1987, the total cost of requisitioned material and services to maintain the whole of the ride operationally was $22,956.98, with over 1000 man hours needed. The turntable component of those costs was $5670, and about 300 man hours. The main issue seemed to be with the rolling wheels, which shed the tyre, bearings in the rolling and thrust wheel collapsing. To replace these failings was labour intensive and costly.

111. It was submitted that air operated jack stands should be installed in lieu of the turntable for the load and unload areas, with a controlled dispatch to pass rafts at timed intervals. It was estimated that the cost of this system would be $7000.

112. In a memorandum from Mr. Len Shaw to Mr. Garth Bell titled, Memorandum 20 February 1990 – Rapid Ride Turntable, improvements to the way rafts were loaded and unloaded at the TRRR were outlined.By February 1990, the issues were said to be urgent with rectification work needing to be carried out as soon as possible. The support track for the turntable was reportedly disintegrating fast, with further wheels needed and the cost of labour and maintenance growing daily. The table was also unable to be driven properly when wet. Further, the ride was unable to be operated with less than two people, and in quiet times, the rafts had to be kept moving as there was nowhere to hold an empty raft. The maintenance cost of the current system was $25,000 per year.

113. An air operated holding and control system was costed to replace the current turntable system. This would allow the rafts to be home when the activity of the ride was zero. The cost of the modification was thought to be less than $5000. It was expected that the new system would be installed before the Easter Holidays.

114. Evidence from employees at the time suggests that Mr. John Angilley was involved in the removal of the turntable and the subsequent redesign of the load and unload areas. Whilst it is not entirely clear when this significant change was undertaken, evidence suggests that it may have been in the 1990s. According to Mr. Tan, the modification took place between 1988 and 1990, and was done as the drive was slipping during wet weather, the bearings were constantly failing due to its submerged operation, and the inadequate fixings of the guide tracks required frequent attention and repairs.

115. Following the removal of the turntable, it appears that the support railings were installed in the trough near the unload area at the end of the conveyor. It seems from the outset, the railings were bolted and welded to the trough, and were required to be checked every day as part of the daily inspections. During the inquest, Mr. Angilley stated, to the best of his recollection, the steel support railings were initially placed as close as possible to the end of the conveyor limiting the gap, however, he was unable to recall the distance with any certainty.

Pumps

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116. In a memorandum from Mr. Len Shaw, Maintenance Manager, to Mr. Wes Hepburn dated 23 November 1987, titled, Memorandum 23 November 1987 – Rapid Ride Pumps, issues were raised with the ‘imbalance of loading’ on the TRRR pumps. This seems to have been a recurring issue, at least since 18 November 1987, following which daily tests had been carried out to try and determine the cause.

117. On 22 January, both pumps had to be stopped and started again in a short period of time. On the first occasion, the No. 2 pump shut down by electrical overload. This pump was able to restart a short time later. After a few minutes it was noted that the electrical load on the No. 1 pump was very heavy, and the pump was restarted. It was suspected that a ‘whirlpool’ at the suction point may be the cause of the issue, which could be rectified if modifications were made to the pump well.

118. Further similar tests were to be conducted over the next few days with differing time lapses. If the findings supported the suspected cause, it was proposed that steps be taken to improve the installation, ‘along with the proposal to modify the conveyor within the next few weeks’.

Operation Control Panel Modifications

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119. From a memorandum directed to Mr. Bob Tan, Mr. Steve Romer and Mr. John Angilley from Mr. Greg Handley on 26 June 1998, titled, Memorandum 26 June 1998 – Operator panel upgrade, it seems that the main Operator controls at the TRRR were upgraded, and appeared as was found by Investigators at the time of the incident This allowed the panel to be operated by way of a start key, with indicators and switches pertaining to the North and South Pump, motor current, conveyor, cave lights, air pressure and the automatic sequence of the ride.

120. It was noted that the emergency stop was to be positioned separately to the main panel, but in close reach to the Operator. The location was to be selected by Operations. The activation of the emergency stop would commence the following steps - (1) shut down the North Pump only, (2) Stop the conveyor, but allow the Operator to restart the conveyor at any time; and (3) Close the emergency gate.

Raft Collar Quote

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121. Documentation shows that in September 2015, a quote was sourced from Dynamic Attractions as to three new floatation collars with a modified lashing strap for the rafts at the TRRR. Dynamic Attractions offer a wide range of engineering, design and building solutions for the amusement industry.

122. In June 2016, a further quote was prepared by Dynamic Attractions for ‘River Rapids Replacement Boats for Dreamworld’. This proposal states that Dreamworld had requested a quote for 12 replacement fibreglass boats for the TRRR. They were to be identical to those currently in use, so as to ‘maintain the look of the fleet and allow Dreamworld to continue to use all of the same parts and attachments’.Per boat, it was estimated that the cost would be $12,125.

123. From the documentation provided and evidence given during the inquest, it is not clear as to the reason this quote was sourced, and why it was not actioned.

 

 

Edited February 24, 2020 by Jamberoo Fan

[Jamberoo Fan]

History & Modifications to the TRRR Since 1986

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General Feasible Improvements

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124. A document dated the 11 October 2004, titled, ‘Thunder River Rapids Ride’ shows clearly that the following feasible improvements to the ride were being considered at that time:

1. Consider and analyse the impact if E-Stop is changed to stop both pumps instead of the current pump.

2. Install a second E-Stop switch at Unload area.

3. Institute timer permitted despatch to both despatch stations.

4. Fabricate and install an additional ‘Raft Hold’ device at location prior to the current unload location. Investigate:

a) Alarm if second gate occupied

b) Then followed by Conveyor Slow down

c) Then followed by Pumps stopping

5. Overhead Handrails with strap grips (similar to types for bus/train standing passengers)

6. Design a device to power rotate raft at the current Unload station – rollers at far end, and a powered conveyor on platform side c/w self-homing feature.

125. It is not clear who authored this memorandum or the reason it was drafted. It is evident from the configuration and state of the ride at the time of the tragic incident that only some of the improvements were considered and had been implemented in the 12 years since.

Changes to the Unload Area

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126. Photographs within other records held by Dreamworld demonstrate the difference following upgrades to the unload area of the TRRR. A photograph dated 14 May 2005 suggests that a wooden platform used to jut from the unloading area back towards the conveyor. A further photograph dated 25 February 2006 shows a permanent concrete structure where the timber boards used to be utilised.

Raft Track

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127. In accordance with a Memorandum dated 25 January 1988 titled, ‘Rapid Ride
Loading Dock Raft Track’, on 12 January 1988, the load and unload dock raft
control arm track fractured, which resulted in 10 metres of track being
destroyed.It was suspected that the support arm suffered a collapsed bearing. 

The track was rebuilt overnight and normal operations commenced on 13 January 1988. The faulty bearing and wheel were replaced.

Conveyor Chain Break and Raft Slip Monitoring

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128. In August 2015, following a risk assessment conducted by the Safety Department in July 2015 (outlined further at page 76 onwards), a scope of work for the upgrades to the Conveyor Chain Break and Raft Slip were prepared. These upgrades were intended to take place at the bottom of the conveyor (beginning of the incline). It does not appear that Mr. Deaves or any member of the E&T Department were directly involved in the risk assessment conducted, although some consultation on-site did take place following the process. It does not appear that discussions as to the risks associated with rafts slipping or colliding at the top of the conveyor near the unload platform were ever conducted.

129. According to Mr. Ritchie, in early 2015, Mr. Deaves highlighted the need to upgrade the conveyor system for the TRRR, during the course of an Engineering Management Team meeting. Mr. Ritchie was not aware of any previously identified hazards or concerns at the top of the conveyor, nor had he been tasked to review the safety mechanisms in that area. It was discussed during this meeting that the upgrade would consist of a replacement of the conveyor chain, the design of an anti-rollback system and an upgrade to the control system, which included a chain break alarm and a safety Programmable Logic Controller (PLC).

130. Mr. Ritchie subsequently prepared a scope of work for the project, which was intended to deal with control systems for the conveyor only, and included the following upgrades:

• Installation of sensors to monitor the movement of the conveyor system to detect a ‘chain break’, and to ‘detect the presence of a raft at the bottom of the conveyor’. The Safety PLC to be used was intended to control the stopping and starting of the conveyor, monitor for Chain Break of the conveyor, monitor the position of rafts at the bottom of the conveyor, and interlock with the main pumping system. It was noted that the PLC should also be adaptable to ‘control and monitor the pumping systems along with the arrival and dispatch gates (stage 2)’.
• The existing lanyard emergency stop devices were to be adapted along with the existing local control panels to fit with the new control system.

131. It was also proposed that the scope of work be expanded to include an upgrade of the Main Control Panel, as it had been ‘adapted and added to over many years and are in a poor state’. Mr. Ritchie clarified that he was referring to the organisation of the wiring on the Main Control Panel as it was difficult to follow and untidy. The hardware was older and there was no colour coding, numbering, labelling or features that would be expected for new wiring that readily identifies the systems that each wire operates. Furthermore, there were no ‘as built’ electrical drawings, as well as different electrical components that had different voltages in the same system. Mr. Ritchie noted that these aspects made reviewing the electrical components of the Main Control Panel ‘slow and time consuming’. He did not consider, however, that the state of the control panel adversely affected the safety or operation of the ride.

132. This upgrade was intended to include the following:

• The addition of a 7-inch Proface Touch Screen which would monitor all alarms, monitor the water level and monitor the pump loads; and
• Upgrade the controls of all arrival and exit gates.

133. It was estimated that the additional cost for this further component to the upgrade, which would ‘future proof this system for years to come’ was $10,000. Mr. Ritchie was of the view that this increase to the scope of work would allow for the necessary infrastructure to make the ride capable of future automation projects, which may be considered, and would also improve the state of the wiring at the Main Control Panel, which would enable faster electrical fault finding in the future.

134. In relation to the monitoring of the water level at the TRRR, Mr. Ritchie was of the view that water level sensors could be installed, which would monitor the operating efficiency of the pumps. He was aware that the pumps for the TRRR accounted for approximately 30% of Dreamworld’s overall electricity bill, and such monitors may allow for the performance of the pumps to be adjusted to increase or decrease the operating capacity, thereby leading to a significant cost saving. 

135. This memorandum was sent to Mr. Deaves by Mr. Ritchie via email. Subsequent discussions were had whereby Mr. Deaves advised that whilst he supported the additional work proposed, it could not proceed at this stage, with the focus to remain on the upgrades to the bottom of the conveyor. Mr. Ritchie understood that the potential hazard identified at the bottom of the conveyor needed to be rectified as a priority. He did not consider that a delay to the second stage of the project would have a negative impact on guests’ or Operator’s safety. 

136. Quotes were subsequently sought from Products for Industry (PFI) and Sage Automation. Ultimately, PFI was engaged to carry out the upgrades to the TRRR, which included the following: 

• Design the electrical integration of the PLC to perform the following functions:

- Conveyor start/stop Operating including jogging and override controls

- Chain Break Detection

- Raft Slip Detection

- Monitoring of the Lanyard Emergency stops

- Monitoring of the emergency stop at the local control panel

• Replace the Existing Local Control panel
• Run new cabling to the local control panel and the ride control station
• Install the Raft position spot 10 safety beam at the bottom of the incline conveyor
• Install the Chain Break spot 10 Safety Beam further up the incline to monitor the wooden cleats on the chain
• Supply all required electrical hardware and software
• Replace the existing local control panel with new panel & controls and incorporate a new safety reset button
• Build and install a new Safety PLC Panel to install in the main electrical control room - New Safety PLC panel to incorporate redundant safety contactors
• Also incorporate to interrupt the drive enable signal to stop the drive before isolating safety contactors
• Program and Commission the Safety PLC
• Perform Safety Validation of the system and documentation

137. The purpose of these upgrades was to ensure that if a raft was stationary at the base of the ride, it was detected and it would shut the conveyor drive down. Detection of a break in the conveyor chain was also designed as part of the upgrade, which by way of a sensor would shut down the conveyor motor. The plate and wiring of the local motor Control Panel was also replaced, with an upgraded E-Stop installed at the unload area, which immediately stopped the conveyor. The controls for the conveyor at the Main Control Panel were also rewired as part of the upgrade.

138. With respect to the function of the E-Stop, Mr. Ritchie consulted with Systems Administrator, Ms. Horton, as to whether it should stop one of the pumps or the conveyor. It was determined that given the ability of the unload Operator to see the conveyor and any associated issues, it would be best if the E-Stop only allowed for a hard stop of the conveyor, with control of the pumps retained by the Operator at the Main Control Panel.

139. PFI was not asked to install a water level monitor on the TRRR. It was noted that there was a request in the scope of works to include a pump interlock in Stage 2 of the upgrade, however, there was no date stipulated as to when this would commence. Mr. Ritchie notes that these upgrades were discussed during the site visit conducted by PFI in August 2015, however, were not to be implemented until after the first upgrade had been successfully implemented.

140. The conveyor upgrades were commenced on 8 February 2016, and completed within a week.In March 2016, PFI was requested to return to site and make the following modifications to the system: 

• Raft stop timer to be extended by 15 seconds at the bottom of the conveyor;
• Installation of an audible alarm on the Operator’s Panel if the conveyor failed;
• Syncing the emergency dispatch gate with the audible alarm if the conveyor stopped to automatically shut the dispatch gates to prevent the further dispatch of rafts;
• Ride enable key must be in to start the conveyor; and
• Location of chain break sensors lowered by 20 mm.

141. Changes to the relevant management documents relating to the TRRR following the above modifications were completed by Mr. Ritchie and Mr. John Lossie at the request of Mr. Deaves. These documents included technical drawings of the work completed, changes and updates to the operating procedures, changes to the service and maintenance procedures and task sheets, as well as details as to the training to be undertaken by the Operator. Two additional checks were added to the daily and weekly maintenance checklists for the TRRR following the modifications.

142. A completion memorandum was subsequently completed by Mr. Ritchie, which was provided to E&T staff only, which explained the changes to the conveyor control system. On-site training was also provided to E&T staff by Mr. Ritchie demonstrating the changes made as detailed in the completion memorandum. It is unclear if any records were retained detailing who undertook this training and were provided with the memorandum.

143. During the inquest, Engineer, Mr. Matthew Sullivan from PFI, gave evidence that some of the spare safety inputs available following the conveyor upgrade could have been used for a safe water level monitoring system.

PFI Modifications to the Log Ride in 2013

144. PFI had previously been engaged by Mr. Deaves to undertake upgrades to the Log Ride in October 2013, which included the installation of a water level monitor by way of two probes sending an electric signal to the PLC that registered the level. It was noted that the water monitoring was an ‘important feature’ of the Log Ride as it was crucial to stopping the boats as they came off the conveyor. Mr. Deaves claims that these upgrades came about after he reviewed the ride controls to consider having one Operator instead of two. He was made aware of concerns as to a raft coming over the top of the conveyor and colliding with another at 70 kmph, and thought that a control system would be necessary to prevent this from occurring. He subsequently approached PFI to have it designed. Mr. Deaves describes the manner in which this upgrade came about as ‘ad hoc’ and in passing, rather than by way of a formal meeting or identified risk, which needed to be rectified. 

145. The scope of work also included monitoring the movements of the boats at the top and bottom of the slide, which was to avoid collisions by way of block controls. The purpose of these controls was to ensure that only one boat entered an area at any given time by way of a sensor at the start and exit point of a designated area. On the Log Ride, this included a block control at the top of the slide and another at the bottom, which was designed to prevent a boat being at the base and another coming towards it and resulting in a collision. 146. The cost of all of the modifications to the Log Ride, which in addition to the above also included manual reset buttons and overrides, was $16,000.

Other Suggested Modifications to the TRRR

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147. Records provided by Ardent Leisure during the course of the coronial investigation suggest that further modifications were considered for the TRRR. Unfortunately, these documents were provided without any context or further records explaining the content or reasoning as to why modifications were examined, nor the decision not to proceed. For completeness, and to highlight the proposed changes, details as to the modifications are outlined below.

Automated Raft Rotation System

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148. Minutes from the Executive Safety Committee Meetings held in February 2004, suggest that consideration was given to a redesign and costing of an automated raft rotation system, which was to be included in the 2005 budget. It appears that Mr. Tan and Mr. Angilley were responsible for this project. Unfortunately, whilst this project is subsequently mentioned in minutes from a further meeting in September 2004, it is not clear why this project did not proceed. In the minutes from the September meeting, it states that ‘issue to be reviewed Feb’ 05. Meantime operator training techniques to be used’. Whilst the issue remains an agenda item for the November 2004 meeting, the notation states, ‘design and costing required for an automated raft rotation system. Work in progress in light of recent events’. It is not clear what the context of this notation was, and why the project did not eventuate.

Single Button Shutdown

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149. According to Ms. Horton, she made a suggestion that a single stop button be installed on the TRRR, as opposed to the four button shutdown sequence, which needed to be undertaken by the Ride Operator at the Main Control Panel. Whilst this proposal wasn’t made due to any safety concerns, Ms. Horton thought this would make the process simpler for Ride Operators.

150. On 6 May 2016, an email was sent from Mr. Jason Johns on behalf of the ‘Dreamworld Attractions Supervisors’ to Mr. Lossie and Mr. Fyfe, which raised the possibility of the four step emergency shutdown procedure for the TRRR being changed to one step. The four steps taken to shut down the ride were as follows: I. Press Emergency Gate Button; II. Press Conveyor Stop; III. Press Emergency Stop; and then IV. Press Rapid Ride alarm button.

151. On the same day, Mr. Lossie replied stating that he would ‘look into what would be required for this to be a one push button’.

152. According to Mr. Johns, this request was made at the behest of Mr. Fyfe, who asked that he explore the possibility of simplifying the shutdown process.

153. Prior to the tragic incident, this simplification of the shutdown process had not been implemented on the TRRR. At the inquest, Mr. Johns confirmed that he had not received any further correspondence about the issue, however, he acknowledged that it was not actioned.]

Sourcing Further Wood for Conveyor in 2016

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154. An email from Mr. Naumann to Gooding Timber dated 30 March 2016, suggests
that pricing was sought for 70 lengths of F14 Hardwood timber. A
representative from Gooding Timber subsequently queried whether the wood
was being used for inside or outside, as this would be relevant to determining
the most suitable product.

155. When questioned as to how and why this quote was sourced during the inquest,
Mr. Naumann stated that he thought it may have been based on his assessment
of what was required and also previous ordering history. He ‘wasn’t sure’
whether it would be pivotal to advise the supplier that the wood was being used
for a water based amusement ride.

156. In an update email sent by Mr. Naumann to Mr. Watkins and Mr. Cox dated 6 May 2016, he noted that ‘we have started alternating the planks on installation – new then, good condition old’. When asked for the rationale as to this approach to replacing the planks, Mr. Naumann was unable to recall the reasoning. He did state, however, that to the best of his recollection, conveyor slats with ‘excessive bowing’ were replaced during the 2016 annual shutdown of the TRRR.

TRAINING & OPERATOR PROCEDURES

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157. For each of the rides at Dreamworld, specific Operating Procedure Manuals were drafted by the Operations Department, with final approval provided by Mr. Margetts. Memorandums were also used to update the Operating Procedures for each ride. These were displayed on a memorandum board. Ride Operators were then retrained on the change in procedure, which was noted on a roster kept with the Supervisors.

158. For each of the attractions at Dreamworld, ride specific training was provided inhouse to new Ride Operators. This was undertaken by Senior Ride Instructors (level 4), who were experienced Ride Operators that had been trained in each level of ride operation. It does not appear that they were required to hold any formal training qualifications or undertake any external course, which would be recognised outside of the Theme Park. That being the case, evidence suggests that internal courses were offered for Instructing Operators, such as the ‘Train the Trainer’, which was conducted at Dreamworld in mid-2016 for all of the Instructing Operators. This course was conducted one day a week for three hours over a 10 week period.

159. Senior Ride Instructors were required to provide instruction to Ride Operators safely and efficiently, whilst also mentoring and training staff on an as required basis. They were also expected to identify and report methods for continuous improvement within the Department and business, as well as any hazards or incidents as identified. One of the key responsibilities of an instructor was to maintain Dreamworld’s high standards of practice and safety by ensuring ‘that your trainee is aware of these safety commitments and they are appropriately trained in all safety matters’.

160. Instructors were required to have one to two years’ exemplary performance in ride operation. However, evidence provided by various staff during the investigation and inquest suggested that there was no enforced set timeframe as to when a Ride Operator could progress to becoming an Instructing Operator. For example, Ms. Amy Crisp progressed to a training position within a year of commencing her employment as a Ride Operator with Dreamworld, although she noted that it normally took staff longer to achieve this.

161. Practically, before a Ride Operator could become an Instructing Operator, they were required to watch other training sessions provided to staff, and would then be observed on at least three different training sessions they provided to new Ride Operators. Once the trainer is deemed to be competent by senior staff, they are allowed to train Ride Operators without supervision.

162. If an Instructor discovers an issue with a procedure or a correction, which needs to be made, there is a suggestion form that can be completed and provided to a Supervisor to be actioned.

163. Instructors were also involved in the auditing of staff, to ensure Ride Operators were still competent and to identify whether any further training may be required. This generally involved computer based and practical on-site observation of the Ride Operator.

164. At the time of the incident, it was estimated that there were eight Instructing Operators, six of whom were competent to train all staff on all rides. The Log Ride and TRRR were the last rides that were taught to Ride Operators and Instructors, due to the ‘higher responsibility’.

