Thunder River Rapids Incident Coronial Inquest Findings

[webslave]

  On 25/02/2020 at 12:26 AM, Skeeta said:

  On 25/02/2020 at 12:07 AM, AlexB said:

MULTIPLE previous historic incidents over more than a decade as justification that the incident was VERY predictable.

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This needs to be highlighted.  

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  On 25/02/2020 at 2:13 AM, Skeeta said:

I'm not looking beyond the incident because the inquest was about the incident.    

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Which is it, Skeet?

[red dragin]

A dozen things could have been changed, any one of which could have stopped this incident. But none of those were implemented. 

[New display name]

Why do I need to repeat myself.   "I'm not looking beyond the incident because the inquest was about the incident".  (looking into the incident can include the lead up to it)

You're throwing in hypothesis that didn't happen and I'm stating the facts in this case.   Skeet is not a what if person.

DW had the opportunity to stop "this incident" years ago and they didn't.     If you want me to be a "what if Skeet' I would have to look at every ride in the park and that just scares the hell out of me. 

 

[Jamberoo Fan]

HISTORY OF EXTERNAL SAFETY AUDITS AT DREAMWORLD

JAK Leisure Company Audits

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512. In a scope of work prepared by Chief Executive Officer, Mr. Tony Braxton-Smith in January 2003, it appears that the need for a safety audit at Dreamworld was introduced, ‘for internal purposes to provide an overall assessment as to the appropriateness of internal maintenance and engineering procedures and the safety of operations.’ The assessment was intended to ‘identify any issues that may impact on continued safe operation and to provide a prioritised list of specific items for management attention’. Accordingly, it was thought that a detailed evaluation would need to be conducted of all amusement rides, attractions, as well as associated buildings and structures, with the support and assistance of maintenance and operations personnel.

513. The Consultant engaged would be required, as part of the evaluation, to review the documentation, interview personnel and make physical inspections of the rides and attractions, with any further expert testing required to then be suggested. A documented report was to be provided summarising the assessment, findings and recommendations, with indications as to priority.

514. In terms of assessing the rides and attractions, Dreamworld required that the Consultant engaged to carry out the safety audit consider the following in relation to each ride:

• Queue lines, walkways, platforms, stairs, ramps and related structures
• Safety systems
• Passenger carrying vehicles
• Passenger restraint systems
• Lighting
• Guards, barriers, fencing and enclosure area
• Track systems
• Structural and support components
• Drive system
• Safety and instructional signage
• Ride area maintenance condition
• Safety related equipment
• Storage areas

515. In addition, the Consultant was also required to evaluate and assess ride operations and maintenance procedures, and comment on the following specific elements:

• Ride inspection and maintenance procedures
• Daily ride opening, operation and closing procedures and compliance with manufacturers requirements
• Training procedures and Operator certification
• Comparison of written procedures and actual application of same
• Review of maintenance documents and procedures
• Review of preventative maintenance procedures and records
• Review of annual service procedures and records
• Review of incident reporting criteria
• Safety and efficiency of ride operations

516. It appears that JAK Leisure Company were ultimately engaged for this purpose. JAK were billed as an internationally recognised auditor, who specialised in Theme Park rides and attractions. 

517. Documentation provided by Ardent Leisure confirms that JAK Leisure Company, which were based in the United States, were engaged at various intervals over a number of years to undertake an ‘independent safety audit’ of Dreamworld to provide an ‘overall assessment as to the appropriateness of internal maintenance and engineering procedures and the safety operations’. In the final reports provided of these assessments, which were titled, ‘Loss prevention Survey’ of the amusement rides and attractions at the park, the scope of work commissioned appears to be,

‘visual safety evaluations of all rides and associated buildings and guest waiting areas directly associated with each ride, including overall assessment of the condition of the ride and evaluation of the maintenance being performed’.

Evaluation of the rides operation and any general issues that are noted regarding the ride.

Visual safety evaluation of associated ride and attraction maintenance support facilities including mechanical inspection, housekeeping and documentation.