165. The manner in which this training was provided by the Instructing Operator was largely based on how and what the Instructor had been shown when they were a Ride Operator, and comprised of on-site practical training whilst the ride was in operation with the Instructor, with a run through of the procedures specified in the applicable operating procedure manual discussed and demonstrated before the ride opened. There was no checklist provided to the Instructor as to topics to be covered during a training session for the ride, rather only a Training Register, which was signed off at the end of the session. The Operating Procedure Manual for a ride was intended to outline the processes to be followed when operating the ride and responding to different scenarios that may arise, including emergencies specific to that attraction. The duration of the training largely depended on the type and complexity of the ride. Trainers were required to make an assessment of the trainee to determine if they were comfortable operating the ride.

166. When training a staff member in the operation of a ride, it was a requirement of Dreamworld policy that a ‘Training Register’ sheet be completed in full. This form states the day and time the employee was trained in a particular role on a ride, and was only to be signed by the trainee if ‘they are confident that they know and understand the procedure’. The instructor is also only to sign the form if they are ‘confident that the operator knows and understands the procedure and is able to operate the ride confidently’. In the Instructor Handbook developed by Dreamworld, there is advice provided to Instructors as to the different adult learning styles and modalities. 

167. The different levels of Operators on a ride indicate the different levels of training and familiarity and seniority in relation to rides. There are requirements as to what level a Ride Operator must be to work on particular rides, with some simple rides only requiring a level 1 Operator.

168. Any change in procedure for a ride, requires that the Ride Operators be briefly re-trained on the new procedure (usually within 15 minutes), which would be recorded in a Training Register.

 

Edited February 24, 2020 by Jamberoo Fan

[Jamberoo Fan]

TRAINING & OPERATOR PROCEDURES

 

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TRRR Position Responsibilities and Training

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169. It was well-known that the Tower of Terror, Log Ride and TRRR were the most
complex rides to operate within the Theme Park, as the Ride Operators had the
most responsibility. Accordingly, a Level 3 (No. 1) Operator was necessary to
control the ride. Like the Log Ride, the TRRR was said to have a number of
manual elements to its operation as opposed to automated controls, which made
the ride more difficult to operate. The panel for the ride was described by Relief
Supervisor, and experienced Ride Operator, Ms. Cotter as being a ‘very complex
panel’.

170. At the TRRR, there were three possible Operator positions, with a maximum of four staff manning the ride on a given day. The number of staff required to operate the ride was dependent on the number of rafts in circulation, and the expected volume of guests. 171. The staffing positions and configuration, which are detailed in the Operator Procedure Manual for the ride, were as follows:

2 staff present (operator and load operator)

1. 1 at main control panel (load
2. 1 at unload

3 staff present (operator, load and deckhand)

1. 1 at main control panel (load)
2. 1 at unload
3. Deckhand at dispatch and roving queue line and assisting with ride express

4 staff present (operator, load and deckhands)

1. 1 at main control panel (load)
2. 1 at unload
3. Deckhand 1 at dispatch
4. Deckhand 2 roving queue line and assisting with Ride Express

172. The responsibilities for each position were outlined in role specific Operator Procedure Manuals. The duration of the training provided for each position is dependent on the level of responsibility. Primary responsibility for the operation of the ride remained with the Level 3 Operator (No. 1), who also had a supervisory responsibility over the Level 2 and Level 1 Operators. 

173. Ms. Horton was responsible for drafting updates to the Operator Procedure Manual for the TRRR, which came into effect in June 2016. The reason for the updates to the procedure was to reflect recent engineering changes to the conveyor operating system, which prevented rafts from rolling back on the conveyor. All Operators were subsequently trained in the draft and implemented changes to the Operator Procedure Manual.At inquest, Ms. Horton stated that whilst she considered the entire contents of the Procedure Manual, she wasn’t aware of any associated memorandums that may be applicable, as these had not been saved on the document management system, Liferay. The Safety Department was not involved in the drafting of any operating procedures.

174. In order to demonstrate the time-frame in which the Operators for the TRRR had to perform their respective functions and tasks, the following table demonstrates the cycle times for the ride, as was documented within the operating procedures maintained at the ride:

AVERAGE CYCLE TIMES

                       Cycles per hour Guests per hour Minutes per cycle

Non Holiday             83.4                      458                       0.72

Holiday                      113                       626                       0.5

175. The roles and responsibilities of each of the Operator positions at the ride are outlined below.

 

Ride Operator Level 1 (No. 3) Deckhand

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176. The Operations Procedure Manual (Rapid Ride Deckhand Operation) states that the Deckhand will be positioned at the dispatch control panel and queue line, to ensure all guests’ belts are secured, and to press and hold the dispatch jack button until the raft has left the jacks.

177. As part of the Operator Procedure Manual, there was also a Rapid Ride Operator Training component. This document seems to apply to the training of the Deckhand position at the TRRR. Section 3.2 of the procedure requires that the training session should be a minimum of 1.5 hours, with 3.2.2 stipulating that Instructing Operators and Attractions Supervisors ‘must never leave any person to operate any equipment unless fully competent. If any doubt exists as to the trainee’s level of competence, the Instructor is to extend the duration of the training session.’ Sections 3.4 of the Procedure requires that the operating procedures as outlined in the manual be explained, as well as ‘all of the emergency and operational/Code 6 procedures’ (3.4.6). The assessment is to ensure that the trainee knows and understands each of the points covered in the training session and once satisfied, the instructor is to assess the trainee’s competency through at least two ride cycles before signing the Attractions Training Register.

178. The Operating Procedure Manual for the Deckhand position is five pages in length. The relevant portions for the purpose of this coronial investigation are as follows:

3.1.6 No 1 operator will ensure deckhand/s are aware of the following:

1. (How to shut down the ride as per 3.4.4
2. Location of telephones to call for assistance and the Emergency telephone number (222)

1. How to advise guests of delay
2. Location of all emergency equipment, Emergency exits, and Evacuation Zones (\
3. Number of rafts in circuit

3.2 Start Up

3.2.1 No.1 Operator is responsible for the startup of the ride

3.2.2 Check with No. 1 Operator for any specific operating instructions for the day

3.4 Operating Problems

3.4.1 Any operating problems must be reported immediately to the No. 1 Operator. No raft should be dispatched if it has the potential for risk to either:

1. Guest/Staff safety or wellbeing
2. Ride operating conditions
3. Damage to ride equipment

3.4.3 No. 1 Operator initiate shut down

Advise the No.1 Operator immediately if any of the following problems arise. No.1 Operator will ensure the rapid ride is shut down in the event of any of the following

1. Loss of power to one or both pumps
2. Loss of power to the conveyor
3. Conveyor chain break
4. Raft stall bottom of conveyor
5. Raft jam
6. Raft slips on the conveyor
7. Load/unload jacks jam closed
8. Any situation where there is a risk of serious injury to guests or Staff 
9. Any situation where there is risk of damage to ride equipment

3.4.4 Shut Down Operation

No. 1 Operator and or a Supervisor may direct Deckhand to shut down the ride in an emergency. Proceed to:

1. Press Emergency Gate Button
2. Press Conveyor stop
3. Press Emergency stop
4. Remove dispatch isolator key
5. Call control via 325 stating the nature of your call
6. Await further instructions from a Supervisor

3.5 Periodic Checks

3.5.1 Monitor raft air pressure and condition of tubes. Report any faults or problems to No. 1 Operator.

3.5.2 Monitor water level. Report any faults or problems to No. 1

Operator 3.5.3 Monitor the operation of all jacks. Report any faults or problems to No. 1 Operator

3.5.4 Monitor the queue lines for guests under the age of 2 years and Ride Express queue line

3.5.5 Monitor the ride for unusual sounds or smells during normal operation. Report any faults or changes to No. 1 Operator

3.5.6 Ensure that the ride and the queue line areas are kept clean and tidy at all times

179. Although the responsibilities of the Deckhand are limited and the training relatively short, it appears from the requirements of the procedure that the employee is required to be conversant with their responsibilities in respect of the above competencies. 180. None of the prescribed procedures for this position give the Deckhand the authority to take action in an emergency situation, without the direction of the No. 1 Operator.

 

 

TRAINING & OPERATOR PROCEDURES

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TRRR Position Responsibilities and Training

Ride Operator Level 2 (No. 2) Load Operation

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181. The training for a No. 2 Operator on any given ride generally involved training on-site for between 1 ½ to 2 hours, which was consistent across the Theme Park. However, if an Instructing Operator was of the view a trainee required additional time to complete the training to the requisite level, this could be requested.

182. According to the ‘Attractions Training Register’ for the No. 2 Operator position at the TRRR, Parts 3.1-3.8 of the Operator Procedure Manual were required to be canvassed during training. These sections of the Manual cover the following topics:

• 3.1 – Opening
• 3.2 – Start up
• 3.3 – Operating
• 3.4 - Operating Problems
• 3.5 – Periodic Checks
• 3.6 – Emergency 
• 3.7 – Closing 
• 3.8 – Spiels
• Lock-out tag-out

183. The Operating Procedure Manual for the No. 2 load Operator position is 16 pages in length. The relevant portions of the Manual for the purpose of this coronial investigation are as follows:

3.1.7 Operator will ensure load operator is aware of the following

1. How to shut down the ride in the event of an Emergency where the No. 1 Operator is incapacitated (shut down procedure)
2. Location of the telephones to call for assistance and the Emergency telephone number (222)
3. How to advise guests of a delay
4. Location of all Emergency equipment, Emergency exits, and evacuation zones
5. Number of rafts in circuit

3.2 Start Up

3.2.1 No. 1 Operator is responsible for the start up of the ride

3.2.2 Check with No. 1 Operator for any specific operating instructions for the day

3.2.3 Assist No. 1 Operator in dispatching rafts for test run

3.2.4 Open the Queue at the prescribed opening time

3.3.1 Staff positioning
…
NOTE: The No. 1 Operator is responsible for the operation of the ride
including the actions of load operator and deckhand/s. The Operator
will be vigilant of operators and ensure all staff rotate positioning (where
possible).

3.3.7 Load Operation (positioned main control panel)

3.3.8 Advise guests to remain behind yellow line until directed to enter
NOTE: Operators must ensure rafts are positioned correctly for
guests to enter/exit safely. Operators may press jack buttons to
turn rafts for correct positioning as necessary. Under no
circumstances are guests permitted to climb over seats to
load/unload.

3.3.9 Advise guests load spiel as per section 3.8.1. Ensure guests are
advised to take care when boarding the raft as the floor may be
slippery and request back/rear seats be filled first
3.3.10 Ensure guests load the raft one at a time
3.3.11 Fill every raft where possible utilising guest from the single/pairs
and Ride Express queue lines
3.3.12 Ensure belt extensions are given to adults accompanying
children if required

NOTE: Ensure the raft is balanced evenly

3.3.13 Ensure loose belongings are stored in the centre of the raft
3.3.14 Advise guests of belt instructions spiel as per 3.8.2
3.3.15 Check all belts are secured correctly

NOTE: A raft must not be dispatched until all belts are secured…

3.3.16 Advise guests of dispatch spiel as per section 3.8.3…
3.3.17 Press ‘load’ jack button on the main control panel (bar)
3.3.18 Hold ‘load’ jack button until the raft has left the jacks

NOTE: to ensure adequate raft spacing, the ‘dispatch’ jack has
an automatic minimum 35 sec delay. ‘Load 2’ button will
illuminate once raft is ready for dispatch. Rafts are unable to be
dispatch until the ‘Load 2’ button (dispatch) illuminates and an
audible alarm sounds.

3.3.19 Press and hold ‘Load 2’ button (dispatch) on the main control
panel until the raft has left the jacks

NOTE: Jacks will automatically close once raft passes dispatch
jack

NOTE: Minimum three rafts must be kept within sight of the No.
1 operator at all times. This is the area between conveyor and dispatch area.

3.3.20 Load Operators must ensure they are watching camera. Cameras must be checked prior to each raft being sent and in any lag time between rafts being sent. Load Operators must be vigilant of raft movements, conveyor operation and ensure no obstructions exists. If in doubt of operating conditions, stop dispatching. Contact a Supervisor via Control stating ‘Rapids – Operational’ and await further operating instructions.

3.3.21 Unload operation (positioned unload control panel)

3.3.22 Advise guests to remain seated with belts secured until the raft completely stops at the unload area (exit)

3.3.23 Once the raft stops at arrival jack, press ‘arrival jack’ button. This will move the raft to the unload 3.

3.24 Monitor the raft as it moves through, again advise guests to remain seated with belts secured until the raft completely stops at the unload area (exit)

NOTE: Operators must ensure rafts are positioned correctly for guests to enter/exit safely. Operators may press jack buttons to turn rafts for correct positioning as necessary. Under no circumstances are guests permitted to climb over seats to load/unload

3.3.25 Advise guests of unload spiel as per section 3.8.4

3.3.26 Farewell all guests as they exit

3.3.27 Visually check no rubbish or loose items are left in the raft. Remove as necessary

3.3.28 Press ‘unload’ jack button. This will move the raft to the load area.

3.3.29 Hold ‘unload’ jack button until the raft has left the jacks

3.3.30 Repeat sections 3.3.2 to 3.3.30 for daily operation

3.4 Operating Problems

3.4.1 Any operating problem must be reported immediately to the No. 1 Operator. No raft should be dispatched if it has the potential for risk to either:

1. Guest/Staff safety or well being
2. Ride operating conditions
3. Damage to ride equipment

3.4.2 Operator Initiate Shut Down

Advise the Operator immediately if any of the following problems arise. Operator will ensure the rapid ride is shut down in the event of any of the following:

1. Loss of power to one or both pumps
2. Loss of power to the conveyor
3. Conveyor chain break
4. Raft stall bottom of conveyor
5. Raft jam
6. Raft slips on the conveyor
7. Load/unload jacks jam closed
8. Any situation where this is a risk of serious injury to Guests or Staff
9. Any situation where there is risk of damage to ride equipment

3.4.3 Shut Down Operation

No. 1 Operator and or a Supervisor may direct load operator to shut down the ride. Proceed to:

1. Press Emergency Gate Button
2. Press Conveyor stop
3. Press Emergency stop
4. Remove dispatch isolator key
5. No. 1 Operator will give direction to load operator attend the bottom of the conveyor and talk with guests until Engineering and Supervisors attend
6. If a deckhand is present No.1 Operator will give direction to attend to the queue line and apologise to the guests as per 3.8.5 
7. Await further instructions from a Supervisor

NOTE: persons in water and or Raft capsized.

Follow emergency procedure sections 3.6.2

3.4.4 Two (2) Rafts Dispatched Together

1. Press emergency gate button
2. Stop dispatching
3. Advise the No. 1 Operator
4. Monitor raft movements via video camera
5. Await further instructions from No. 1 Operator and/or Supervisor

3.4.5 Loss of Air Pressure (Low air alarm)

1. Advise the No. 1 Operator
2. Stop dispatching
3. Await further instructions from the No. 1 Operator

3.4.6 Motor over Current

NOTE: Audible and visual alarm will activate when current is over 500 amps

1. (i) Advise the No. 1 Operator (ii)
2. Stop dispatching (iii)
3. Await further instructions from the No. 1 operator

3.4.7 Video Monitor Failure

1. Advise the No. 1 Operator
2. Stop Dispatching
3. Await further instructions from the No. 1 operator

3.4.8 Raft stall bottom of conveyor

NOTE: conveyor will automatically stop in the event of a raft stalling at the bottom of the conveyor. An audible alarm will be heard from the panel and conveyor reset button will illuminate

1. Advise the No. 1 Operator
2. Stop dispatching
3. Await further instructions from the No. 1 Operator

NOTE: Operators are not permitted to restart the conveyor. This must be done by Engineering and/or Supervisors

3.4.9 Conveyor chain break

NOTE: Conveyor will automatically stop in the event of a chain break. An audible alarm will be heard from the panel and conveyor reseat button will illuminate

1. Advise the No. 1 Operator
2. Stop dispatching
3. Await further instructions from the No. 1 operator

NOTE: Operators are not permitted to restart the conveyor. This must be done by Engineering and/or Supervisors

3.5 Periodic Checks

3.5.1 Monitor raft movements, conveyor operation and ensure nothing is obstructing the video monitor images. If in doubt of operating conditions, stop dispatching and advise the No. 1 operator

3.5.2 Monitor cameras and load/unload platforms for persons in water and or raft capsized. Follow procedure 3.6.2

3.5.3 Monitor rafts loading onto the conveyor and/or conveyor failure. Advise the No. 1 Operator if an operating problem arises

3.5.4 Monitor raft air pressure and condition of tubes. Report any faults or problems to No. 1 operator

3.5.5 Monitor water level. Report any faults or problems to the No. 1 operator

3.5.6 Monitor the operation of all jacks. Report any faults or problems to No. 1 operator

3.5.7 Monitor North and South pump amps. If a pump readout is above 500 amps advise the No. 1 operator

3.5.8 Monitor the queue line for guests under the age of 2 years

3.5.9 Monitor the ride for unusual sounds or smells during normal operation. Report any faults or changes to the No. 1 Operator

3.5.10 Monitor the control panel. Report any faults or changes to the No. 1 operator

3.5.11 Ensure that the ride and the queue line areas are kept clean and tidy at all times

3.5.12 Monitor all riders during a cycle via the video monitor system. Report any concerns to the No. 1 operator

3.5.13 Ensure video monitor displays all camera images at all times. Report any faults or changes to the Operator

3.5.14 Monitor weather conditions. A Supervisor and/or the No. 1 Operator may advise to dispatch less frequently

3.5.15 Monitor ride express queue line and incorporate loading guests in daily operation

3.6 Emergency

3.6.1 In the event of serious injury to a guest or staff member contact the Emergency Station

Via telephone

1. Contact the Emergency Station via telephone ‘222’

NOTE: Remain calm, speak slowly and clearly

2. State ‘who you are, where you are and the nature of the emergency’

3. Ensure that you are the last to hang up the telephone

4. Await for the arrival of the ‘Emergency Response Team’

5. If possible, control any bystanders and/or assist where possible

6. Retain any witnesses if possible

7.Advise the guests in the queue line of the delay

8. Complete all reports

Via two way

(i) Ensure the two way is turned ‘on’ and transmitting on channel ‘one’. Ensure that the two way volume is on high.

…

3.6.2 Persons in water and or Raft Capsized

1. Press Emergency Gate Button

2. Press Conveyor stop

3. Press emergency stop

4. Remove dispatch isolator key

5. Press rapid ride alarm button

6. Contact the emergency station as per section 3.6.1

NOTE: the dispatch isolator key must be retained by the No. 1 operator at all times when the operator is away from the operator’s panel

7. Throw a life buoy to the person (if possible)

8. No. 1 operator will give direction to attend the bottom of the conveyor throw life buoy

NOTE: Ensure the dispatch isolator is given to the No. 1 Operator before leaving the area

9. If a deckhand is present, Operator will direct them to attend the yellow gate, near the Car park B entry, to throw life buoy

10. Await further instructions from a Supervisor

3.6.3 If the No. 1 Operator is injured or incapacitated load operator will:

1. Press emergency gate button
2. Press conveyor stop
3. Press emergency stop
4. Contact the emergency station as per section 3.6.1
5. Stay at the control panel, await further instructions from a Supervisor

NOTE: if a deckhand is present, give direction to proceed to the conveyor to talk with guests and apologise for delay as per 3.8.5

184. Essentially, once the TRRR is operational, the No. 2 Operator has the same tasks and periodic checks as the No. 1 Operator. Both are expected to swap positions from the unload area and the Main Control Panel at regular intervals. The No. 1 Operator, however, retains overall responsibility for the operation of the ride. Unless the No. 1 Operator is incapacitated, or in certain specific circumstances, such as a person is in the water or a raft is capsized, it is clear that the No. 2 Operator does not have authority to complete certain tasks, such as responding to operational issues and shutting down the ride, except at the direction of the No. 1 Operator.

185. The training provided to staff for the No. 2 Operator role involves both verbal and visual instruction on each of the requisite areas whilst at the ride. The trainee is required to read through the Operations Procedure Manual, and any memorandums or addendum to the procedure, which are maintained in a folder at the ride. At the completion of the training, both the trainer and trainee complete and sign the Attractions Training Register.

 

[Jamberoo Fan]

TRAINING & OPERATOR PROCEDURES

Spoiler

TRRR Position Responsibilities and Training

Ride Operator Level 3 (No. 1) 

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186. The No. 1 Operator for the TRRR held primary responsibility for the operation of the ride, as well as supervisory duty for the No. 2 and No. 3 Operators.

187. Unlike the other positions for the ride, the training for the No. 1 Operator at the TRRR, consisted of a full day (8 hours approximately), which was carried out onsite with an Instructor whilst the ride was in operation.This training was described by Mr. Nemeth as ‘onsite training and they’re showing you step-bystep what to do and then you have to demonstrate that you can operate the ride in front of the instructor’. The Instructor takes the trainee through the operating procedure manual whilst onsite. The following day, the Instructor also observed the No. 1 Operator to open and close the ride.

188. The discrepancy of the training provided to the No. 1 and No.2 Operator is said to reflect the greater responsibility placed on the No. 1 Operator, who is responsible for the operation of the ride, and has some supervisory capacity over the No. 2 Operator. This was generally understood by staff trained in both positions of the ride.

189. The Operations Procedure Manual for the ‘Rapid Ride Operator’ consisted of 18 pages.It largely mirrors that of the No. 2 Operator with respect to the load and unloading of guests, however, primary control for the operation of the ride rests with the No. 1 Operator, including decisions as to operational issues and the actions of the No. 2 and 3 Operators.280

190. Relevant further portions of the Operating Procedure Manual for the No. 1 Operator are as follows:

3.4 Operating Problems

3.4.1 Any operating problem must be reported immediately to your Supervisor if it has the potential for risk to either:

1. Guest/Staff safety or well being
2. (ii) Ride operating condition
3. (iii) Damage to ride equipment

3.4.2 Operator Initiate Shut Down

The Rapid ride must be shut down if any of the following occur as directed by a Supervisor

1. Loss of power to one or both pumps
2. Loss of power to the conveyor
3. Conveyor chain break
4. Raft stall bottom of conveyor
5. Raft jam
6. Raft slips on the conveyor
7. Load/unload jacks jam closed
8. Any situation where this is a risk of serious injury to Guests or Staff
9. Any situation where there is risk of damage to ride equipment

3.4.3 Shut Down Operation

1. Press Emergency Gate Button
2. Press Conveyor stop
3. Press Emergency stop
4. Remove dispatch isolator key
5. Contact control on 325 stating ‘Rapid Ride – Code 6’ and advise why shutdown was initiated e.g. loss of power to conveyor
6. Direct Load operator to attend the bottom of the conveyor
7. If a deckhand is present direct them to attend the queue line and advise guests of delay as per 3.8.5
8. Count how many rafts are retrieved (from conveyor to dispatch control panel area)
9. Await further instructions from a Supervisor
10. Advise guests of an operational delay as per section 3.8.5
11. Record downtime 

NOTE: In the event of persons in water and or Raft capsized follow emergency procedure sections 3.6.2

NOTE: Number of rafts in circuit is vital information for shutdown procedure. Supervisors will contact operators to determine exactly how many rafts are left in circuit to retrieve

3.4.4 Two (2) Rafts Dispatched Together

1. Press emergency gate button
2. Stop dispatching
3. Contact a Supervisor via Control stating ‘Rapid Ride – Operational’
4. Monitor raft movements via video camera
5. Await further instructions from Supervisor

3.4.5 Loss of Air Pressure (Low air alarm)

1.Stop dispatching

2.Contact a Supervisor via control stating ‘Rapid Ride – Code 6’

3. Press Emergency Gate Button

4. Remove dispatch isolator key

NOTE: The dispatch isolator key must be retained by the operator at all times when the operator is away from the operator’s panel

5. Tie the front raft to the deck railing at the end of the dispatch control panel area

6. Insert dispatch isolator key

7. Retrieve all rafts in circuit

8. Unload guests (only if safe to do so)

9. Switch off one pump by pressing red pump stop button (north or south) (x) Advise guests of an operational delay as per section 3.8.5

10. Await further instructions from a Supervisor (xii) Record downtime

3.4.6 Motor over Current

NOTE: Audible and visual alarm will activate when current is over 500 amps

1. Stop dispatching
2. Contact a Supervisor via control stating ‘Rapids – Operation ASAP’
3. Retrieve all rafts in circuit
4. Remove dispatch isolator key
5. Advise guests of an operational delay as per section 3.8.5
6. Await further instructions from a Supervisor (vii) Record downtime

3.4.7 Video Monitor Failure

1. Stop Dispatching
2. Contact a Supervisor via Control stating ‘Rapids – Operational ASAP’
3. Retrieve all rafts in circuit
4. Remove dispatch isolator key
5. Advise guests of an operational delay as per section 3.8.5
6. Await further instructions from a Supervisor
7. Record downtime

NOTE: The Emergency stop button located on the pole at the unload station will stop one pump and the conveyor when pressed

3.4.8 Raft stall bottom of conveyor

NOTE: conveyor will automatically stop in the event of a raft stalling at the bottom of the conveyor. An audible alarm will be heard from the panel and conveyor reset button will illuminate

1. Press Emergency Gate Button
2. Press Conveyor stop
3. Press Emergency Stop
4. Remove dispatch isolator key
5. Contact Control on 325 stating ‘Rapid Ride – Code 6’ (vi) Direct Load Operator to attend the bottom of the conveyor
6. If a Deckhand is present direct them to attend the queue line and advise guests of delay as per 3.8.5

NOTE: Operators are not permitted to restart the conveyor. This must be done by Engineering and/or Supervisors

3.4.9 Conveyor chain break

NOTE: Conveyor will automatically stop in the event of a chain break. An audible alarm will be heard from the panel and conveyor reseat button will illuminate

1. Press Emergency Gate Button
2. Press Conveyor stop
3. Press Emergency Stop
4. Remove dispatch isolator key
5. Contact Control on 325 stating ‘Rapid Ride – Code 6’ (vi) Direct Load Operator to attend the bottom of the conveyor
6. If a Deckhand is present direct them to attend the queue line and advise guests of delay as per 3.8.5

NOTE: Operators are not permitted to restart the conveyor. This must be done by Engineering and/or Supervisor

191. In relation to the Periodic checks, which are set out at 3.7 of the No. 1 Operator Procedure Manual, the requirements mirror those of the No. 2 Operator. The only addition is section 3.5.13, which requires the No. 1 Operator to ‘monitor all operator movements, ensure staff rotate operating positions throughout the day(where possible).’

192. In relation to the required response to Emergencies, which is set out in section 3.6 of the Manual, the same process as that of the No. 2 Operator is followed, however, the No. 1 Operator is also required to count how many rafts are retrieved and record the down-time for the ride.

193. Each of the Ride Operators, who had been trained on the ride, noted that a requirement of each of the roles was to watch the water level. This was done by looking at an informal ‘scum’ mark around the trough of the ride, as well as the buoyancy of the rafts at the load and unload station, and whether they were sitting on the rails.

194. It seems to be the consensus amongst Ride Operators, that the TRRR was one of the most stressful rides to operate because of the difficulty and demands on the Operators, which included monitoring of the pumps, CCTV, air pressure of the gates and queue lines. Generally, it appears that more experienced Ride Operators would be rostered to run the ride.

Memorandums for the TRRR

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195. In addition to the Operator Procedure Manual for each position of the TRRR, memorandums were issued by the Supervisory Team to inform Ride Operators of changes to procedure, draw attention to an issue that had arisen on the ride, or to clarify roles and responsibilities. It became apparent during the inquest hearing that there were no records maintained, and therefore no way to ascertain with any certainty, who had authored a particular memorandum and what the reason or purpose was for such a document to be created. According to Mr. Fyfe, who was responsible for the Supervisory Team that authored the document, each memorandum was supposed to be provided to him for final approval.Unfortunately, in practice, it appears that he had no direct knowledge of who wrote each memorandum, the specific reason it was created, and whether a process of consultation between the Supervisors had been undertaken prior to a memorandum being published. He would occasionally author some memorandums himself.

196. According to Mr. Fyfe, memorandums were generally issued if there had been a change of ride operation, which could follow from advice provided by the E&T Department as there were equipment or mechanical changes to a ride, or from the Operations Department.

197. A copy of an issued memorandum was kept with the Operating Procedure at the ride, and also where staff first attended in the morning on the memo board. If it was deemed a significant memorandum (although there was no clear guideline on how this was determined) staff were required to sign off that they had read it before they are able to operate a ride.

198. The relevant memorandums that had been issued and were in effect for the TRRR at the time of the tragic incident, are detailed below.

12 February 2016

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199. A ‘priority urgent’ memorandum was issued by the Supervisory team to all Operators and Load Operators for the TRR, titled ‘TRR New buttons’. The memorandum stated that:

When doing your morning checks, the conveyor control panel has changed. We must now check the e-stop is out and the three switches below the e-stop are in Auto, Forward and Run.

The Rapid Ride panel has been now fitted with a new Blue Button (conveyor reset) this is for engineering only.

Two new sensors have been fitted at the bottom and half way up the conveyor. In the event of a raft slipping or becoming stuck at the bottom of the conveyor for more than 10 seconds, the conveyor will automatically stop and the blue ‘conveyor reset’ button will flash. In the event of this happening normal shut down procedure must be followed.

Also we have a new e-stop on the unload platform, this will stop the conveyor. Operators and load operators CAN press this ONLY in the event of an emergency, as the emergency shut down procedure must follow.

Any further questions please see the supervisory team.

200. In relation to the memorandum dated 12 February 2016, this was issued by the Attractions Supervisory Team as a collective document, which was primarily prepared by Ms. Crisp and Ms. Tracey McGraw. This memorandum was said to have been issued following modifications made to the ride, including the installation of sensors on the conveyor and a new E-Stop at the unload area, however, the Operating Procedures were yet to be updated.

201. The term ‘emergency’ was not defined in the document. Each of the Supervisors who provided evidence during the inquest gave somewhat different definitions of what an ‘emergency’ may have meant. There was clearly no universally understood meaning of “emergency” that would have been easily understood by Ride Operators stationed at the TRRR.

202. The wording of this memorandum is confusing, poorly defined, unclear and at its highest, ambiguous and couched generally in negative terms. It is a significant oversight that the term ‘emergency’, which is highlighted in the document in connection with the use of the E-Stop, is not defined with examples provided. It is entirely reasonable and foreseeable that Ride Operators and Supervisors
would have differing views as to what circumstances this direction may apply in,
which became evident during the evidence provided at the inquest. This is so
especially for newly trained or inexperienced Operators

29 May 2016

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203. A further ‘priority urgent’ memorandum was issued to all Rapid Ride Operators and Load Operators by the Supervisory Team, which was titled, Monitoring conveyor movements’. This memorandum provides that: To All Thunder River Rapids Operator and Load Operators. Please ensure you are remaining vigilant when monitoring conveyor movements. This includes any obstructions that may interfere with rafts such as bent or broken brackets. If you identify an issue of this nature, Operators are to bring all rafts home and call for an ‘Operational ASAP’ via control on 325 and wait further instructions from a supervisor.

204. According to Supervisor, Ms. Jennie Knight this memorandum was issued following a clip coming off the conveyor, which was subsequently replaced. Ride Operators were requested to be mindful in case another incident occurred.

18 October 2016

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205. A further ‘priority urgent’ memorandum, also couched in negative terms, was issued to Rapid Ride Operators and Load Operators by the Supervisory Team, which was titled, ‘Unload E-Stop’. This memorandum stated:

All Thunder River Rapids operators and Load operators,

The E-Stop situated at unload platform must only be pressed in the event the main control panel cannot be reached when there is potential or immediate risk either: (emphasis added)

1. Guest/Staff safety or well being
2. Ride operating conditions
3. Damage to ride equipment

Activating this will cause the rides conveyor to stop.

206. According to Ms. Knight, whilst she did not specifically draft this memorandum, she is aware through consultation that it was created as there was a misunderstanding amongst Ride Operators as to whether the E-Stop at the unload area stopped the conveyor and one pump or just the conveyor.

207.It is significant that, despite being the Attractions and Entertainment Manager, whom the Supervisors answered to, Mr. Fyfe had no knowledge of the memorandums issued in relation to the TRRR, and was unable to advise who had authored the documents or the reasons each of them were issued. He acknowledged during the inquest that the wording of this memorandum was ambiguous, especially for a first day Operator.

208. When this memorandum is read in conjunction with sections 3.1.7 and 3.6.3 of the Operating Procedure Manual, it is clear that the direction to the No. 2 Operator is that the E-Stop is only to be pressed in the event that the No. 1 Operator is incapacitated, and under no other circumstances. Mr. Fyfe agreed with this interpretation during the inquest. It is very clear from the Operating Procedure Manual that the No. 1 Operator is responsible for the operation of the ride, which includes the command of Code 6 situations, where they are not incapacitated.

 

Pre-ride Checks on the TRRR

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209. Under usual conditions, when the No. 1 Operator arrived at the TRRR to open for the day, they attended the Main Control Panel to carry out the pre-start checklist.303 This checklist required that the Operator check the following: 

1. Engineering have signed the checklist signaling that they had completed the necessary checks of the ride;
2. That ‘Area Open’ has signed;
3. Check that the Rapids Alarm has been tested; 
4. That the access area is clear;
5. Fire-Extinguisher is charged and tamper seal is in place;
6. The First Aid kit is stocked; and
7. That Ride Express equipment is present.

210. The Pre-Operational service sheets, which are to be completed daily by staff from the E&T Department, reflect the service checks conducted on rides. Each item listed on the sheet needs to be considered and inspected by the allocated staff, and is specific to each ride. Each component of the ride to be inspected is initialed by the staff members responsible. If an issue is identified with a ride during these checks, depending on the complexity, it will often be escalated to an E&T Supervisor to determine whether it needs to be fixed immediately or at a later time. To ensure the service sheets are being completed, an audit is conducted by supervisors every Tuesday. The TRRR requires the check of around 40-50 items each day. In addition, since early 2016, there are weekly checks conducted of the sensors installed at the bottom of the conveyor.

211. The Ride Operator is then required to sign the checklist to signify that the above had been completed. If there is an issue with any of these actions, an Operator is required to call a Supervisor for them to rectify the issue. If the checklist is missing a signature from the E&T Department, the ride will not be opened to the public.

212. As part of the start-up, the Ride Operator is also required to do the following:

• Check that three switches are in the correct position, and that the Emergency Stop on the control panel is not activated.
• Turn the control panel on with a key;
• Place the isolator key in the control panel;
• Press the jack reset button to activate the jacks;
• Commence the automatic-sequence start-up for the water pumps, which takes approximately 7 minutes for the South Pump to automatically start; and
• Dispatch an empty raft as a test-run before guests are allowed to board the ride.

213. At the TRRR, a folder with various documentation was maintained. From an E&T perspective, this folder contained two weeks’ worth of daily checklists.Downtime sheets recording when a ride has been out of operation (e.g. shutdown following a breakdown) are stapled to the back of the sheet. The down-times for each ride are subsequently entered into a computer spreadsheet by a Supervisor, with older sheets being removed each Sunday and replaced with a new sheet.

214. Decisions as to when rides are closed due to operational issues or following a breakdown was a matter for E&T Department Supervisors. E&T staff are the only ones permitted to restart a ride. Once they restart the ride, the Operator does not go through the start-up checklist again.

Emergency Scenario Training

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215. Whilst emergency response drills have previously been carried out at Dreamworld for the Buzzsaw ride and a Tiger escape, no practical scenario training for emergency situations were ever implemented for the TRRR. This is despite recommendations made following previous incidents that this should take place.

216. It was noted by Ride Operators of the TRRR that whilst responses to emergency situations, which may arise on the ride, were outlined in the Operator Procedure Manuals, no practical scenario training was provided to equip Operators with the means to respond to various operating problems.

 

Edited February 24, 2020 by Jamberoo Fan

[Jay Jay The Jet Plane]

Just confirmed via 9 News Live Stream on FB

 

Memorial Garden will built at Dreamworld 

Construction timeframe for the garden will be finalised in the coming months

[Jamberoo Fan]

PAST INCIDENTS ON THE TRRR

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217. Documentation provided by Ardent Leisure over the course of the coronial investigation, and also produced during the inquest hearing, confirmed that there had been a number of previous incidents on the TRRR over the course of its 30 year commission. A summary of the most relevant incidents is detailed below.

18 January 2001 – H101/0019 – Property Damage

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218. On 18th January 2001, Ms. Melinda Lynd was rostered to perform the role of No. 1 Ride Operator on the TRRR. She commenced the start-up procedure at approximately 9:17 am, releasing all of the rafts to run a full cycle, prior to opening the ride to guests. She was the only Operator present at the time. At around 9:30 am, Mr. Joe Stenning, who was rostered on as the No. 2 Operator for the TRRR that day, arrived and opened the queue line for guests. Whilst the empty rafts were travelling the water course, guests had commenced lining up. As Ms. Lynd began speaking to guests in line, two rafts became stationary at the unload area, with a further three traveling down the conveyor, having completed a full cycle of the ride. This was noticed by both Ms. Lynd and Mr. Stenning, however, no attempt was made by Ms. Lynd to release the stranded rafts. As the three additional rafts came off the conveyor, they collided with the stationary rafts, causing one to flip. Having seen the rafts flip, an operational Code 6 was called, at which time Ms. Lynd called 222 and tried to describe the incident, which was not clear. She then hit the emergency jack button and stopped the conveyor. The rafts were unable to be freed. Senior Attractions staff arrived at the TRRR shortly thereafter, and guests were cleared from the area. The following photographs of the aftermath of the incident depict the scene.

2001 INCIDENT - Ex. B10(1)

219. Ms. Lynd commenced employment with Dreamworld in the late 1990s, and had been a Ride Operator for around five years prior to the incident. She recalls being trained as an Assistant Operator on the TRRR on her first day working at Dreamworld. It was a few years before she was trained as the No. 1 Operator. 

220. In relation to the incident, Ms. Lynd recalls in her statement that she was very upset by what had happened, and did not believe there was anything that she could have done to prevent it from occurring.

221. Mr. Stenning had been working at Dreamworld since 1999 as an Attractions staff member, which included the operation of some of the simpler rides. He recalls being trained as a Deckhand and at the unload station of the TRRR, however, never manned the control panel or was taught to shut down the ride.

222. Mr. Stenning recalls that following the incident, he was taken away from the area separately to Ms. Lynd, and was not able to speak about the incident whilst the investigation was pending. He believes that he may have participated in a debrief discussion following the event.

Incident Report

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223. An investigation into the cause of the incident was conducted and a report compiled (‘the Report’). It was found that, ‘the push of the conveyor caused a compaction effect, resulting in the rafts being caught at the unload area and one raft flipping. It is then believed that the unload button may have been depressed releasing a raft, but the second raft with the push of the additional rafts behind had got caught on the edge of the platform’.

224. The incident was identified as a ‘dangerous event’, following which OIR were called. Having explained the sequence of events verbally, it was determined that no formal notification was required. The Report notes that ‘the response team including TBS, RB, BT, SH & AN identified the incident as a dangerous event and at 10:08 am AN contacted the Workplace Health & Safety – South Coast Division and was put through the Dave Mazzer, District Manager Workplace Health & Safety (Southport). The sequence of events was explained by mobile phone. Dave responded that he was confident with DW’s own internal investigation process and requested that a file be kept that a courtesy call was made to the Division. No formal notification was required.’

225. The contributing factors with respect to the actions of the Operator, were found to be as follows:

• Distraction from guests – attention was diverted from operating ride.
• Second employee stuck – there should have been two Operators start the ride at 9:15 am.
• Employee panicking – Operator responded inappropriately. Lack of confidence to make own decision in an emergency situation (when it was noted that she is the more Senior Operator). 
• Communication – employee did not relay details of events satisfactorily to Control or Supervisors.

226. The final outcome of the incident was determined to be that there had had been a failure to adhere to the start-up procedure, and the Operator had not followed the correct emergency response procedure. As part of the investigation into the incident, the Report notes that a review of the operational procedures of the TRRR was conducted, and that the possibility of the same event occurring whilst guests were on the rafts was held to be ‘nil’. This conclusion was based on the following reasoning (assuming the correct operating procedures were being followed):

• There would have been two people operating the ride;
• No loaded rafts are to be dispatched without the second Operator being present, which would eliminate the rafts banking up at the unload area. The Deckhand has control of the unload of guests and the flow of rafts through to the unload area;
• The dispatch time between the rafts would have been greater, giving the Deckhand and No. 1 Operator more time to react to the situation; and
• The Deckhand would have seen the situation as it was evolving and been able to react in a more timely fashion and/or followed correct emergency procedures.

227. A review of the training procedures for the TRRR and Ms. Lynd’s records were also undertaken as part of the investigation. It was noted in the Report that she had been trained by Mr. David Wilkinson, a Relief Supervisor (who was an accredited trainer, and staff member for 12 years), and subsequently audited by Mr. Garren Cox, who was an Attractions Supervisor and Training Coordinator.

228. It was further acknowledged that there had been a breakdown in the communication process and notification by way of the two-way broadcast. That was because the incident was not called in as a ‘Code 222-Grey’ but rather dubbed ‘operational’.

229. During the inquest, Mr. Stenning stated that he was not made aware of the findings of the investigation report following the incident.

Recommendations

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230. The following recommendations were made following this incident:

• Emergency Response Scenario Training for all Ride Operators in the various Code 222’s in order to improve confidence when involved in an emergency situation.
• Communication – a review of determining notification of broadcast from Code 222 phone calls.
• Human Resources to be involved in disciplinary action in regard to incorrect operation of ride.
• Amend procedure so that both Operator and the deckhand should be present to start ride (opening and operating procedures) on all occasions.

231. Following the incident, Ms. Lynd was moved into a position working in the Food and Beverage division of Dreamworld, however, resigned shortly thereafter.

Comments About the Incident

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232. From the extensive documentary exhibits provided by Ardent Leisure, and the evidence given during the course of the inquest, it does not appear that the investigation into this particular incident extended to consider the design of the ride, although subsequent modifications were made to the unload platform.

233. I am satisfied that a thorough engineering hazard or risk assessment of the ride was not conducted as a result of this incident. Engineering staff, who were employed at the time, were not consulted as to whether any modifications needed to be made to the ride to ensure a similar incident did not reoccur.

234. Despite the recommendations of this incident, no practice scenario-based training for emergency situations was ever provided for the TRRR, or any other ride at Dreamworld prior to the subject tragedy. It is unknown why this recommendation was never implemented. A thorough review of this incident would have presented a timely and graphic reminder to all safety staff as to what, potentially, could have occurred once a raft blocked the passage of following rafts coming down the conveyor. It is fortunate there were no passengers in the rafts at the time.

 

7 October 2004

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235. At around 3:05 pm on 7 October 2004, a raft on the TRRR entered the unload station and patrons started to disembark. As the final passenger was leaving the raft with the assistance of an Operator, another raft entered the unloading dock and made contact with the stationary raft. The passenger lost her balance and fell into the water, passing under the raft. A fellow passenger and the Ride Operator entered the water to provide assistance and retrieve the guest. No injuries aside from subsequent neck pain were sustained by the passenger.

236. OIR were notified of the incident via telephone on 7 October 2004. No statutory notices were issued under the condition that the incident was internally investigated by Dreamworld, and engineering controls to prevent the incident from re-occurring were considered. 