518. The method and assessments conducted for the purpose of these inspections, included the following:

• Personnel spent 12 days on-site observing and accessing the procedures and conditions of the park.
• Various management staff in the Engineering and Operations department were interviewed. In addition, mechanical and electrical technicians and Ride Operators were interviewed and observed in the function of their work.
• Procedures applicable to the Engineering and Operations Departments were considered before staff were observed to evaluate compliance.
• Manufacturer’s manuals were considered to determine compliance.
• Compliance with Daily checklists by engineering and operations personnel were observed to determine compliance with procedures, as well as manufacturers and industry standards.
• JAK personnel walked each queue area, including stairs, ramps to note the condition. Safety signage was also observed and considered.
• All passenger carrying vehicles and restraint systems were examined.
• Track systems, ride structure, drive systems and storage areas (where applicable to the rides) were also examined.
• General Ride maintenance and condition were accessed on each ride and attraction.
• Safety equipment, including fire extinguishers, water rescue equipment and general life safety equipment and procedures were accessed.
• Operations training procedures, certification process and effectiveness were reviewed and confirmed.
• Reviewed preventative maintenance records and accident reporting.
• Evaluated Fire Safety systems in buildings, structural safety where applicable, and general condition of buildings.
• Reviewed organisational charts in both engineering and operations, and job descriptions of personnel in the Engineering Department.

519. Whilst it’s not clear from the varied and somewhat sparse records available, it appears that inspections were carried out by JAK Leisure Company in the following years:

• 2003;
• 2004;
• 2006;
• 2008-9; 
• 2012; and
• 2013

520. Mr. Dennis Gilbert, who was the President of JAK Leisure Company, during their engagement with Dreamworld, had previously held various positions within different International Amusement Parks, including Chief Operations Officer and General Manager. In terms of engineering and mechanical matters, it does not appear as though he had any formal qualifications.

521. Mr. Kevin Hehn, who reportedly accompanied Mr. Gilbert during some of the inspections conducted at Dreamworld, was a certified Amusement Ride Inspector and maintenance technician, who had previously held positions as a Loss Control Specialist, ride mechanic and mechanical supervisor at various United States Theme Parks.

522. Mr. Tan was responsible for assisting and coordinating JAK’s audits, with support from the Operations and Safety Managers. The reports provided by JAK following the audits were considered by the managers of the Engineering, Operational and Safety Departments. 

523. A summary of the findings of each of these Surveys, in relation to the TRRR, are outlined below.

May 2003 – Inspection

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524. From the final report provided by JAK, it appears that assessments of each of the rides at Dreamworld were conducted by Mr. Dennis Gilbert and Mr. Kevin Hehn, ‘two qualified and experienced inspectors’, between 1st to 14th May 2003.

525. With respect to the TRRR, the following issues were highlighted in Chapter 15 of the Final Report: 

1. DWORLD 03-15-01: It was noted that the E-Stop button on the Operator’s control panel does not disable the conveyor when depressed. It was recommended that the system be adapted to ensure positive emergency stop to include all moving components to ensure full stop. II.
2. DWORLD 03-15-02: The permanently mounted evacuation ladders poses as a blunt impact or possible entanglement hazard and should be removed or elevated higher. III. 
3. DWORLD 03-15-03: Loose anchor nuts on the guide rail bracket base, located near the crocodile element, which were recommended to be tightened.IV.
4. DWORLD 03-15-04: Heavy corrosion noted beneath the station platform should be cleaned, evaluated and corrected. V.
5. DWORLD 03-15-05: Recommend the placement of additional signage within the rafts stating the need to keep arms and legs within the raft at all times to ensure that all riders see decals. VI.
6. DWORLD 03-15-06: The location of the high voltage equipment for the main pumps in relation to the electrical panels could pose itself as a serious electrical hazard, should the adjacent retaining wall be breached by water. It was recommended that this issue be considered by a qualified electrical engineer. VII.
7. DWORLD 03-15-07: Recommend installing a removable guide rail across the opening of the reservoir gate/dam at raft level to prevent the possibilities of blunt impact VIII.
8. DWORLD 03-15-08: Recommend that all control buttons be permanently labelled. IX.
9. DWORLD 03-15-09: The monitor at the Operator position had been removed. As this was the only means of observing the lower conveyor area, it was recommended that the monitor be replaced immediately and that the ride not be operated without this monitor in place or an Operator in place at a positon to observe the lower area. X.
10. DWORLD 03-15-10: Recommend that the areas that are step off, such as the unload area, be highlighted to bring attention to the change in elevation XI.
11. DWORLD 03-15-11: Noted emergency stop on conveyor. Recommend all emergency stops be accented with the red colour. XII.
12. DWORLD 03-15-12: The life ring at the base of the conveyor was noted to not have AS certification stamp and is not recognised as a life saving device. IT was recommended that all life rings and life jackets be AS certified and dated. These should then be put on a review plan to ensure that they are checked every year for current dates.XIII.
13. DWORLD 03-15-13: Recommended proper safety signage of the Chlorine storage behind the TRRR. XIV.
14. DWORLD 03-15-14: Recommended that the Ride be pumped down on a more frequent basis that annually to allow a visual inspection of the weir logs, rail anchors and conveyor hardware, which are normally covered by water.