237. It appears that the incident was investigated by Dreamworld, with a report subsequently prepared. The contributing factors to the incident were identified as follows:

• Raft spacing – during normal ride operation, the rafts are released from the loading dock at uniform intervals, which is designed to prevent contact between the rafts allowing patrons sufficient time to disembark. However, extra time taken for passengers to disembark from a raft or a difference in the speed at which the rafts travel, can cause the rafts to ‘queue up’ and make contact at the unloading area.
• Engineering control – the Report noted that ‘at the time of the incident, administrative procedures and engineering controls were employed to prevent rafts contacting. However, the ride could be improved by implementing further engineering controls…’
• Operational factors – the efficiency and time required to disembark passengers from the raft at the end of the ride is related to the experience of the Operator. Video footage of the incident suggests that the Ride Operator assisting guests to disembark, who was relatively new, may have ‘struggled’ to be meeting the unloading demands. 

238. A number of short-term and long-term corrective actions were identified to ‘more adequately control the risk of raft collision’. These actions included:

• Installation of emergency stops: It was noted that an additional emergency stop button had been installed in the un-loading dock, which shuts down one of the two main pumps circulating water through the ride. Further investigation was to be ‘directed towards ‘double pump’ E stopping’, which was intended to immediately shut down both pumps to ‘rapidly dissipate the water’. 
• Fewer rafts circulating the ride: It was noted in the Report that a ‘timer permitted dispatch is scheduled for installation by late 2004’, which would release rafts at the loading dock at predetermined intervals. Following the incident, the rafts used in circulation for the ride was decreased from 12 to eight. A standing order was then put in place, which limited the maximum number of rafts in circulation to eight. It was noted that ‘This will remain current until the completion of improvements to the ride and further assessments indicate a higher number can be safely operated’.
• Additional raft hold gate: A further holding gate was to be positioned before the unloading dock, to ensure that a raft approaching the unload area would not make contact with another raft. This gate was subsequently installed at some time before 21 October 2004.
• Conveyor speed controller: The Report noted that ‘some investigation has already been undertaken into the possible installation of a conveyor belt speed controller. This controller (operated by the unload attendant) would lower the speed of the conveyor belt should rafts begin to queue in the unload dock. At this time, the speed controller is not considered necessary. However if collision potential is still unsatisfactory following installation of the timer and holding gate, further investigation into the speed controller will take place.’
• Power assisted raft positioners: the Report stated that ‘the process of correctly positioning the raft in the unloading dock is planned to be automated via the use of a mechanical raft positioner. The positioner will no longer require the operator to manually manoevre the raft with their arms and legs.’ The intention of this corrective action was to reduce the Operator’s ‘manual task exposure’. According to the Report, this system was in the ‘design stage’ and intended to be installed during major refurbishments of the ride in 2005.

239. In addition, operational issues were identified following the incident. Whilst the Report noted that ‘all staff required to operate the Rapids Ride undertake comprehensive training in all facets of the ride’s operation and emergency procedures’, a number of changes were subsequently made to the training regime. These changes included, refresher training to be provided to Operators, an update of the procedures manual, as well as the expansion of the auditing checklists to include an assessment of the rafts queuing in the unload dock. It was intended, according to the Report, for the operating procedures manual to be updated to include the engineering controls once installed.

240. It was also recommended, following the investigation into this incident, that Senior Ride Operators may be required to monitor the ability of the unload attendant to ‘cope’ with the unloading demands, so that those who were thought to be struggling could be provided with additional training and mentoring.

241. The Report acknowledged that at the time of the incident, administrative controls were the primary means of avoiding raft collision at the unload area. The corrective actions suggested were intended to more adequately control the risk of future raft collisions.

Further Consideration and Implementation of the Recommendations by Dreamworld

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242. Following the incident, consideration was given to increasing the number of rafts in circulation at the TRRR from 10 to 11 with a three person operation. The purpose and findings of the investigation were detailed in a Report (‘the Report’).

The Report was intended to exclude the model where only two Operators were present, as a maximum of nine rafts would continue to be used.

243. Since the incident in October, an additional holding gate had been installed at the unload area, as well as an automated timer for the dispatch of rafts to ensure they were dispatched with a minimum time lag of 30 seconds. The Report noted that ‘the combination of these controls ensures that the rafts are sufficiently separated and at no time can a raft being unloaded ever be contacted by a following raft.’ Following the implementation of these engineering controls, the number of rafts in operation was increased to nine for two Operators and 10 for three.

244. The intention of having an extra raft in use was to ensure there was an additional raft available at the load area to minimise the time guests have to wait to load a raft, which was thought to positively increase capacity.

245. An assessment was conducted of the further increase in the number of rafts. As detailed in the Report, it was found that:

• A complete circuit of the TRRR from the timed release gate to the holding gate was around 245 seconds. Therefore, if a raft is released by the timed gate every 30 seconds, the maximum number of rafts that can be in circuit between the timed gate and the first unload gate is nine.
• Due to the number of rafts that would be operational, it would require efficient running of the ride, in order to prevent an accumulation of rafts at the load area.
• If an accumulation of rafts was to occur, four could be in place between the load and unload dock before any issue arose.

246. The limitations of the assessment as to the increase in the number of rafts was stated in the Report to be that it was based on sighting eight rafts in operation with both two and three Operators. It was recommended that a trial of 11 rafts should be undertaken before final approval was made.

247. Ultimately, the final recommendations made were:

• To mitigate risk, only experienced staff should operate the TRRR when 11 rafts are in operation.
• Trials should be undertaken outside of standard operating hours to ensure no other risks are identified and to ensure timings are accurate.
• Implementation should be monitored and reviewed to ensure the operation of 11 rafts is sustainable.
• Two rafts must be taken out of circuit and stored appropriately in the holding area if the operation of the attraction is reduced to two Operators.

Comments about the Incident

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248. It is unclear from the Report, further documentary material and the evidence provided during the inquest, as to whether any Engineering input was sought for the purpose of the investigation and/or Report. On balance, it appears that those in the E&T Department did not consider the risks associated with the ride following this incident.

249. It is clear given the configuration of the TRRR at the time of the tragic incident in 2016, not all of the recommendations, particularly the further engineering controls, had been implemented. It is unclear based on the records available as to why this course was taken.

 

28 August 2005

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250. On 28 August 2005, the Unload Ride Operator observed an extended gap between the rafts arriving at the unload dock. He observed on the conveyor that three rafts were traveling on the belt together. The Ride Load Operator immediately closed the emergency jack to prevent further rafts from being dispatched, and all guests were returned and able to disembark safely.

251. Supervisors from the Engineering and Operations Departments were called to attend the incident. It was found that the first raft had taken on water, and was removed from circulation. This may have contributed to the incident by making it more difficult for the raft to transition onto the conveyor belt and a lower stance when on the water.

252. The investigation Report (‘the Report’) prepared following the incident noted that there were limitations to the coverage provided by the current CCTV monitoring system at the TRRR, which was only a single camera located beneath the Mine Ride. The Report noted that, ‘this location may be inappropriate and thus compromise the ability of the load operator monitor the belt effectively’.

253. The following recommendations and corrective actions were undertaken as a result of the incident:

(iv) Short-term

• Extensive testing was carried out to determine the cause of the water leak in the initial raft. A more comprehensive system for dewatering the rafts was subsequently developed, which was to occur four times a week (rather than three). Records of this dewatering activity were also introduced.
• In order to assist Ride Operators to monitor the conveyor belt, consideration was to be given to a second CCTV screen positioned at the unload station. The intention of the screen was to ‘solely display the conveyor belt and enable the unload operator to monitor raft spacing more effectively and consistently. Furthermore, this would also be advantageous to the load operator, who must perform numerous tasks simultaneously – many of which are cognitively draining.’
• A warning was also issued to all Attractions Supervisors and TRRR Ride Operators, which emphasised the need for Operators to monitor raft gaps and CCTV coverage of the conveyor belt prior to dispatching rafts. Operators were also advised that the Load Operator’s screen had been re-configured to ‘enlarge the view of the conveyor belt camera. This will enable more effective monitoring of raft transition onto the conveyor belt’.

(v) Long-term

• It was noted that the TRRR’s safety would also benefit from Attractions Supervisors continuing to carry out visual assessments of the Ride Operators, in particular, focusing on the required periodic checks.
• Raft floatation indicators were also being investigated by the Engineering Department in order to ‘assist operators in identifying possible water infiltration during operation’.

26 February 2008

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254. On 26 February 2008 at around 11:10 am, Ride Operators experienced issues with the raft dispatch sensor, which prevented rafts from being dispatched consistently. A Supervisor was contacted and advised of the problem. An E&T employee attended the TRRR and repaired the sensor. By this time, three rafts had banked up at the dispatch area and were resting on the emergency jack. Whilst three empty rafts were cleared by being released, there was concern that there may have been inadequate spacing. A further four rafts were released, one with patrons on board. Two of the rafts initially dispatched became jammed at the jungle section of the TRRR, which caused the other four rafts to stop, including the one containing guests. The emergency procedure was activated and the guests were evacuated without incident.

255. Following an investigation of the incident, the factors found to have contributed were:

• Breach of operational procedure: the Investigation Report (‘the Report’) noted that whilst the operating procedures for the TRRR are ‘clear and unambiguous’, there was a clear breach of the requirement to monitor rafts via the CCTV and to heed the spacing stipulations. The breach of the procedure was considered to be the major contributing factor towards the incident. The Operator admitted to being aware of the procedure and the safety implications of having rafts dispatched at incorrect intervals, saying that ‘rafts could jam or flip under these circumstances’.
• Release of rafts procedure: Whilst not considered to be a major contributing factor towards the incident, the release by the engineer of the rafts banked up at the emergency jack without appropriate spacing intervals due to the technical nature of the jack, was identified as an issue, which could be further investigated.380 
• Ride control status during Code 6: Whilst not found to be a major contributing factor to the incident, the ‘change-over’ of control of the ride between Engineering and Attractions staff was identified as a potential issue.381 256.

Ultimately, the following recommendations were made:

• Engineering: Investigate whether the electrical/mechanical systems controlling the emergency jack can be modified so as to release one raft at a time.382
• Procedural: Further definition to be provided as to when Ride Operators hand over control of the ride to engineering staff, and vice-versa.383

6 November 2014 – ‘The BUSS Incident’

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257. On 6 November 2014 at around 12:30 pm, Mr. Stephen Buss was the No. 1 Ride Operator at the TRRR. He claims that he heard the backup compressor shut down, without the sounding of a low air alarm. Around 10 minutes later, he claims that a low air alarm sounded and he stopped the dispatching of rafts, before roping and securing the 1st raft. The water level was observed to drop following the sounding of the alarm. Mr. Buss subsequently retrieved six of the nine rafts in circulation. He admitted that he had mistakenly turned a single pump off during the incident. Due to the lower water level, a raft had stopped at the unload area shortly off the end of the conveyor and was stuck on the rails, with another approaching on the conveyor. Upon noticing this, Mr. Buss claims that he turned the conveyor off to avoid a collision. Video footage of the incident, however, shows that the conveyor was only stopped after the rafts came into contact with one another with the tubes bumping as the conveyor continued to move. This accords with the No. 2 Operator’s recollection of the incident. Mr. Buss then manually restarted the pump he had turned off, retrieving the 7th and 8th rafts. He was notified by the gift stop that the 9th raft had drifted in to the reservoir, at which time he commenced a Code 6. Accounts suggest this occurred at around 12:32 pm. When Mr. Buss observed the 9th raft at the bottom of the conveyor, he decided to restart the ride in an attempt to retrieve the raft.

258. Supervisors and E&T staff arrived at the TRRR shortly after the Code 6 was called in relation to the incident. Mr. Buss, however, continued to operate the TRRR for the remaining part of that day.

259. An investigation into the incident, which was deemed a ‘serious breach of safety’, was subsequently commenced. In addition to viewing CCTV footage of the incident, staff were interviewed and a number of meetings were held with Mr. Buss. It was alleged that he had failed to follow the correct procedure for a ‘Loss of Air Pressure Alarm (Low Air Alarm)’ at the TRRR, and had subsequently restarted equipment without authorisation or direction, which had resulted in creating a significant risk to guest safety.

260. Ultimately, Dreamworld found the following in relation to the incident: 

• Surveillance footage confirmed that Mr. Buss did not follow the correct procedure for a ‘Low Air Alarm’, and had shut down a pump at the TRRR without verifying the location of all rafts in operation in the ride circuit. This led to a situation where a raft containing patrons ‘bottomed out’ at the top of the conveyor due to a lack of water supply, and an additional raft containing guests has then collided with it. This raft continued to be pushed by the conveyor until the conveyor was shut down. In shutting down the pump, footage confirmed that this resulted in a change of direction for the water at the bottom of the conveyor, which forced a raft with guests on board into the reservoir, where they floated unattended for a period of more than two minutes.
• Mr. Buss confirmed that he had manually restarted the pump he had shut down, which was not in line with the procedure for a ‘Loss of Air Pressure Alarm’ or the ‘Operator Initiate Shut Down’ procedures. This action was completed without authorisation or direction, and created a significant risk to guest safety.
• After freeing the two rafts at the top of the conveyor by manually restarting the shut-down pump, the No. 2 Operator advised Mr. Buss that there were guests stuck at the entrance of the reservoir. At this time, he escalated the incident from an ‘Operational’ to a ‘Code 6’, however, did not follow the procedure to initiate an Operator Shut Down as per the operating procedure of the TRRR. He also did not raise the ‘Rapid Ride Alarm’. Instead, Mr. Buss restarted the conveyor to capture another raft that was visible in his monitor at the bottom of the conveyor. He then called off the ‘Code 6’ claiming that all the rafts had been homed. It was noted that, ‘This raft, left sitting at the bottom of the conveyor was at serious risk of flipping due to the increased pressure from the re-started pump’.

261. Mr. Buss’ conduct was held to constitute a serious breach of safety and the Dreamworld Code of Conduct, ‘Expectations of all Team Members’. He was asked to show cause as to why his employment should not be ceased due to his conduct and concerns in relation to his ability to operate rides in a safe manner. He failed to do so and was terminated.

262. Mr. Buss was first employed with Dreamworld in 2006. At the time of the incident, he was an experienced Level 3 (No. 1) Operator for all of the rides at the Theme Park. From the various records provided, it appears that Mr. Buss was first trained as a Ride Operator on the TRRR in April 2008. During the inquest, he claimed that he had been rostered on to operate the TRRR around once a week and was very familiar with the ride. He had also previously been involved in Code 6s at the TRRR with various causes, including a pump failure and low pressure alarm. Mr. Buss, despite being one of the most senior Ride Operators at the park at the time, was not offered any retraining prior to his dismissal.

263. Despite his extensive experience, Mr. Buss described the operation of the TRRR as more difficult than other rides as there were a lot of tasks to undertake simultaneously. 

264. It does not appear that following Mr. Buss’ termination, his actions from a safety perspective were discussed or redressed by way of training with other Ride Operators.

 

PAST INCIDENTS ON THE TRRR

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13 November 2014 - Bob Tan Email to Leadership Team

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265. On 13 November 2014, following the incident involving Mr. Buss, Mr. Bob Tan, General Manager of Special Projects, sent an email to the Dreamworld Leadership Team titled, ‘Re: Ride incidents of relevance’. The email highlights some ‘peak relevant incidents’ on similar rides, following a discussion at the meeting that day concerning breaches/deviations in procedures.

266. The first incident occurred in Texas in 2013, when a woman fell from a Giant roller coaster. It was thought that she may have been of too large a size to be secured by the restraint bar. Mr. Tan noted that, ‘Actual cause still unconfirmed, but an innocent guest dies because a safety process was deficient…’

267. The second incident highlighted the incident involving Ms. Lynd in 2001, with pictures of the flipped rafts attached. Mr. Tan noted, ‘This occurred on the rapid ride several years ago, and fortunately there was no injury except for property damage. I shudder when I think if there had been guests on the rafts…’

268. The Head of the Engineering Department, Mr. Christopher Deaves, responded to Mr. Tan’s email inquiring as to how the incident on the TRRR had occurred, as he had never ‘seen or heard’ of the event. Mr. Tan responded stating, ‘scary photos huh?’. He also noted, ‘Allowing rafts to bank up against a raft at unload dock’. 

269. Mr. Deaves subsequently asked whether the risks highlighted (presumably from the Texas incident) were ongoing from seat belts being undone on rides. In response, Mr. Tan relevantly stated that, ‘No, 2 senior long service operators/instructors breeching procedures: Rapid Ride – Shut off a pump/restarted again. Also stopped conveyor, all against procedure...’

 

 

Edited February 24, 2020 by Jamberoo Fan

[Jamberoo Fan]

PAST INCIDENTS ON THE TRRR

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Further Incidents Recorded in Log Reports

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270. A number of other less significant incidents and issues, which occurred on the TRRR, were identified in Log Reports provided as part of the documentary material supplied by Ardent Leisure.

271. A summary of some of the more pertinent incidents and issues are as follows:

• 27 June 2010: A power dip caused the South Pump at the ride to shut down. The alarm was sounded by the Operators. Two rafts floated into the reservoir where they were retrieved by engineering staff. A third raft stalled between the conveyor and the unload station, and guests were unable to be safely unloaded until both pumps could be restarted.
• 30 June 2010: Report that a guest fell into the water whilst helping another guest out of the raft. Other rafts have pushed through the stopping jack and contacted stationary raft. Guest landed between the metal guard rails. Operations and Attractions in attendance.
• 16 September 2011: Reported that guest was on the ride when the raft was climbing the conveyor and has slipped down and contacted another raft at the bottom of the conveyor.
• 13 October 2012: An incident occurred when three rafts jammed together in the trough next to the sand filter. The trough was inspected and the water level was checked, and it appeared to be an issue with the dispatch of the rafts.
• 23 December 2013: Staff member was working at the unload dock of the ride, when they slipped and fell into the water on the up current side of the raft. Employee had started to be dragged under the raft, and was grabbed by the guest. Rapids ride alarm was hit and the ride stopped.
• 29 February 2016: The alarm was set off when the conveyor ceased to work. There were approximately five rafts stopped at the bottom of the conveyor. Engineers, attractions supervisors, first aid and security attended the incident. There were no reported injuries as a result. Approximately 28 guests were involved.
• 15 June 2016: Under “issues” on the Engineering Supervisors Sheet, it was noted that the Rapid Ride South Pump had a bearing failure and there was monitoring of southern pump temperatures.
• 22 June 2016: The TRRR was under service from 10 am until 11:30 am due to issues with the South Pump Flange (Code 237).

Edited February 24, 2020 by Jamberoo Fan

[jjuttp]

Just saw the report 9NEWS in Sydney.

I honestly never knew Richard Simmons ran DW.

[Jamberoo Fan]

DREAMWORLD SAFETY DEPARTMENT

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272. The purpose of the Dreamworld Safety Department was to assist with safety compliance and continually improve culture/business practice in conjunction with other Departments. At the time of the tragic incident, the team consisted of four Safety Officers, two of whom were experienced paramedics, Mr. John Clark and Ms. Allyson Sutcliffe, a First Aid Officer, Mr. Benjamin Hicks and Ms. Rebecca Ramsey, a Registered Nurse. Ms. Ramsey describes her responsibilities on a daily basis as checking the risk management system, Figtree to see what incidents had occurred around the park in order to determine what further investigations needed to be undertaken, which included risk assessments.

273. Mr. Mark Thompson was the Safety Manager (Dreamworld), and Mr. Angus Hutchings was the Group Safety Manager for Ardent Leisure. Mr. Hutchings and Mr. Davidson were responsible for ensuring that Senior Committee and Board of Director members were kept abreast of safety related issues at Dreamworld. 

274. Mr. Hutchings, as the Group Safety Manager for Ardent Leisure, had a number of broad responsibilities across various businesses, which included Dreamworld. He was required to provide support and assistance to Ardent Safety Managers as to a range of safety and risk issues at strategic and operational levels, as well as monitor group wide OHS performance and coordinate various audits, inspections and safety initiatives throughout the group.

275. As the Safety Manager, Mr. Thompson describes his role as ‘one of consultancy and advisory response’ whereby he did not have decision making powers. His responsibilities included the following: 

• Deliver training on general safety matters at induction, including basic hazard identification information;
• Deliver training on park-wide matters such as lock-out, tag out procedures or chemical training;
• Respond to management or employee issues that were raised through the Figtree system and implement control measures for hazards through the process;
• Attend meetings of Senior Leadership Team, the Safety Executive, Park Operations Meetings and Engineers Supervisors;
• Investigate workers compensation claims;
• Investigate suspected safety breaches or operating procedures for Human Resources or the relevant Departments;
• Order PPE;
• Oversee management of the First Aid Clinic; and
• Preparation of various reports.

276. Mr. Thompson did not conduct regular safety audits or inspections at Dreamworld. He states that he thought these were organised by Mr. Hutchings with external auditors or carried out by Health and Safety Representatives (also known as safety ambassadors). Whilst Mr. Thompson did not conduct any holistic risk assessments of rides having the view that the E&T Department were responsible for such matters, he did note during the inquest that individual components of rides were assessed from time to time, such as the cleanliness of the water in use for the cannons located on the walkway near the TRRR. There were no safety audits conducted, according to Mr. Thompson, as to the human components of the ride systems at Dreamworld. 

277. It is significant to note that Mr. Thompson, as the Safety Manager of Dreamworld, was not aware of the recommendations made by any external auditors commissioned by Dreamworld to conduct assessments in relation to safety of the rides and attractions, and did not have a copy of the reports commissioned. Decisions as to the implementation of external auditor recommendations were made by Mr. Hutchings, Mr. Deaves and Mr. Tan before his departure. 

278. According to Mr. Thompson, the Safety Team at Dreamworld was not structured to operate effectively. He describes his role as having a large amount of responsibility, which made it difficult for him to complete the reactive work required, let alone any proactive safety management. He notes that on a daily basis, members of the Safety Team would be ‘pulled away’ to conduct ride assessments for guests arriving at the Park or other tasks, which left the group short staffed. This meant Mr. Thompson was personally required to compensate and carry out the tasks of his delegates. This was an ongoing issue he claims he raised directly with Mr. Hutchings. Furthermore, the members of the Safety Team were primarily first aid officers, rather than experienced safety officers.

Mr. Thompson described the safety systems in place at Dreamworld at the time of his commencement as ‘quite immature’. 

279. In terms of issues associated with rides or operating procedures, Mr. Thompson stated during the inquest that whilst he would have assisted had any issues been raised with him, he does not recall this ever taking place in relation to the TRRR.

Figtree Reporting System

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280. Figtree is an electronic database that was utilised by Dreamworld at the time of the tragic incident to record any injuries, hazards or incidents that occurred throughout the Theme Park. Corrective action taken was then noted in the system. Mr. Thompson described the system as ‘reactive management’.

281. During the inquest, Mr. Hutchings stated that he wanted to introduce a risk register across the business, which would record all of the risks within each department, the perceived level of risk and also ways to control and reduce the risk. He stated that he received some ‘pushback’ for this idea. Mr. Hutchings noted that at the time, the document control systems in place at Dreamworld were ‘quite poor’, and he was concerned that there may have been a range of risk management activities occurring, which weren’t being recorded in any kind of formal register. He was advised over a number of years that the funding wasn’t available for such a register.In 2009, a new risk management system was introduced to Dreamworld, however, Mr. Hutchings noted that the system was not used as widely as he would have hoped as it was not sufficiently user friendly.

282. Mr. Hutchings acknowledged that within Dreamworld there was segmentation of knowledge between the Departments, which caused him concern as there was a perception and tendency that issues within Dreamworld were someone else’s responsibility. This tendency was not deliberate, but rather a misunderstanding as to each Department’s responsibility.

TRRR Risk Assessments

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283. From the sparse and haphazard records provided by Ardent Leisure, it appears that various ‘risk assessments’ were conducted on different aspects of the rides by members of the Safety, Operations and Attractions Departments. The template documents used for these assessments had a risk matrix, which were pre-designed and broadly applied for all of the investigations conducted. The catalyst for such assessments seem to be issues raised by Ride Operators or other staff about corrective actions or work that needed to be undertaken. 

284. Whilst the scope of these risk assessments varied somewhat, it is clear from the material provided that a documented engineering risk assessment of the ride, adequately considering the hazards posed by different components or the ride as a whole, was never conducted. This is particularly troubling having regard to the previous incidents already documented.

285. Based upon the documentation, a summary of the ‘risk assessments’ conducted on the TRRR is outlined below. Given the limited and poor record keeping and databases maintained in relation to such assessments, it is not possible to determine if any further undocumented assessments were conducted, and what changes if any were subsequently made.

286. On 9 July 2015, Mr. Deaves, Mr. Alex Navarro, Mr. Shane Green and Ms. Anneke Triebels conducted a ‘risk assessment’ of various aspects of the TRRR, including breakage of the conveyor chain and the depth of the watercourse. It is not clear what the catalyst was for this risk assessment. Ms. Horton does recall two instances were rafts had slid down the conveyor, whilst on the mechanism.

287. The issues considered and findings reached in the Risk Assessment Form are as follows:

288. The chart shows how the Likelihood (L), Consequence (C) and overall qualitative risk (R) was rated by the evaluation team. The R measurement of four for most of the potential hazards cited suggested that they were a ‘low risk’. The risk of rafts sliding backwards and colliding was found to be 12, which is in the ‘high risk’ rating and required management’s attention.

289. A further Risk Assessment was conducted on 19 October 2015, in relation to the sufficiency of the CCTV monitoring at the TRRR, which consisted of one small monitor broken up into nine screens. It was thought that a further screen would allow the Ride Operator at the Main Control Panel to have better visibility of the ride in order to evaluate the risks in the ‘ride envelope’. It is significant to note that one of the reasons for the need to be able to evaluate the risk of the ride was increased ride breakdowns in recent months.

290. Ms. Ramsay and Mr. Jason Johns subsequently attended the TRRR for the purpose of conducting a ‘risk assessment’ of the issue, which consisted of examining the monitors and speaking to the Ride Operators on shift to ascertain their thoughts on whether the change would be of assistance. The risk assessment was subsequently sent to Mr. Fyfe, and a work order generated. An extra larger screen was installed at the ride as a result.

291. The Risk Assessment Form, and findings reached, are as follows:

292. Whist a score of nine on the risk analysis matrix was found to be a ‘moderate risk’, it was noted in the risk assessment that Attractions Supervisors had the ability to source another monitor if required, and could increase the size to make it easier for Operators to see guests in rafts, guests that have the potential to fall in the water, guests in restricted areas and another potential danger that arises during the operation of the ride. It was specifically recognised that, ‘As we are unable to lose one camera, the recommendation is to have one monitor with 4 split screens and an additional monitor with 1 big screen to monitor rafts as they approach the conveyor area. This is the area that is high risk if there is a breakdown on the ride’.

 

ENGINEERING & TECHNICAL (E&T) DEPARTMENT

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293. At the time of the incident, Mr. Christopher Deaves was the General Manager of the E&T Department, whom consisted of around 40 staff members, 25 of which worked on amusement rides at the Park. He was not a qualified engineer, although he had an Advanced Diploma in Mechanical Engineering as well as trade qualifications in metal fabrication. He commenced employment with Dreamworld in April 2012.

294. As the General Manager of Engineering, Mr. Deaves describes his responsibilities as including asset management through repairs and maintenance, which includes amusement rides as well as other varied business facilities. He previously worked at Village Roadshow for 12 years as the Engineering Coordinator, where he had oversight of the Engineering Department for Sea World, Movie World, Wet ‘n’ Wild, Paradise Country and Australia Outback Spectacular. When Mr. Deaves was first recruited by Dreamworld, he reported to Mr. Bob Tan, who was the General Manager of Engineering and Special Projects. The position Mr. Deaves occupied had reportedly been vacant for some time. Mr. Tan left Dreamworld in January 2016. He is presently the Vice President of Technical Developments at PT Trans Studio in Indonesia.

295. Upon commencing at Dreamworld, Mr. Deaves found that the records and document control, including for the rides, safety systems, maintenance and training of staff, were significantly lacking, with the limited information available difficult to navigate for the purpose of retrieval, cataloguing and distribution. Compared to the document control architecture in place at Village Roadshow, Mr. Deaves described that at Dreamworld as needing to evolve, with the first step being to ensure that the right information was available. He notes that he was focused on addressing the asset management system, which was to interface with the safety management system, of which MEX was a large component. However, without a formal document and control system in place, he notes that, ‘most of the platforms to manage safety of all asset management were failing because the information always wasn’t available and it wasn’t available to everybody who needed it’. The sourcing and storage of information was also difficult, as it was not easy to locate and therefore hard to determine whether the requisite up to date information as to ride, maintenance and staffing had been maintained. Mr. Deaves commenced by trying to gather information and records to create an asset register so as to determine whether each of the rides were compliant with various specifications and the requisite Australian Standards. Once all of the information had been collated and it was determined to be adequate, he intended to develop systems to ensure this document control continued, which was still taking place at the time of the tragic incident. According to Mr. Deaves, this was an ‘enormous process’, which he estimated would take at least two years. 

296. Mr. Scott Ritchie was the Engineering Supervisor (Electrical), with Mr. Mark Watkins and Mr. Wayne Cox performing the role of Engineering Supervisors (Mechanical). Mr. Ritchie is a qualified electrician, having commenced in the role of Electrical Supervisor in 2013. Mr. Watkins and Mr. Cox are both qualified fitters and turners, with a wealth of experience.

297. Engineering Supervisors were required to manage teams of E&T staff and coordinate and supervise daily work, as well as plan maintenance to be undertaken within the Park. All of the Engineering Supervisors reported to Mr. Deaves.

298. Within the E&T Department there were qualified electricians, fitters and turners, mechanics, boilermakers, welders, trades assistants and apprentices. The electrical team, which consisted of a number of electricians, including Mr. Jacob Wilson, Mr. Quentin Dennis, Mr. Mark Palmer, Mr. Daniel Thompson, Mr. Francois De Villiers and Mr. John Lossie were specifically managed by Mr. Ritchie. Their responsibilities on any given day included the following: 

• Performing prescheduled maintenance of equipment around the park on any electrical components (which includes pumps, motors and anything electrical); and
• At times, undertaking the role of electrical ‘Park Technician’ and attending breakdowns of any electrical components of rides. This includes attending rides to resolve any issues, as well as carrying out general electrical repairs for items, such as air conditioners, power points, lighting and switches.

299. Within the E&T Team, daily pre-start meetings with all staff allocated on shift that day were generally held, conducted by the Supervisor rostered that day. Topics discussed during these meetings included who was allocated to which ride, nominations of the Park Technicians for the day, procedures and any faults that had been experienced on rides the previous day. Weekly safety meetings were also conducted, and generally took place on a Wednesday for all staff.

300. Informal ‘Take 5’ or ‘Toolbox’ meetings were also conducted, which typically occurred at least once a month to discuss specific work related issues and safety topics. These sessions were conducted by the Engineering Supervisors or Mr. Deaves, with the information discussed being placed on the Notice Board for all employees to read. Formal training was also provided in relation to specific safety issues and procedures, such as chemical training, low voltage rescues or lock-out procedures.

301. Two Park Technicians were rostered each day from the E&T Department, who were responsible for attending each of the ride breakdowns. They were required to attempt to diagnose the issue and rectify it if possible. Other specialty staff were also able to be called to assist with the issue, if necessary. The response was time-based, so extra support would be provided if a fault could not be rectified in a certain time. Whilst it was intended that one of the Park Technicians be from the electrical specialty and the other mechanical, it was sometimes the case that, due to staff constraints, both of the nominated Park Technicians were mechanical staff.

Safety Issues Identified by E&T Staff

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302. According to Mr. Wilson, an electrician, staff were encouraged to communicate any safety issues with a Supervisor at any time, which could be informing a direct line Supervisor or another of the E&T Department supervisors. If any concerns were held by a member of the E&T Department as to the safety of a ride, this was to be escalated to an Engineering Supervisor to consider having it shut down. This decision rested with the Supervisor. Mr. Lossie shared this view, stating that all employees had the authority to express safety concerns about a ride to an E&T Supervisor or Mr. Deaves. Mr. Cox reiterated this was the case, and that he would make a determination as to the further action necessary.

303. Down-time reports for rides were clipped up on the whiteboard in the Engineering workshop for all staff to consider.

304. It does not appear that ‘risk assessments’ of rides within the park were carried out by members of the E&T Department prior to the incident.Evidence provided by staff within the Department suggests that the team were delegated to develop and implement controls for a potential hazard, once this had been brought to the attention of the E&T Department. According to Mr. Deaves, he recalls participating in a few ride risk assessments in relation to components of rides at the request of other Departments, however, describes them as ‘very ad hoc’. He was unaware if there was any documentation to reflect that such an assessment had taken place. Mr. Murphy, the maintenance manager, notes that whilst no one had the specific task of conducting risk assessments on rides or specific components, it was expected that if a staff member identified a problem they would report it. 

305. It does not appear from the records available, and the accounts of senior staff, that a full risk assessment of the TRRR was ever undertaken internally by Dreamworld. Mr. Deaves states that to his knowledge, there had not been any ‘formal assessment’ of the load and unload area of the TRRR. Whilst the ride was inspected daily by E&T staff, there was no regular assessment process to proactively determine whether hazards existed on rides, including the TRRR. Rather, issues would only be considered reactively, when an incident occurred. Furthermore, staff within the E&T Department were not aware of any previous risk assessments that may have been carried out on the TRRR.

306. Mr. Deaves describes the Operations Department as owning the device or ride, and the E&T Department as the maintainers.

Training for E&T Department Staff

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307. Staff have stated that for new members of the E&T Department one on one learning sessions were provided, until a staff member was assessed as competent for a particular ride. Each person deemed competent to maintain a ride, would be noted in the log book located at the ride.

308. Staff from the E&T Department have previously participated in some training and drills for emergency response and management, which include tiger escapes and simulated emergency response drills for the Buzzsaw ride.

309. Electrical staff also participate in role specific training from time to time, including low voltage rescues, and CPR and First Aid courses (which are undertaken annually). New procedures for rides, such as lock-out tag-out training is also completed, the most recent prior to the incident being in early 2016.

Role of Junior Engineer

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310. In September 2014, Mr. Gen Cruz was employed as a junior engineer to work within the E&T Department at Dreamworld reporting to Mr. Deaves. He had an engineering degree, which he obtained in 2013.

311. According to Mr. Deaves, Mr. Cruz was recruited for two main purposes, one of which was to consider the efficiency of the utilities, such as water, gas and electricity within the Park. The second was to gather current information and data as to rides, maintenance and training. He was not employed to undertake risk assessments of the rides, and it was recognised that he did not have the necessary skills to do so. It appears that Mr. Cruz was required to consider and audit the records pertaining to each ride, referred to as ‘data mining compliance’, which he commenced with the Class 5 thrill rides. This involved identifying gaps in the information retained by Dreamworld with respect to the rides.

312. Mr. Cruz described his responsibilities as a project relating to ‘ride auditing’, by considering existing maintenance programs within Dreamworld for each of the rides, and ensuring that they harmonised with the national audit tool and were up to date with the manufacturers’ specifications, standards and regulations. He was also considering the power and water usage around the Park. Mr. Cruz states that in order to perform his role, he considered AS-3533 Part 3, which relates to in-service inspections, for which he was mentored directly by Mr. Deaves. He subsequently developed checklists, which he went through for each of the rides, in consultation with Mr. Deaves.

313. With respect to the TRRR, prior to the tragic incident, Mr. Cruz had not conducted a risk assessment of the ride, nor considered the maintenance program. He does not recall ever sighting a documented risk assessment relating to the TRRR. According to Mr. Deaves, Mr. Cruz was only a few months away from considering the TRRR as part of his audit. The difficulty associated with locating the information pertaining to the ride was that it wasn’t in a central location, but rather detailed in paper-based records, and also on individual’s computers and hard drives.

314. During the inquest, Mr. Cruz stated that he had been instructed to prioritise the nine Big Thrill Rides (Class 5 rides), with the TRRR toward the end of the list of rides to audit as it was a Class 2 ride. The decision on how rides were prioritised rested with Mr. Deaves. Mr. Deaves explained during the inquest, that Class 5 rides had more complex systems controlling them, and as such, the inspection criteria under the Australian Standards would be higher. 

315. Mr. Cruz confirmed during the inquest that he did not conduct any engineering risk assessments of any of the rides at Dreamworld prior to the tragic incident. Mr. Deaves stated during the inquest that following the mining of information being undertaken by Mr. Cruz for each ride, the next step was ‘hazard discovery’. This process had not commenced at the time of the tragic incident.

316. Following the tragic incident, Mr. Cruz’s role changed ‘dramatically’ whereby he is now more involved in the corrective actions imposed by external auditors.

Mr. Bob Tan’s Role

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317. Mr. Tan was the longest serving staff member of the E&T Department, ceasing employment with Dreamworld around 10 months before the tragic incident. He commenced working at the Theme Park in September 1987, initially as an Assistant Maintenance Controller. He held a Diploma in Mechanical Engineering awarded by Singapore Polytechnic in 1976, and whilst employed by Dreamworld, he obtained First Class Honours in Mechanical Engineering from QUT in 1992, and a Post Graduate Diploma from QUT in Project Management in 1994. He became the Technical and Services Director at Dreamworld in 1996, before being moved to Special Projects briefly in 2004. He was appointed as the General Manager of Engineering in 2007, before becoming the General Manager of Special Projects in 2014. 

318. In 2005, Mr. Tan was given the responsibility of project managing the development of White Water World, as well as the introduction of the new ride, the FlowRider, at Dreamworld. During this time, given the scope of the project, the role of the General Manager of Engineering was filled by Mr. Tony Hawkins. By 2007, Mr. Tan had returned to being the General Manager of Engineering for Dreamworld, however, in addition, he retained the responsibility of implementing new rides at the Theme Park.

319. As the Engineering Manager at Dreamworld over a number of years, which included between 2007 to 2013, Mr. Tan’s responsibilities, per the position description prepared, appear to have included the following:

• Oversee the maintenance of all rides, plant, equipment, property and operating assets; define and review preventative maintenance schedules to optimise efficiency, safety and best practice methods.
• Establish engineering methods, policies and procedures and oversee their implementation to give effect to safety policy.
• Direct the regular review of plant and equipment to ensure it meets safety, efficiency and quality requirements and report on other options available to achieve objectives.
• Implement approved safety-related actions as determined by Safety Executive Committee, QEST and audits.
• Establish the systems for and oversee the keeping of maintenance records.
• Ensure activities related to the engineering and technical function comply with relevant Acts, legal demands and ethical standards.

320. As the Engineering Manager, Mr. Tan had the authority to:

• Take actions and issue inspections that may be reasonably required to assure safety of any ride, equipment or asset; 
• Sign off on expenditure up to the delegated amount; and
• Represent the company to statutory body officials in regard to technical matters.

321. Whilst Mr. Tan held a number of different positions during his almost 30 year tenure with Dreamworld, given his expertise and experience, it is clear that he was consistently involved in the engineering aspects and decisions made at the Theme Park. Whilst he primarily reported directly to the CEO, at different times, he also had various staff reporting to him, including the Engineering Manager.

322. Mr. Tan claims that in relation to decisions as to the conduct of ‘safety audits’ of amusement ride, directives were given by the Board to the CEO, who in turn allocated such matters to the Safety Manager and Mr. Tan to implement. Records in relation to these audits were maintained by the Safety Department.

323. During the inquest, Mr. Tan stated that he and the E&T Department were responsible for conducting assessments of amusement rides at Dreamworld to the AS-3533.  He claims this was done by way of the daily inspections and ‘our regime of periodic inspections on equipment’, including the annual shutdowns. He clarified that this did not involve considering the design of the ride, pursuant to AS3533.1, but rather the maintenance requirements in Part 2 and 3. 

324. Mr. Tan left Dreamworld in January 2016 in order to accept a role in Dubai. Following his departure, Mr. Tan’s hard drive was retained by the Theme Park, as it contained a number of significant historical and current records relating to the engineering aspects and history of the rides, including drawings, manuals, incident reports, design registration documentation, as well as electrical, mechanical and structural drawings and documentation. It appears that the contents of this hard drive was gradually integrated into the broader system held by Dreamworld, however, was only accessible by E&T staff.

325. During the inquest, Mr. Tan acknowledged that given his long tenure at Dreamworld and the roles he performed, he had extensive knowledge of the engineering aspects of the Theme Park. Nonetheless, he was unable to say where information as to a safety audit conducted on a ride or decisions made to alter or modify devices were documented and retained. Mr. Tan did state, however, that up until 2000, records were maintained manually before the process of recording electronically was commenced.

 

 

Edited February 24, 2020 by Jamberoo Fan

[Jamberoo Fan]

ENGINEERING & TECHNICAL (E&T) DEPARTMENT

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E&T Department Knowledge of the Design, Modifications and Incidents on the TRRR

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326. From the accounts provided during the course of the investigation and inquest hearing, it is evident that only a scant amount of knowledge was held by those in management positions at Dreamworld, including Mr. Deaves, as the General Manager of Engineering, as to the design, modifications and past notable incidents on the TRRR.

327. Mr. Deaves was unaware as to when any of the changes to the TRRR, such as the removal of the turntable or the conveyor slats, had been undertaken, or the reasons why such alterations were made. Mr. Deaves noted that to his knowledge, there had not been any ‘formal assessment’ of the load and unload area of the TRRR. Whilst the ride was inspected daily by E&T staff, there was no regular assessment process to proactively determine whether hazards existed on rides, including the TRRR. Rather, issues would only be considered reactively, when an incident occurred.

328. It was recognised by Mr. Deaves that there were no records kept, which were easily accessible or centrally located, whereby staff responsible for the safety of the rides, both from an operations and engineering perspective, could examine and consider previous issues associated with a device. This absence of effective and complete record keeping essentially precluded any staff from being in a position to be able to appropriately and adequately assess and manage the risks, which may be present on rides, particularly those like the TRRR, which was 30 years of age. It is significant that the General Manager of Engineering at Dreamworld had no knowledge of past incidents involving rafts coming together on the TRRR. It is arguable that this lack of knowledge essentially prevented him, and anyone else, from assessing or determining risks associated with the TRRR from an engineering perspective.

329. Furthermore, it became clear during examination at the inquest that Mr. Deaves had a very limited knowledge of the operation of the ride and the various components. Whilst his role may have involved a heavy administrative and coordination component, the fact that there was no one employed at Dreamworld who was dedicated or qualified to undertake full risk assessments of the rides, including the TRRR, from an engineering and hazard perspective, is of significant concern.

330. Mr. Deaves acknowledged during the inquest that given the previous incidents, which had occurred on the TRRR, a root cause analysis should have been conducted, to determine whether engineering upgrades or modifications needed to be made to the TRRR to ensure that contact between rafts didn’t happen again. 

331. Whilst Mr. Tan, given the duration of his tenure and involvement, was expected to have retained personal knowledge of these modifications, when he left Dreamworld in 2016, records as to the alterations made and reasoning were scant and difficult to locate.

332. In relation to the TRRR, Mr. Tan claims that he had no direct knowledge of the design of the ride as it was already in operation when he commenced employment with the Theme Park. He was aware of issues associated with the rotating table initially in place on the ride, and the conveyor motor power capacity.The modifications subsequently made to address these issues were to rectify the bearings and track, as well as reducing the load on the conveyor by removing the number of slats. Mr. Tan claims that whilst he was aware that there were no manufacturer’s specifications and recommendations as the ride was built in house, the maintenance schedule and strategy for the ride was developed prior to his commencement at Dreamworld. He acknowledged that he was involved in the additions and changes made to the TRRR up until the time he resigned from Dreamworld. He further stated that whilst there was no formal process for considering holistically the component parts and maintenance suggestions for the ride, this was done.

333. In relation to the ‘nip point’ between the end of the conveyor and steel support rails on the TRRR, Mr. Tan stated during the inquest that he never identified this as an issue from an engineering perspective.

334. According to Mr. Tan, engineering controls were considered for the TRRR to stop the conveyor in the event of a pump failure, however, a safer system could not be identified. Mr. Tan noted, ‘simply stopping the conveyor if a pump failed had the potential to create new hazards and risks’.

335. Mr. Tan was unable to recall whether consideration had been given to the installation of an interlock system shutting down the conveyor automatically in the event that a raft was stranded on the support rails positioned near the unload area, shortly after the end of the conveyor for a period of time, or from a reduced water level.

 

RIDE MAINTENANCE AT DREAMWORLD

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336. For each ride, including the TRRR, daily, weekly, monthly and yearly checks by various Departments within Dreamworld were conducted. The E&T Department were responsible for carrying out these tasks at the direction of Mr. Deaves and the Supervisors.

337. Mr. Stephen Murphy was the Maintenance Team Leader at Dreamworld at the time of the tragic incident, a position he had held for 2 ½ years. He is a qualified fitter and turner.

338. Mr. Grant Naumann, a qualified fitter and turner, was the Maintenance Planner at Dreamworld, having held this position since 2007. He reported to Mr. Deaves. A position description relating to Mr. Naumann’s role describes the purpose of the position was, ‘to provide leadership, training and management of outlined reports within the technical services department and ensure all procedures are adhered to in accordance with the business.’ He was responsible for the servicing and maintenance of equipment and all buildings at Dreamworld to the prescribed standards to ensure their safe and efficient operation. This responsibility included the annual maintenance of all major rides from an administrative perspective, for which he was required to supervise the process, organize and direct staff. According to Mr. Naumann, the prescribed standards applicable to his role related to the requirements of the Original Equipment Manufacturer, AS-3533 and any regulatory requirements, for which he was not provided with any specific training.

339. Mr. Naumann states that he was hired by Dreamworld to assist with the implementation of the computerised maintenance management software, known as MEX, which included the scheduling of works on rides through work orders.

340. The MEX system allowed for preventative maintenance to be scheduled for a ride, which was manually controlled by Mr. Naumann, who was also responsible for generating the associated work orders. Whilst he was aware of the Breakdown Policy for rides, he was not notified of any breakdowns on rides.

341. According to Mr. Naumann, work orders for maintenance and changes to rides could be generated by the Safety Department or Mr. Deaves as the head of the E&T Department, following the identification of an issue, or based on recommendations made by JAK and other external auditors. A MEX ops is the avenue available for members of other departments, such as Food and Beverages or Attractions, to request certain maintenance work be undertaken. Such requests could be declined if capital expenditure was needed, which would require a supervisor to obtain the relevant permissions or for a necessary risk assessment to be carried out. To the best of Mr. Naumann’s knowledge, risk assessments of the rides were carried out by the Safety Team at Dreamworld and not the E&T Department.

342. In terms of records retained in relation to maintenance at Dreamworld, whilst log books were not maintained, daily work orders and spreadsheets were kept for each ride, with annual maintenance information recorded on a spreadsheet listing the tasks to be performed and those who had actioned it. Mr. Naumann stated during the inquest that he was only ‘vaguely’ aware of where the various maintenance tasks lists for the TRRR, as an in-house custom built ride, were generated.

343. Mr. Deaves claims that whilst budgetary constraints at Dreamworld may have impacted on requests to rectify negotiable components of the Park, such as presentation like paint work, upgrades or changes to safety systems and the maintenance of the rides were not delayed or refused due to cost.

Daily Inspection

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344. Checklists were developed for each ride listing the items that needed to be examined and inspected by maintenance and engineering staff on a daily basis. The time taken to carry out and complete the requirements of each checklist differed. It was estimated that the daily service and inspection of the TRRR was around 35 minutes to 60 minutes for two staff.

345. For the TRRR, staff were required to check a number of points on the ride including:

• Operators Report - carrying out any repairs listed
• Operation: remove ride inhibitors and E-stop lanyard function
• Conveyor: Various including chains, planks and bolts, chain-break sensor
• Raft Gates: Various including pivot bushes and pins, gate operation
• Rafts: Various including tubes check for damage, tube inflation, seating plug, seat belt security and integrity, drain rafts.
• Pumps: Spider bearings and glands
• Waterway: Various including barriers, logs and water top-up 
• Animation: Tunnel lights and animation operational
• Camera: Check operation 5 off
• Filter: back wash filter under Mine raft
• Rafts in use: Number of rafts in use circled

346. Each of these components, once checked, was required to be initialled by the competent person. These daily checks were conducted by members of the E&T Department, however, an electrician (members of this group) was generally not involved unless an electrical issue was identified by the technicians undertaking the checks. On average, it took a team of two staff from the E&T Department 40-45 minutes to complete the requisite checks daily.

347. It was noted by members of the E&T Department that the conveyor planks were checked regularly and replaced if there was any sign of damage or they were deemed to be in poor condition.

348. In the event that an issue with a ride was identified during the daily inspections, E&T staff were required to escalate it to the shift Supervisor for a determination to be made as to whether a maintenance work order needed to be generated for rectification. The urgency by which corrective action needed to be undertaken would determine the priority placed on the work order.

Daily Operator Pre Start Up and Post Operation Shutdown Sheets

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349. At each ride, a daily record of checks by Operations and E&T staff is maintained. These are designed to ensure the ‘safe daily operation of rides and correct closure at the end of the day’. Before a ride is able to be opened for the day, these inspection sheets, which also record the completion of the E&T Department inspections, in addition to the pre-operation check by the ride attendants, have to be completed. Prior to an Operator leaving the ride at the end of the day, the post shutdown checks need to be completed.

Breakdown Procedure

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350. A formal Breakdown Procedure (‘the Procedure’) was in place at Dreamworld, which outlined ‘the procedure to be followed when a major ride or piece of equipment is out of service or reduced capacity due to equipment fault or failure'. This document was authored by Mr. Deaves. 

351. The TRRR was a ‘major ride’ within the meaning of the definitions in Part 4 of the Procedure.

352. Part 5 of the Procedure provided:

• The first response to a breakdown call is to ascertain if there is any immediate danger to persons or equipment. If so, isolate the danger. If you are unsure how to do this safely, call a Supervisor BEFORE proceeding.
• If there is no immediate danger attempt to ascertain the fault with the equipment. If the fault is clearly evident and the repair can be effected within 15 minutes, carry out the repair and report to the Supervisor at the next available opportunity. 
• If there is a repeat of the fault within the next 24 hours do not attempt to rectify the fault until the Engineering Supervisor has been notified and given authority to rectify the problem.
• If the equipment is likely to be inoperable for more than 15 minutes the Engineering Supervisor must be called. 
• For any equipment that is inoperable for more than 1 (one) hour or is required to operate at reduced capacity, the Engineering Manager must be notified. If a repair or alteration is required to be performed on any control circuitry or on any other part or component of a piece of essential safety equipment. The Engineering Supervisor must be notified and an independent functional safety test should be carried out before the equipment is permitted to return to service. The Engineering Manager will report to the General Manager accordingly.
• If the cause of an issue can’t be positively identified the Supervisor is to be called and all parties must be satisfied there are no problems operating the equipment.
• At no time will any safety control systems be compromised to allow for equipment availability. Any discussion on acceptable criteria under this procedure must include the involvement of the Engineering Supervisor or the Engineering Manager. The Engineering Manager will report to the General Manager accordingly. 
• Should a fault or failure occur to a critical component the Engineering Supervisor and/or the Engineering Manager MUST be consulted to ascertain if further checks are to be carried out. 
• This procedure MUST be followed even when the fault is clearly diagnosed and seems to be of an insignificant nature. Examples of equipment requiring reporting would be: harnesses, brakes, zone and speed control systems.
• During any absences by the Engineering Manager or General Manager, a delegation of authority will remain in effect until either returns to work.
• If a device is to operate at reduced capacity or with a known non critical maintenance issue an action plan must be put in place from the person giving authority to continue operating.

353. Mr. Deaves stated that it was his intention for the Procedure to reflect that if there was a reoccurrence of a fault within a day (24 hour period), then it was to be escalated to a Supervisor.

354. There was some discrepancy in how this Procedure applied to ride breakdowns across the Park and when rides would be shut down. According to electrician, Mr. Dennis, his understanding was that if there were two breakdowns on a ride in one day, then the Supervisor was to be advised, and could decide whether the ride remained open. He states that some staff believed that it was three breakdowns in one day. Mr. Gordon was of the view that, based upon a verbal direction given by Supervisor, Mr. Wayne Cox during an early morning meeting, a fault had to occur three times before it was escalated to a Supervisor. Mr. Cox described the Procedure as follows, ‘we have a policy that if there are three faults with a ride within the same day, then we close the ride down to source and rectify the problem.’ Mr. Cruz also shared this view based upon a discussion during a meeting in October 2015, whereby it was stated that the escalation of a fault to a Supervisor was to occur after the third occasion.

355. From the various accounts provided by members of the E&T Department, there was clearly some confusion as to how this policy was to be applied, and whether a fault needed to occur two or three times before it was escalated to a Supervisor to consider whether the ride needed to be shut down for safety issues. Whilst the written Procedure was kept in the workshop, it seems that a verbal direction may have been given, which suggested that the same fault needed to occur three times before it was necessary to escalate it to a Supervisor. Regardless of whether this was the case or not, it was evident that there was a lot of confusion amongst experienced members of the E&T Department as to what the applicable policy was in relation to ride breakdowns. It appears that some members of the E&T Department had not seen the formal written Procedure for some time prior to the incident, and were relying on verbal accounts.

356. Furthermore, in relation to ascertaining what may constitute ‘immediate danger’ for a particular ride, including the TRRR, there was no specific training provided to staff nor any guidance outlined in the Procedure. During the inquest, evidence was given that staff were not provided with training as to any particular risks or dangers, which might be present for a ride, or any particular component of a ride.

Park Technician Procedure

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357. Dreamworld also had in place a Park Technicians Procedure, which was a formalised document required to be followed by an E&T staff member nominated for the role on a particular day. The reference document listed as part of this procedure was the ‘Breakdown Policy’, which it can be assumed was intended to be a reference to the ‘Breakdown Procedure’.

358. The Park Technician Procedure stipulates the following:

• On any day during park operating hours there will be at least two people/staff assigned to the role of Park Technician. One should be Electrical and the other Mechanical.
• Unless committed to a higher priority both technicians should attend a call and stay with the rectifications work until complete or otherwise directed.
• If multiple requests are received simultaneously, the Park Technicians should contact their Supervisor for assistance.
• Should the situation be, that the first call can be safely completed by 1 (one) technician, they may separate to attend another call.
• Park Technicians should have their breaks at different times to the majority of engineering staff to allow for responsibility hand over during their breaks.
• When called to a breakdown, the Breakdown Procedure MUST be followed.
• If the Park Technicians do not have sufficient experience or training in the area of need, they are to call their Supervisor for further support BEFORE undertaking any rectification work. 
• Generally, it would be expected that a Park Technician with lesser experience would be coupled with an experienced Park Technician, to assist with locations, company policies and procedures, and the decision making process. 
• Two way code will be mechanical 5 and calls will be taken directly by the technician. 
• Where practical, there should be a brief meeting between the Park Technicians and a senior staff member before the start of each operation shift.
• Topics covered during meetings should include:

- Any special events for the day/night 

- Any rides not operating or on annual shutdown

- Reported incidents

- Staffing – which staff are available/unavailable.

359. A printed copy of this Procedure was available in the E&T Department workshop. According to some staff, Supervisors often reminded them of the policy requirements during pre-start meetings.

360. Evidence from staff suggests that this policy was introduced a few years prior to the incident when the Park Technician role was established. When the policy was first introduced, E&T staff were trained in the policy. It is not clear from the recollection of staff whether refresher training was ever provided to E&T staff, either by way of targeted training or during ‘Take 5’ meetings.

361. Any repairs or rectification of issues carried out by E&T staff were recorded in the Ride Logs, which were located in a folder at each ride. The Park Technicians are required to fill out the ‘Down Time’ sheet in the Ride Log folder setting out what the issue was, what was done to resolve the issue, and the length of time the ride was not operating. The Down Time sheets were collated each day by the Attractions Supervisors who put the information contained in these documents into a report, which was emailed daily to Mr. Margetts, Mr. Fyfe and the E&T Team. The Down Time report is also given to the Park Technicians each morning, as well as were placed on the whiteboard in the Engineering workshop.

 

TRRR YEARLY PREVENTATIVE MAINTENANCE INSPECTION

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362. For each ride at Dreamworld, annual preventative maintenance inspections are conducted, which involve the shutdown of the attraction for a requisite duration, and various tasks to be completed and examined, which are stipulated on a ride specific checklist. 

363. In relation to the TRRR, the annual preventative maintenance inspection, which involved around eight E&T Departmental staff, included examination and servicing of the following components of the ride:

• Southern and northern pump, which included electrical connections at the motor; 
• Pump area for the removal of waste material;
• Screens, which include inspection for integrity, security and corrosion;
• Trough area, which includes a visual inspection of trough joints, as well as the trough gates and logs etc. for security;
• Holding gates 1-6, which includes the operation and integrity of control valves, airlines and pivot points;
• Tunnel, where the integrity and security of concrete ceiling was to be inspected; and
• Conveyor, which included the motor (megger test and record results), Gearbox (for leaks and replace oil), drive train (sprockets for excessive wear).

364. Any repairs or upgrades to a component of the ride, including replacement parts and inspections, were to be carried out during this shutdown. All task performed were documented on a spreadsheet, with the work carried out signed off by staff. This sheet was retained electronically and as a hard copy.

365. In relation to the TRRR, annual maintenance required that the ride be shut down for around three to four weeks.

Shutdown June 2016

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366. Mr. Naumann supervised the TRRR annual maintenance in 2016. He notes that the shutdown maintenance undertaken was routine, aside from replacement of the conveyor chain, which involved the removal of planks attached to the chain, so that it could be replaced, as well as some old planks replaced with new. He notes that the conveyor had a mixture of new and old planks.

367. During these shut downs, external contractors would sometimes be engaged to attend the ride to service various components, including the Danfoss Variable Speed Drives (VSD’s). The most recent occasion that this had occurred was during the shutdown on 15 June 2016, during which the following areas were canvassed:

• Back up of all drive parameters to LCP
• Check heat sink cooling fan operation
• Visual checks for ‘hotspots’, corrosion and vermin ingress
• Check all Line input and motor connections
• Check earthing and cable screening
• Replace filters where fitted
• Check internal fuses
• Check PCB plugs are correctly fitted and secure
• Remove dust and any other contamination
• Checks DC bus
• Check input & output Voltages & Currents
• Save all settings and other info

368. It should be noted that on this occasion, due to a breakdown of the south pump on the TRRR, both VSD’s could not be test run. The south pump was down for maintenance that day. Accordingly, the ‘Check input & output Voltages & Currents’ component of the schedule could not be completed.

RECENT BREAKDOWNS OF THE TRRR

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369. On the days shortly prior to the tragic incident, maintenance and down time records for the TRRR confirm that the ride had experienced a number of breakdowns, which were primarily related to an ‘earth fault’ recorded on the drive of the South Pump. The relevant circumstances of each of these breakdowns are outlined below.

 

Edited February 24, 2020 by Jamberoo Fan

[coasterdude44]

So this is the final inquest is it?

[Jamberoo Fan]

RECENT BREAKDOWNS OF THE TRRR

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19 October 2016

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370. The Down Time Report for the TRRR commencing the week of 17 October 2016, shows that the ride broke down on 19 October 2016 at 11:20 am with the cause cited as ‘South pump tripped out – alarm earth fault’. A reset test was conducted, and the ride returned to operation at 11:57 am.

371. Electrician, Mr. Jacob Wilson attended the Main Control Panel and requested backup from other members of the E&T Department, due to the nature of the ride. Team Leader, Mr. Dave Foster, Mr. Michael Stead and Mr. Mark Gordon subsequently attended the ride to assist.

372. Mr. Wilson was advised by Ms. Sarah Cotter, Attractions Supervisor, that the pump had ceased to operate by itself, and the ride had been shut down. Mr. Quentin Dennis attended the ride in support of Mr. Wilson, and went to the Control Room, where the switchboard and drives are located, to try and determine the cause of the issue. He advised Mr. Wilson over the two-way radio that the South Pump display window showed an error, ‘Earth Fault – Alarm 14’. It was decided that the ride should be evacuated, as the error required further investigation. Mr. Wilson advised the other E&T staff who had attended to assist with the evacuation of guests.

373. Once guests were evacuated from the ride, Mr. Wilson handed control of the Main Control Panel to E&T mechanical team member, Mr. Michael Stead and went to the Control Room to assist Mr. Dennis. Mr. Wilson took a photograph of the error message on the south pump drive, before attempting to reset the drive. Despite pressing the reset button on the drive, the fault did not clear. Mr. Wilson contacted Mr. Scott Ritchie, Engineering Supervisor (Electrical), and advised him of the earth fault.

374. Mr. Dennis subsequently tried to fix the error by turning the isolator switch on the front of the drive to remove power to see if it would reset. When power was restored, the earth fault had cleared. The south pump was then restarted from the main Operator control panel, and worked without issue. All the rafts were moved into the home position at the dispatch area. Mr. Wilson advised Mr. Ritchie as to the process undertaken.

375. On this occasion, Mr. Ritchie was notified and made the decision to have the ‘drive guys’ from Applied Electro attend to examine the cause of the fault. A request was subsequently made on 22 October 2016 for Mr. Michael Takac, an Electrician with Applied Electro, to attend the TRRR for a service call for the VLT. Mr. Ritchie stated that, ‘we have experienced an earth fault on two separate occasions and cannot fault the motor. We are back up and running now, however the sooner you are able to get to the site, the better.’ He was scheduled to attend site on 27 October 2016.

22 October 2016

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376. At 11:05 am on 22 October 2016, a breakdown occurred at the TRRR, which was attributed to a ‘South Pump earth fault’. This required the ride to be shut down between 11:05 am and 11:56 am. Mr. Wilson attended this breakdown with Mr. Mark Watkins. He went to the Control Room, with Mr. Watkins stationed at the Main Control Panel. He was advised that the south pump had ceased to operate by itself, however, would not be able to be restarted immediately as there were ducklings in the area that would need to be removed beforehand. Guests were subsequently evacuated from the ride.

377. Mr. Wilson noticed that the South Pump drive had the same fault as had occurred on 19 October 2016, which he photographed. He called Mr. Ritchie over the twoway radio, who subsequently attended the Control Room. Mr. Wilson performed the same reset as Mr. Dennis had on the previous occasion, which cleared the earth fault. Mr. Ritchie made a comment that he was unsure if the cooling fans were working, however, this was not a significant concern, which would warrant the ride being shut down. The south pump was then reset at the Main Control Panel, and the rafts were returned to the dispatch area.

378. Mr. Ritchie advised Mr. Wilson that he would get ‘the drive guys’ out to look at the fault. Mr. Wilson offered to megger the motors (conduct an insulation resistance test), however, Mr. Ritchie stated that this was not necessary.

379. Mr. Ritchie subsequently notified Mr. Deaves that day of the fault. According to Mr. Ritchie he told Mr. Deaves that he believed that there was an intermittent earth fault with the drive on the South Pump, and given it was the second occurrence in four days, he intended to request that external drive specialists attend to further investigate. Mr. Deaves agreed that this was an appropriate course. According to Mr. Ritchie, the TRRR was ‘the most popular ride in the Park’ and he was concerned to ensure it was operating properly. He further states that whilst he was motivated to have the drive specialist attend to investigate the fault, this was to avoid any further operational down-time not because he had any concern as to any risk posed from further faults.

380. Mr. Ritchie subsequently sent an email to Mr. David Butler at Applied Electro, the authorised service agent for the Danfoss drives in use, requesting that they attend site to investigate the recurring issue. Arrangements to have the drives looked at by external contractors was communicated by way of email to the E&T Supervisors by Mr. Ritchie that evening.

23 October 2016

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381. At 10:45 am on 23 October 2016, the TRRR broke down once again due to ‘South pump – tripped north pump earth fault’. A reset test was conducted, and the ride was returned to operation at 11:02 am. E&T team members, Mr. Stephen Murphy, Mr. Quentin Dennis and Mr. Frank De Villiers attended the Code 6 on this occasion, with Mr. Dennis and Mr. De Villiers resetting the drive in the control room, allowing the pumps to be restarted. It is not clear from the evidence provided whether an E&T Supervisor was notified of this breakdown.

382. According to Mr. Dennis, he was unaware of the fault the previous day, and had not been advised by Supervisors at the morning ‘tool-box’ talk.

383. The following day, Mr. Ritchie was made aware of the fault by way of an ‘Operations Report’, which briefly outlines any issues with rides the previous day, and is sent via email to all Operations Management Team members and Maintenance Supervisors.

Day of the Incident – 25 October 2016

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384. Specific details as to the break downs that were experienced on the day of the tragic incident are outlined further under the heading, Timeline of Events on 25th October 2016.

385. By way of a brief summary, the Down Time Report for the TRRR on 25th October 2016, shows that the ride broke down at 11:50 am and 1:09 pm. On both occasions, the reasons stated for the down time was, ‘South pump dropped out earth Fault’. The action taken by E&T staff that day was recorded as evacuating the guests and resetting the drive, following which the ride restarted.

386. Arrangements had been made by Mr. Ritchie for Applied Electro to attend site to inspect the drives on Thursday, 27 October 2016.

387. These records confirm that in the seven days prior to the fatal incident, there were five breakdowns of the TRRR, which were attributed to a failure of the south pump due to an ‘Earth fault’. On each occasion, the drive was reset without any diagnosis of the cause or further investigation being conducted.

 

Edited February 24, 2020 by Jamberoo Fan

[Levithian]

5 minutes ago, coasterdude44 said:

So this is the final inquest is it?

There is only ever one inquest by the coroner. 

Civil lawsuits will follow, plus maybe any industrial action like jail time and fines. That all depends on if OIR (office industrial relations) thinks they have enough evidence to launch prosecution. 

[coasterdude44]

1 minute ago, Levithian said:

There is only ever one inquest by the coroner. 

Civil lawsuits will follow, plus maybe any industrial action like jail time and fines. That all depends on if OIR (office industrial relations) thinks they have enough evidence to launch prosecution. 

But there isn't at this stage isn't there

[Levithian]

It seems like there is as they have referred it to them. 

Its entirely up to the OIR to decide if they will follow through with it though.

The coroner has nothing to do with civil or industrial action. They cant say someone is culpable and hand out fines. They cant prosecute someone essentially. Its an office that is supposed to stay neutral and hand down the facts as investigated.

[coasterdude44]

Keep me updated if you find anything else

[Jamberoo Fan]

TIMELINE OF EVENTS ON 25 OCTOBER 2016

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388. On 25 October 2016, the TRRR was operating with nine rafts in circulation and two Ride Operators. This is the maximum number of rafts able to be utilised with a two person Operator model. Under this model, there is a No. 1 Operator and No. 2 operator, who have different responsibilities for the manning and command of the ride. The No. 1 Operator is responsible for the operation of the TRRR, as well as the actions of the Load Operator (No. 2 operator). At all times, one operator is positioned at the Main Control Panel with the other at the unload station. It is standard practice that the Operators switch roles at regular intervals, however, the responsibility for the ride remains that of the No. 1 Ride Operator, no matter where they are positioned.

389. At the time of the incident, Mr. Peter Nemeth (38 years of age) was performing the No. 1 Operator role, with Ms. Courtney Rhianne Williams (21 years of age) as the No. 2 Operator. Mr. Nemeth was an experienced Ride Operator having worked at Dreamworld for four years prior to the incident. He had worked on the TRRR over the previous two years, initially as a No. 2 Operator for the first six months, and then as a No. 1 Operator. Training records confirm that he was trained as a No. 2 Operator for the TRRR on 21 August 2015, which took one hour and 45 minutes. He estimates that within the last year, he had operated the TRRR on 50 occasions.

390. Due to his experience and tenure, Mr. Nemeth was also a safety representative for Ride Operators, and engaged in safety audits of rides, which included the TRRR, identifying any issues of concern to be rectified. These audits were subsequently submitted to supervisors and the Safety Department for their consideration and action. Mr. Nemeth was not provided with any specific training in order to conduct audits, except by the prior representative. He participated in monthly meetings with the Safety Department and group inspections were conducted of different departments around the park. 

391. Whilst Ms. Williams had worked as a Ride Operator in both a part-time and fulltime capacity at Dreamworld since July 2015, the 25 October 2016 was the first day she was trained as the No. 2 Operator for the TRRR. She had previously been trained as a Deckhand on the TRRR in December 2015.

392. Ms. Amy Crisp and Ms. Sarah Cotter were the Relief Supervisors for the Ride Operators assigned that day. Ms. Crisp was also performing the role of Instructing Operator and Induction Presenter. As Supervisors, they were responsible for the general running of the park and attending all reported park problems, including ride operational issues, which were notified by the Security Control room. Ms. Crisp commenced employment with Dreamworld as a Ride Operator in March 2011, and was employed as an Instructing Operator on a fulltime basis since April 2012. Prior to 25 October 2016, she had trained approximately 30 to 40 people in the varied roles at the TRRR, a majority of which were at the Level 2 or 1 roles.

393. Mr. Wayne Cox was the E&T Supervisor rostered that day. Mr. Gordon and Mr. Matthew Robertson were the nominated Park Technicians. At the pre-work briefing that morning, Mr. Cox advised staff that if a ride had the same fault three times, on the third occasion then it needed to be escalated to a supervisor to investigate further.

394. Having considered the witness statements, documentation and evidence provided during the inquest, the timeline of critical events leading up to the tragic incident on 25 October 2016, are as follows.

8:00 am: An E&T Pre-Service Inspection on TRRR

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395. At 8:00 am, Park Technician, Mr. Robertson, who was a Park Technician for the day, and Mechanical Tradesperson, Mr. Kamlesh Prasad carried out the E&T Pre-service Inspection on the TRRR. The requisite checklist was completed, which requires specific components of the ride to be inspected on a daily basis, including components of the north and south pumps, gates, draining of the rafts and raft tube inflation. There were no issues with the checks conducted on that morning, and the service sheet was initialled as required.

9:25 am: Courtney Williams commenced training

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396. Having been advised that morning by the rostering coordinator that she was to be trained on ‘Rapids Load’ at the TRRR, Ms. Williams attended the administration block at 9:25 am, where she met Ms. Crisp, who was scheduled to train her at the TRRR in the Number 2 Operator position. Training was commenced in transit to the ride. According to Ms. Williams, Ms. Crisp spoke to her about the evacuation points and how to manoeuvre the rafts with her feet. 397. Upon arriving at the ride, Ms. Crisp showed Ms. Williams the first Emergency Evacuation point for the TRRR, which is near the guest line up. A walk through of the ride was conducted, where components were pointed out relevant to the role. Ms. Crisp highlighted the steel support beams around the ride, including those at the unload station, and advised her that the rafts would rest on these if the water drained out of the ride following a malfunction. According to Ms. Crisp, whilst near the conveyor, she spoke to Ms. Williams about Code 6 situations on the ride, comparing it to the responsibilities of the Deckhand at the Log Ride, which would require her as the No. 2 Operator to attend the bottom of the conveyor and speak to guests. The operation of the jacks at the unload area were also explained to Ms. Williams, as was the second emergency evacuation point near the guest line up. Ms. Williams stated during the inquest that Ms. Crisp did not explain to her about the water level dropping and rafts resting on the supporting rails, however, she was generally aware that the water level needed to be monitored.

398. Ms. Crisp then took Ms. Williams to the main Operator panel, where certain buttons were demonstrated, including the gate reset button (for a Code 6) and emergency stop button above the panel. The release of the rafts and the holding gate were also explained and shown. Ms. Crisp claimed in a response provided to OIR that she advised Ms. Williams that she could not dispatch two rafts together as the timer would prevent this from occurring. She claims that she explained to Ms. Williams that if two rafts were sent together, they could bump into one another resulting in a potential capsize. Ms. Crisp also claims that she discussed the amp readings for the pump with Ms. Williams, as well as the need for her to stop operating if the reading was over 500, and have her No. 1 Operator attend so the operational issue could be dealt with.

399. Although during her interview with the Police, Ms. Crisp seemed to acknowledge that she did not show Ms. Williams the start-up and shut down of the ride, in her statement subsequently provided to OIR, she claimed that she ‘showed Courtney how to shut down the conveyor as part of the emergency shut-down procedures.’ She claims that she explained how to shut down the ride at the Main Control Panel, and also how to shut down the conveyor at the unload station.Ms. Williams acknowledged during her interview with OIR and at the inquest that she had been shown four buttons as part of circular motion to shut down the ride on the main panel, which included two emergency stops. However, Ms. Williams disagrees that she was shown the shutdown for the conveyor as part of the emergency shutdown procedure to be followed at the Main Control Panel. She was simply shown the buttons to press during the procedure, and was not aware mechanically what those buttons did.

400. Ms. Williams was also shown the unload area, where the respective yellow poles with buttons, which open the gates in the area, were explained.

401. Ms. Williams’s induction training went for approximately 15-20 minutes, until the No.1 Operator rostered that morning, Mr. Tim Williams arrived to open the ride. Training records indicate that he had been trained as the No. 2 Operator for the TRRR on 26 September 2014. He was not trained in the No. 1 Operator role until 5 October 2016 by Ms. Cotter.

9:50 am: Operator start-up checks conducted

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402. Upon arrival, No. 1 Operator, Mr. Williams carried out the ‘Operator Pre Start-up Checks’, noting that Engineering Staff had signed the checklist. He stated that during these checks, the amps for the South Pump fluctuated and at one point exceeded 500 amps, however, a visual alarm on the panel did not activate, which should occur. He spoke to Ms. Crisp about the issue, and also sought advice from Relief Supervisor, Ms. Cotter. Whilst speaking to Ms. Cotter, Mr. Williams noticed that the south pump amps dropped back down to 420, which was in line with the north pump. Ms. Cotter contacted Mr. Francois De Villiers, who attended the TRRR and inspected the control panel. Mr. Williams was advised to keep an eye on the fault and to call E&T Department staff if the fault reoccurred or any further problems arose.

403. Ms. Williams stayed with Mr. Williams whilst he turned the ride on, however, was also observing Ms. Crisp as she demonstrated how to run the queue line. Ms. Williams recalls that she returned to the unload area and watched as the pumps began to operate. Ms. Crisp demonstrated how to stand at the unload area to ensure the conveyor was being monitored, and which buttons on the poles needed to be pressed at certain times. Ms. Crisp demonstrated the first practice run, allowing Ms. Williams to undertake the second. Ms. Crisp had to correct Ms. Williams to ensure her body was facing the conveyor and to prevent her from straining whilst guiding the raft into position. She states that she impressed upon Ms. Williams the importance of not having her back to the conveyor at the unload area. Ms. Williams undertook approximately two to three test runs before guests were traveling on the ride.

10:05 am: TRRR opens to the public

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404. The ride was opened to the public by the operators. Mr. Williams was stationed at the Main Control Panel loading guests onto the ride, with Ms. Williams (still being trained by Ms. Crisp) at the unload area, and performing the role of unloading guests. Ms. Crisp performed the first few unloads of guests, whilst Ms. Williams watched, before seeing whether she was comfortable to undertake the next round. Ms. Williams continued to perform the unloading of guests under Ms. Crisp’s watch and guidance.

405. Ms. Crisp states that she advised Ms. Williams as to the water level, and referred her to the markings on the wall. She stated, ‘As long as the rafts are bobbling around you know that your water level is enough. As soon as they’re not moving or as soon as you notice that level there drop that’s how you know your water level is right’.

406. According to Ms. Williams, whilst she was at the Main Control Panel with Ms. Crisp, the yellow case enclosing the E-Stop button at the unload area was pointed out from a distance, which at the time had Mr. Williams drink bottle on it. According to Ms. Williams, Ms. Crisp stated that this was the E-Stop button for the unload side, and words to the effect of ‘but don’t worry about it, no one ever uses it’.According to Ms. Crisp, she pointed out the E-Stop button, and advised Ms. Williams that it would stop the conveyor and a pump. She claims that she also stated that ‘the only situation you’d use that in is, say you were unloading and Tim fell in, he obviously can’t shut down the ride on himself, you can hit that to start the process rolling.’ In her subsequent statement to OIR, Ms. Crisp states that she told Ms. Williams that she could press the E-Stop if she was at the unload area and there was an emergency and the ride needed to be stopped to ‘get the shutdown started’, however, she needed to alert the No. 1 Operator. She claims that she specifically mentioned the scenario of someone standing on the conveyor or a raft slipping down in the context of explaining what an emergency situation may be.

407. At inquest, Ms. Williams stated that Ms. Crisp did not tell her that the E-Stop button at the unload area stopped the conveyor. She claims that this would have been important information for her to be told.

10:30 am: Operator positions swapped

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408. Mr. Williams swapped positions with Ms. Williams (who was still accompanied by Ms. Crisp), so that she could be trained at the Main Control Panel in the loading area. Ms. Williams describes Ms. Crisp as loading the first couple of sets of guests onto rafts to allow her to observe. In between guests boarding the rafts, Ms. Crisp is said to have taken Ms. Williams to the control panel to demonstrate, which buttons to press and not to press. Ms. Williams subsequently performed the loading of guests onto the rafts under Ms. Crisp’s guidance and instruction as to each step to be undertaken.

11:15 am: Ms. Williams completed training

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409. Ms. Williams was deemed to have completed her training as the No. 2 Operator at the TRRR by Ms. Crisp, and both signed the requisite training documents. Ms. Williams recalls that at this time, she read through documents in the folder kept at the ride, including the Operator Procedure Manual and memorandums. According to Ms. Crisp, she pointed out the memorandum relating to the E-Stop. This training was also considered to be a concurrent retraining of the Deckhand role (No. 3) at the TRRR.

410. Ms. Crisp then left the TRRR with Ms. Williams’ manning the Main Control Panel. The total time Ms. Williams was provided with training in the No.2 Operator role at the TRRR was 1 ½ hours.

11:30 am: Operator change

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411. At this time, Ms. Chloe Brix arrived at the TRRR to relieve Ms. Williams at the Main Control Panel, whilst Mr. Williams remained at the unload platform. Ms. Brix was a Senior Ride Operator, who commenced working at Dreamworld in December 2011. She was first trained as the No. 2 Operator on the TRRR in 2013, and in the No. 1 Operator position on 17 September 2015. She recalls that prior to attending the TRRR, she had spoken to Ms. Crisp, who advised her that Ms. Williams had been trained in the No. 2 Operator position that morning, and was performing well. She requested that Ms. Brix check to see whether Ms. Williams had any questions when she attended the ride.

11:50 am: 1st pump breakdown – South pump failed - Code 6

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412. Whilst Ms. Brix was at the Main Control Panel performing the No. 2 Operator position, she noticed that the water level had dropped. She called to Mr. Williams at the unload area. At this time, a raft had just exited the conveyor and entered the first jack area. Mr. Williams asked Ms. Brix to wait whilst he managed the raft and passengers. He then noticed that the raft did not move when he pressed the first jack button as it was sitting on the rails, and soon realised that the south pump was off. After telling the patrons in the raft to stay seated, he attended the Main Control Panel and commenced the shutdown procedure for the ride, which included closing the emergency jack, turning off the conveyor and pressing the emergency stop for one pump. Mr. Williams then called Control to report a Code 6. Ms. Brix attended the bottom of the conveyor to tell the passengers about the issue and to ask them to remain seated.

413. Mr. Mark Gordon and Mr. Robertson attended the ride to inspect the issue. Mr. Robertson attempted to reset the south pump at the Main Control Panel, however, this was not successful. He subsequently contacted the Electrical Department to request assistance. Electrician, Mr. Frank De Villiers attended the control room where the pump drives are located. He noticed that the drive for the South Pump had tripped and there was an alarm on it, which read ‘Alarm 14 Earth Fault’. He contacted Mr. Robertson at the Main Control Panel to advise him that he was going to try and reset the drive by pressing the reset button on the keypad where the fault was displayed. This did not work, so Mr. De Villiers decided to turn the south drive off. After allowing the drive to power down, he turned it back on, and this cleared the fault. He then requested that Mr. Robertson attempt to reset the pumps once again at the Main Control Panel, which was successful.

414. Mr. Robertson requested that Mr. De Villiers show himself and Mr. Gordon how to re-set the south pump, should the fault occur again, which he did by demonstrating the main switch (large lever) in the control room, which powered the pump motor. During the inquest, Mr. Robertson claimed that he made such a request as the Electrical team were ‘distracted that day’ by other electrical issues within the Park that needed to be resolved. Accordingly, the timeframe taken to evacuate guests had been prolonged awaiting electrical assistance, which had caused some upset. Mr. Robertson thought that if he could reset the pump himself, this would speed up any subsequent attendances.

415. Ms. Cotter and Ms. Crisp also attended the ride and made sure that the required switches at the Main Control Panel were turned off and the ride was locked out. Whilst the Engineering and Electrical staff were attempting to rectify the issue, a decision was made to evacuate the guests from the ride as some were getting impatient with rafts stranded at various places around the watercourse.

416. Once the pumps were reset and the ride restarted successfully, Ms. Cotter handed control of the ride back to Mr. Williams.

417. At a later time that day, Mr. Williams, whilst manning the Giant Drop, recalls hearing Ms. Cotter speaking to the E&T staff, whereby it was stated that if there was another failure of the pump, the ride would be closed for the day. According to Ms. Cotter the issue with the south pump had been ‘happening frequently over the last week’ following which the water level drops ‘dramatically’. The consequence of this has been that the north pump ceases to operate, which causes the ride to lose almost all of the water.

418. Mr. De Villiers subsequently had a conversation with Mr. Ritchie later that day about the pump tripping, where he states that it was decided that the South Motor would be megger(ed) on the following day before Dreamworld opened to the public. According to Mr. Ritchie, he spoke to Mr. De Villiers briefly about what may have been causing the issue and formed the belief that it was an intermittent fault in the drive and not with the motor. He advised Mr. De Villiers that the drive specialists were attending to inspect the issue on Thursday.

12:21 pm: TRRR reopened to the public

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419. The TRRR was reopened to the public, with Ms. Williams returning from her lunch break, relieving Mr. Williams. He did not return to the TRRR that day.

420. Ms. Williams recalls that Mr. Williams explained that there had been an increase in the amps reading for the pumps whilst she was on lunch and the ride had to be shut down.

1:09 pm: 2nd pump breakdown – South pump failed – Code 6

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421. Whilst Ms. Williams was stationed at the Main Control Panel, Ms. Brix, who was at the unload station, approached her and advised that the south pump light was flashing, which means that one of the two pumps had faulted. As the No. 1 Operator, Ms. Brix instructed Ms. Williams to stand at the end of the conveyor whilst she undertook the shutdown procedure. During her field interview, Ms. Brix stated that Ms. Williams was not allowed to shut down the ride even though she was stationed at the Main Control Panel at the time, as she remained the No. 2 Operator for the ride. Ms. Williams recalls that during the time the ride shut down, the water level had dropped and completely drained out of the pool, which left the rafts resting on the support railings.

422. Mr. Gordon and Mr. Robertson attended the TRRR once again. Whilst Mr. Robertson went to the Main Control Panel, Mr. Gordon attended the control room and reset the pump drive for the south pump motor, as was demonstrated by Mr. De Villiers. Mr. Robertson subsequently successfully reset the south pump at the control panel. They assisted to return rafts to the dispatch area, before evacuating guests.

423. Ms. Cotter also attended to ensure that the ride was operating correctly, before handing back control of the ride to Ms. Brix. Ms. Cotter recalls saying to Mr. Robertson, ‘What are we doing about this pump problem. This is ridiculous’. He is said to have advised her that ‘It’s our procedure that the alarm has to occur three times before the ride is shut down. If another one happens we will close the ride for the day. The ride is fine now to run.’ It does not appear that the second fault of the south pump was escalated to an E&T Department Supervisor.

1:25 pm: TRRR was reopened to the public

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424. The ride was reopened to the public with Ms. Brix stationed at the Main Control Panel and Ms. Williams at the unload station. Shortly thereafter, Mr. Peter Nemeth arrived at the TRRR to relieve Ms. Brix as the No. 1 Operator for the afternoon. He was stationed at the Main Control Panel, with Ms. Williams remaining at the unload area.

425. As Mr. Nemeth arrived at the TRRR, Ms. Cotter told him that there had been water level issues earlier in the day, as the water pump had stopped on two occasions. He was aware that there were two pumps that serviced the ride, which in the event one failed, the water level of the ride dropped dramatically. In such circumstances, the ride needed to be shut down. Ms. Cotter advised Mr. Nemeth that if there was a further issue, the ride would have to be closed.

2:00 pm: Raft 6 loaded and released

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426. Raft 6 carrying Mr. Stephen Anthorpe, Ms. Bree Dedini, Arlen Anthorpe (one year of age), Chase Anthorpe (4 years of age), Ms. Michelle Farah and Dakota Marks (4 years of age), was released onto the water course by Mr. Nemeth.

427. Ms. Williams states that at around this time, she had intended to swap positions with Mr. Nemeth, who was still at the Main Control Panel. She unsuccessfully attempted to get his attention, as she did not see a raft coming down the conveyor. When she turned around, she observed a raft coming down the conveyor, which she brought into the unloading area to allow the patrons to disembark.

2:01 pm: Raft 5 loaded and released

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428. Raft 5 carrying Ms. Goodchild, Ebony Turner, Mr. Dorsett, Ms. Low, Keiran Low and Mr. Araghi was loaded and released into the watercourse by Mr. Nemeth.

429. Between 2:01:28 pm and 2:03:35 pm, Raft 6 can be seen on CCTV footage provided by five cameras situated around the watercourse, traveling the ride without incident. At this time, the raft is picked up by the conveyor. Similarly, between 2:02:12 pm and 2:03:53 pm, Raft 5 can be seen traveling the watercourse without incident.

2:03:50 pm: CCTV captures south pump stopping

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430. Camera 14, which is positioned on a southern maintenance shed and provided a view over the south pump inlet and the descending end of the conveyor, captured the south pump ceasing to work, with water visibly flowing back into the pump outlet.

2:03:53 pm: Raft 6 descends the conveyor belt

2:04:10 pm: Raft 6 becomes stranded on the support rails

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431. Camera 14 of the CCTV footages captures Raft 6 descending the conveyor before becoming stranded on the support rails near the unload station. Ms. Williams claims that upon seeing this, she pressed the green button on the first pole in the unload area to try and open the first gate, however, this did not assist. Knowing that she needed to notify the No. 1 Operator who was in control of the ride, she claims that she turned towards the main control booth and tried to get Mr. Nemeth’s attention, as she was aware that this was a Code 6 situation.She states that at the time, he had his back to her and was loading people into a raft. Ms. Williams turned back to the guests in the stranded raft and advised them that there would be a short delay. A photograph of the guests being loaded into the raft where Mr. Nemeth was stationed was time stamped as 2:04 pm. It is evident from the photograph that the water level in the watercourse is significantly reduced at this time.

432. According to Mr. Nemeth, as he was viewing the loading area where guests were boarding the rafts, he noticed that the water level was going down dramatically, and he could see the support railings, which were normally under water. He notes that ‘it only takes a few seconds for the water level to go down enough for the rafts to sit on the rails’, following which the rafts cannot be moved. At the time, Mr. Nemeth recalls that one raft was ready to be released onto the watercourse, with a further behind it that had been loaded with guests. At the unload area, he noticed that there were two rafts waiting to be unloaded, one of which had come off the conveyor and was sitting on the supporting railings, as the water level had reduced.

433. According to Mr. Nemeth, he told the guests he had loaded into the raft that they would need to disembark as the ride could not operate. He assisted the guests to exit the raft. Mr. Nemeth acknowledges that this was a Code 6 situation, and he would need to shut down the ride and notify his Supervisor and the Control Room.

434. According to guests on the raft Mr. Nemeth was loading, it took around 40 seconds for all of the guests to be seated. A photograph of the group was taken, however, the raft did not move. One of the occupants recalls seeing Mr. Nemeth turn to the control panel, which was about a metre away, for around 10 seconds, before advising them that they needed to disembark. It was thought that he may have been using a two-way radio at this time. Mr. Nemeth is said to have mentioned that the water level was too low, and an engineer would need to come and reset the ride.

2:04:22 pm: Raft 5 is picked up by the conveyor

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435. Camera 9 at this time captures Raft 5 being picked up by the conveyor. During Mr. Nemeth’s field interview, he stated that at this time he had realised that Raft 6 was stranded on the support rails at the unload area, however, didn’t see another raft on the conveyor. He did, however, see that the conveyor was still operating. Mr. Nemeth claims he commenced the procedure for a Code 6, however, could not recall if he had called first or commenced the ride shutdown.

2:04:50 pm: Raft 5 begins to descend the conveyor

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436. Camera 14 captured Raft 5 as it began to descend the conveyor towards where Raft 6 was stranded on the metal support railings. Mr. Nemeth stated that Raft 5 appeared on the conveyor all of a sudden and he could see that it was getting close to Raft 6. He claims that he pressed the red conveyor stop button a few times (maybe two or three times) in a panic, however, the conveyor did not stop. During his first field interview, Mr. Nemeth initially claims that when he first saw Raft 5 it was just ‘over the top’ of the conveyor. He then demonstrates where the raft was at the time, and claims that it was ‘not far away from the end of the conveyor’. During the inquest, Mr. Nemeth clarified that there was between 5 to 10 metres between the rafts when he first saw Raft 5 on the conveyor.

437. According to Mr. Nemeth, the collision then occurred, which is when it ‘became really serious’, and he used the phone to call 222, which is an emergency call. He claims after he hung up the telephone, he then pushed an audible alarm, which is intended to advise all of the departments in the Theme Park to attend a ride urgently.

438. Ms. Williams claims that whilst she had her back to the conveyor attempting to communicate with Mr. Nemeth about the situation, she saw that his ‘facial expressions just completely dropped’. She turned around and saw that a raft was traveling down the conveyor, and would collide with the raft stranded on the metal support rails. She claims that she didn’t move from the unload area, as she wasn’t sure if it was a Code 6 and Mr. Nemeth wanted her to attend the deck at the bottom of the conveyor, as she had previously done during the Code 6 earlier that day. In a later statement, Ms. Williams further states that she saw Mr. Nemeth was looking over in her direction at the time, and she had assumed that he was counting the rafts so that he could inform control when he called, as is required of the No. 1 Operator.Mr. Nemeth acknowledges in a field interview with OIR that he made eye contact with Ms. Williams before he saw the raft was approaching the other stranded on the railings.To the best of his recollection, he believes that he had tried to stop the conveyor before he made eye contact with Ms. Williams. During the inquest, Mr. Nemeth acknowledged that whilst he was looking at Ms. Williams prior to the collision, he never directed or told her to activate the E-Stop at the unload platform.

2:05:03 pm: Raft 5 first contact with Raft 6

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439. Camera 14 captured Raft 5 as it first collides with Raft 6 at the end of the conveyor near the unload platform.

2:05:06 pm: Raft 5 and Raft 6 pivot upwards

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440. Camera 14 captures Raft 5 as it continues to be propelled forward by the moving conveyor belt, causing both rafts to pivot upwards.

2:05:07 pm: Raft 5 aligned with the conveyor head and support rails

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441. Raft 5 can be seen on the CCTV to continue into a vertical position with Raft 6 seen to fall back into a horizontal position resting on the rails. Raft 5 is then shaken violently, as the conveyor belt continues to rotate.

442. Ms. Williams claims that during this time, Mr. Nemeth appeared to have an empty expression, and he was just staring. She ran to the conveyor to assist.

2:05:11 pm: Ms. Goodchild is seen to fall from the bottom left hand side of Raft 5

2:05:13 pm: Mr. Dorsett is seen to fall from the top of Raft 5

2:05:14 pm: The conveyor is seen on the CCTV to start to slow down speed

2:04:22 pm: The conveyor is seen on the CCTV to cease movement

2:05:27 pm: Ebony Turner is observed to climb out of Raft 5 onto a concrete platform

2:05:35 pm: Kieran Low is observed to climb out of Raft 5 onto an employee walkway

Immediate Response to the Tragic Incident

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443. While the recollection provided by Mr. Nemeth is somewhat conflicting, it appears that immediately following the collision of the rafts, he remained at the Main Control Panel and rang ‘222’ speaking to Security Officer, Mr. Nigel Irwin. Mr. Irwin was the sole staff member rostered to work in the control room that day. His general responsibility was communications throughout the park by way of three different hard wired radios and monitoring CCTV footage. 

444. Mr. Nemeth advised Mr. Irwin that there was a ‘Code 222 Blue’ at the TRRR, and that there was a raft on the conveyor. Mr. Irwin initiated this call over the twoway radio, however, upgraded the incident to a ‘Code 222 Grey’ once he had viewed the CCTV footage, and noticed that a raft was in a vertical position.This Code alerts all responding staff that there is machinery involved in the medical emergency and ride shut down. Mr. Irwin noted that the River Rapid alarm had not sounded, which is meant to occur over every two way radio in the Park when the pumps fail. This is a manual alarm at the control panel at the TRRR, which is activated by the Ride Operator.

445. Ms. Williams, along with occupants of Raft 6 and other patrons in the vicinity of the incident, immediately helped to evacuate uninjured guests from the area. Ms. Williams crossed the conveyor to assist Kieran, who was seated next to the upturned raft, to usher him away from the scene. Mr. Danny Haber, who was queuing up for the ride, assisted Kieran to cross the conveyor belt so that he could be removed from the area.

446. Mr. Steven Anthorpe, who was in Raft 6 with his family, secured his children and immediately entered the watercourse via the conveyor to try and assist Ms. Goodchild. He saw that there was a female and male trapped in the raft. Other patrons in the area provided him with assistance, including Mr. Haber. Mr. Anthorpe immediately commenced CPR on Ms. Goodchild, and was joined soon thereafter by Dreamworld First Aid Officers, including Mr. John Clark.Attempts were made to remove Ms. Goodchild from the watercourse using a nearby garden hose, however, these were unsuccessful. As the water receded, Ms. Goodchild was dragged onto a hard flat surface, so that further resuscitation efforts could be carried out. By this time, she had ceased breathing. Chest compressions were commenced, and Mr. Clark was provided with his first response bag. Further life saving measures, including mouth to mouth resuscitation, were carried out prior to Queensland Ambulance Service (QAS) arrival at the scene. 

447. At 2:09 pm, other Dreamworld employees from all over the Park arrived on the scene and attempted to assist with the evacuation area and also securing the rafts to the conveyor.

448. A number of calls were made immediately to emergency services, the first being at 2:10 pm by Mr. Irwin. The QAS contacted QPS at 2:16 pm, who arrived on the scene within six minutes. At 2:17 pm, a QAS call taker provided instructions regarding the treatment of patients. It is clear from this phone conversation that only two patients, Ms. Goodchild and Mr. Dorsett had been located at this time.

449. A short time after QAS arrived on the scene, Mr. Irwin was contacted by Mr. Margetts via the two way radio. He requested that Mr. Irwin switch to Channel six, which is used solely by senior management. He asked questions as to how many people were in the raft. Mr. Irwin viewed the CCTV footage and subsequently advised Mr. Margetts that there were six people in the raft, however, two children had appeared to have exited the raft safely.

450. The first responding QAS officers arrived at the scene at 2:22 pm. Following this time, a further 9 QAS officers attended the scene to provide medical assistance to all of the patients involved in the tragic incident. QAS officers conducted rapid assessments of Ms. Low and Mr. Dorsett, who were trapped in the mechanism of the conveyor. Life extinct was declared shortly thereafter for Ms. Low at 2:25 pm and Mr. Dorsett at 2:27 pm. Mr. Araghi, who was still receiving CPR at the time, was also subject to a rapid discontinuation assessment, and subsequently declared life extinct at 2:33 pm. During this time, Ms. Goodchild continued to receive CPR, however, despite extensive resuscitation measures, she was unable to be revived, and life extinct was declared at 2:45 pm.

451. The actions of patrons and some Dreamworld staff immediately following the event, in what was extremely traumatic and difficult circumstances, was truly remarkable and should be commended.

Further Evidence from Ms. Williams

Spoiler

452. During the course of the coronial investigation, Ms. Williams provided a number of statements and participated in a walkthrough of the scene with OIR investigators. In addition, Ms. Williams gave evidence during the proceedings over the course of two days.

453. Ms. Williams claims that she was provided with training in respect of some hazards related to the ride, which included monitoring patron’s movements in rafts by way of the CCTV, and how to progress a raft with her foot whilst in the load and unload bays. She was also advised about the water pumps green light on the control panel and the amp readings, as the ride would stop if either pump failed. Ms. Williams was also made aware of a drop in water in the event that one of the pumps failed, however, thought the ride would stop automatically. She knew that there were no water level indicators on the ride, and Operators were required to keep an eye on the water itself. In terms of considering the written components of the 18 page Operator Procedure Manual, Ms. Williams stated during the inquest that whilst she was given the opportunity to consider the content at the end of her training session, it was only ‘briefly’ and she was required to digest and comprehend the sections herself.

454. As the No. 2 Operator for the TRRR, Ms. Williams was of the understanding that it was No. 1 Operator’s responsibility to take control of any Code 6 issues on the ride, and her role would be to attend the deck under the bridge immediately prior to the conveyor belt. Whilst she was shown some details as to the shutdown controls, it was her understanding that if she was ‘comfortable and confident doing so’, then she could undertake the four button shutdown. Given she had not been trained in the No. 1 Operator position, and had only received training for the No. 2 Operator responsibilities that morning, she was understandably not ‘100 % comfortable with being the one to shut-down the ride’.

455. In support of Ms. Williams understanding as to the role of the No. 2 Operator in a Code 6 situation, Ms. Crisp stated during her field interview that in relation to shut down procedures and reasons this may occur, it was for the No. 1 Operator to know, which is what she advised Ms. Williams. Furthermore, Ms. Crisp noted that whist showing Ms. Williams the Main Control Panel she ‘was a bit overwhelmed’ as she knew she was going to have to start moving the rafts, so they stayed at the unload area until she was comfortable. In relation to the Operator Procedure Manual for the No. 1 Operator, Ms. Williams stated during the inquest that whilst she had skimmed this manual present at the ride, she didn’t take much notice of it as she was being trained in the No. 2 Operator role only. 

456. It was Ms. Williams’ understanding that as the No. 1 Operator, Mr. Nemeth would shut down the ride, and she would be required to attend the deck near the conveyor. 

457. In relation to the E-Stop button, Ms. Williams stated that ‘in the heat of the moment’ she did not consider pressing the button, for the following reasons: 

1. It was her first day in the No. 2 Operator role at the ride and there ‘was lots to be thinking about all at once’;
2. When the incident occurred, and the raft had tipped, she was focused on the events that were unfolding in front of her;
3. It was her understanding that at all times the No. 1 Operator was in control of the Main Control Panel. Had she been directed to press the E-Stop she would have pressed it.
4. Given Ms. Crisp’s comments to her about the E-Stop, it seemed that the button was less important than the controls at the Main Control Panel; and
5. Whilst she had a general understanding that E-Stop buttons for different theme-park rides stopped the ride, she was not aware that the E-Stop at the TRRR stopped the conveyor, or another aspect of the ride.

458. Ms. Williams noted that she received no training as to what to do if a raft came down the conveyor when a Code 6 occurred.

Further Evidence of Mr. Nemeth

Spoiler

459. Mr. Nemeth was aware that the No. 1 Operator for the TRRR was ‘responsible for the ride’, which included a supervisory role over the No. 2 Operator. He received training in the No. 1 Operator position around a 1 ½ years before the incident, by Ms. Crisp. This training involved a full day operating the ride whilst being simultaneously trained, as well as opening and closing the ride with the trainer the following day.He recalls that the Operating Procedure Manual was used during the training, as he was taken through each step and then able to read it in its entirety at the conclusion of the training session. Whilst various hazards, such as the pumps or conveyor stopping, were brought to his attention, the prospects of rafts colliding were not canvassed.

460. At inquest, Mr. Nemeth noted that he had found it difficult to communicate with the unload Operator whilst at the Main Control Panel, however, had never raised this issue with the Supervisors.

461. In relation to the E-Stop at the unload area, Mr. Nemeth stated during his field interview that he was aware that it could stop the conveyor, however, was of the understanding following training that ‘it should only be used if the – if the emergency stop is not accessible on the control panel’. During a field interview, Mr. Nemeth was asked about the various memorandums relating to the TRRR, particularly that of the 18 October 2016 relating to the E-Stop. It was his understanding that this memorandum was to inform staff as to the use of the EStop, which was to be pressed in an emergency if that Main Control Panel could not be accessed.

462. With respect to the water level, Mr. Nemeth noted that there were no official markers around the trough of the ride, rather Operators used the discoloration marker around the edge to gauge whether the water level had dropped, and may be too low.

463. During training, various Code 6 scenarios were considered, including one or both pumps stopping. It was his understanding that a Code 6 applied to circumstances when the ride was not fully operational and unsafe to operate.

464. In relation to the pump breaking down, Mr. Nemeth stated that he was aware that there had been an issue with the south pump turning off, which had been happening over a number of days. This seemed to be common knowledge amongst Ride Operators.

465. Mr. Nemeth was not aware of the Breakdown Procedure, which was applicable to staff in the E&T Department as to ride closures.

466. Mr. Nemeth stated that he had pressed the conveyor stop button several times on previous occasions whilst operating the ride, and had never had an issue with it working before. He stated during the inquest that he had previously been in situations on the TRRR where the rafts had been resting on the rails due to a drop in the water level, and on these occasions, he had turned to the Main Control Panel, and carried out the shutdown procedure per the Operators Procedure Manual.

Discussion with QPS, OIR & Dreamworld Management on 25 October 2016

Spoiler

467. Commencing at 5:27 pm on 25 October 2016, shortly following the tragic incident, a number of recorded discussions took place on-site at Dreamworld with the following participants:

• Senior Constable Paul Joyce – QPS, Forensic Crash Unit
• Mr. Michael Chan – OIR, Chief Safety Engineer
• Mr. Ian Stewart – OIR, Principal Inspector
• Mr. Craig Davidson – CEO, Dreamworld
• Mr. Chris Deaves – General Manager, Engineering, Dreamworld
• Mr. Clinton Ford – Pitt and Sherry Consulting Engineers, Consulting Engineer
• Mr. Angus Hutchings – Safety Manager, Ardent Leisure 
• Mr. Mark Thompson – Safety Manager, Dreamworld
• Mr. Troy Margetts – General Manager of Operations, Dreamworld
• Mr. Scott Ritchie – Engineering Supervisor, Dreamworld
• Mr. Damien Hegarty – Kaden Borros Legal, Representing Ardent Leisure

468. A general discussion was had as to what was known about the incident at the time, the mechanism and operation of the ride, as well as further information that needed to be provided by Dreamworld for the purpose of the OIR and QPS investigation into the circumstances of the tragedy.

469. Relevantly, during the conversation the following comments were made:

• Mr. Deaves noted that there was a ‘pinch point’ at the conveyor.
• Mr. Deaves confirmed that the focus of the improvements to the ride have been at the start of the conveyor where there had been a bank up of rafts prior to the conveyor. He claimed that this was based on ‘historical knowledge’.
• Mr. Ritchie advised investigators of the PLC switches at the beginning of the conveyor, and explained that they had been installed to ‘stop the raft tip’ if a pump stopped operating causing the water level to drop, it was recognised that there was the potential to catch on the conveyor and get tipped upwards.
• Mr. Deaves claimed that there was review of the ride and testing was conducted. He recalls discussing the consequences of a pump failure, and what the best course of action would be in response to this, such as stopping the conveyor or the pumps. During these discussions, it seemed to have been accepted that the top of the conveyor, where the incident happened, was ‘ok’ as there was no historical knowledge of any problems.

That's just 1/3 of the Queensland Coroner's Findings Of Inquest so far. Hope it is convenient for you all. I'll post the other two-thirds over the coming days. In the meantime, you can read the full report via @webslave's post.

Edited February 24, 2020 by Jamberoo Fan

[DaptoFunlandGuy]

That’s a lot of stuff to stick to my fridge @Jamberoo Fan! Monster effort!

mod team - is there anyway JF’s posts can be consolidated or kept together? The random replies and multiple posts are a bit hard to read through.

[ejpdtd]

Great work guys, interesting reads for sure. 

[Levithian]

Excellent break down provided. Very well done.

The whole report is like a textbook of how not to maintain safe operational control of a theme park.

I got to about page 180 of the report before i needed a break. Its hard reading, frustrating, makes you angry, makes you mad. Its really all over the place with the complete almost cascading like failure through just about all levels of management.

Its literally like a bunch of these people got together and collectively decided nobody told them how to do their jobs, so that absolves them of any responsibility. We will just pretend theres nothing to address. 

Thats before you get to the actual findings on the ride which basically reduce it down to a few things;

Water level. Lack of automated monitoring of water level tied into a safety system that would halt the ride when water level drops below a safe level.

Lack of a single dedicated estop that halts all operation and a complex stop proceedure.

Gap between conveyor and axle to the supporting rails in the trough was an issue and should have been picked up by any competent engineer. 

Gaps between slats on conveyor. 

Staff training, competency and understanding of ride operation, largely due to inadequate operational proceedures all staff should base their training upon.

A number of upgrades were proposed that would improve operational safety. It was noted in particular that the lack of warning or automated stoppage due to water level dropping after pump failure was a direct contributor to the deaths. The danger was highlighted with previous incidents, including the last incident that lead to an operators dismissal. At no stage were these issues improved upon or addressed to prevent similar breakdown in operation of the ride both at a mechanical and operations (staff) level. On top of that, these failings were not shared with other staff and a number of managers had no knowledge of previous incidents.

There was really, really disturbing insight into the lack of documentation, error reporting and compliance that existed in most departments which was highlighted by a number of independant auditors, even when not tasked with actual ride investigation. Poor implementation of recommendations and lack of improvement were noted, though big improvements had been made in the lead up to the accident.

Basically, the short short version of what happened on the day is stuff went wrong. A Combination of existing design, uncontrolled modification, faults during operation and operation of the ride on the day contributed to the deaths. There was enough opportunity to address a number of issues which would have reduced risk or completely prevented the deaths from occuring. None of these actions were taken by ardent or park management and directly contributed to the deaths.

Edited February 24, 2020 by Levithian

[Brad2912]

And to think at the end of the day, a water level sensor - that, lets be honest, would seem like a stock standard instrument on ANY ride incorporating water - was all that was required to save 4 lives. In 30 years of operation, and probably 1000s of sets of eyes, no one thought that to be worth the pittance (in relative terms) It would have cost. 

Edited February 24, 2020 by Brad2912

[Levithian]

It was noted that at the time the above was raised in regards to implementing an upgrade the cost was $10,000. 

At this time the engineering manager acknowledged the proposal but directed that the existing plan for upgrades of sensors at the start of the conveyor preventing roll back was the focus. Nothing further was done. 

$2500 each. Someone, or a group of someones decided that our lives werent worth $2500. Lets make no mistake, while a number of failures had to occurr for the incident to play out, the report makes it clear that it was sheer luck, not good or proper management that further (or earlier) deaths had not occurred. 

$2500. Each. Let that sink in. What does $2500 buy you? A new tv? A used car? A short holiday? Its abhorrent a life is reduced to such a worthless sum.

These people ruined 4 lives directly, destroyed families in the process, exposing kids to something adults are not capable of handling, and resulted in many people, their own staff included suffering psycological trauma they are still dealing with. 

None of you should have any jobs. Many of you should be turned out for contributing directly to their deaths and face the possibility of jail time, and any penalties leveled at ardent should be so severe that any company even contemplating putting a price on the lives and safety of your guests and staff should only have to mention the name dreamworld before being instantly aware of their stupidity. 

Ill be really fucking surprised if the company is even penalised a 7 figure sum. 

And thats a god damn travesty the qld government should automatically appeal because its in the interests of the whole country that an element of justice is actually served and someone, if not multiple people have been held to account. 

Edited February 24, 2020 by Levithian