8526. Whilst documentation in relation to the TRRR was requested by JAK, it is not clear, from the records available, what information may have been provided for the purpose of the audit.

527. Upon completion of the final report, JAK presented the findings and recommendations to the Safety Executive Committee.

528. Following receipt of the report, it appears that an internal review by Dreamworld was to be undertaken to determine the priorities for each recommendation. This included a number of meetings, which were held between an Implementation Team that consisted of representatives from the Safety, Operations and Engineering Departments, who were required to consider and progress the recommendations made. According to Mr. Hutchings, this Implementation Team were responsible for categorizing the recommendations based on the risk posed, and the subsequent timeframe for which it needed to be executed. He noted that whilst the aim was to implement all of the recommendations, there were occasions when a decision was made not to do so, which would be recorded. According to Mr. Hutchings, there was no financial expenditure barrier to implementing the recommendations made by JAK.

529. Decisions as to the recommendations to be actioned and the timeframes were transferred into an Excel spreadsheet, which was updated when the status of items changed. The progress of implementing the recommendations was to be reviewed by Dreamworld’s Safety Executive Committee on a quarterly basis, with monthly reviews undertaken by Departments. Each Department Manager was responsible for the final inspection and sign off on each item.

November 2004 – Inspection

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530. Documentation provided suggests that further inspections were carried out by JAK between 2 and 11 November 2004. However, a letter dated 3 September 2004, addressed to Mr. Bob Tan, who was the General Manager of the E&T Department at Dreamworld at the time, suggests that an alternative had been sought to the ‘full independent safety audit proposal’ initially provided by JAK. The alternate proposal was for a ‘follow-up audit to review the progress from the previous visit’.The extent of this ‘follow-up’ audit is outlined as follows:

• On-site audit and review of all items that were noted in the previous safety audit conducted by JAK in May 2003;
• Documentation and comment on progress made at Dreamworld on those items noted in the previous safety audit; and 
• Documentation on items outstanding from previous report.

531. It was proposed that the inspection was to be conducted with one qualified inspector, and an electronic report prepared with photographs and ‘the appropriate code and standards comments’, which was then to be presented to management at the conclusion.The cost of the report was quoted as being $9,500 ($US). At the conclusion of the correspondence, it was stated that:

It is the recommendation from JAK Leisure Company to all of our clients that consideration be given to the advantage of having our inspectors conduct a full independent safety audit on an annual basis. With the full audit, repeat items from previous reports are noted, as well as, all attractions and facilities are inspected for operational and maintenance safety issues.’

532. The findings in relation to the TRRR were outlined in Chapter 15 of the final report. Helpfully, this report considered the recommendations made in 2003, and confirmed whether the recommended changes had been implemented. The findings were as follows:

1. DWORLD 04-15-01: E-Stop at the control panel now able to disable the conveyor as well. II.
2. DWORLD 04-15-02: Management assessed that the rafts do not hit the area where the evacuation ladder was placed. Action was marked as incomplete. III.
3. DWORLD 04-15-03: This item was marked as corrected and ongoing.IV.
4. DWORLD 04-15-04: In terms of the heavy corrosion observed bellow the station platform, this action item was marked as on going. It was further noted that given the age of the ride, the corrosion hidden by the themed elements may be ‘severe’. As such, plans should be made to evaluate these areas for possible failure. This item was marked as ‘ongoing’.V.
5. DWORLD 04-15-05: The additional signage had not been placed in the rafts. The item was marked as ‘incomplete’. VI.
6. DWORLD 04-15-06: RCD protection was added to the high voltage equipment, and as such, the item was marked as complete.VII.
7. DWORLD 04-15-07: The flow of water was evaluated by management and it was determined that reservoir gating, which may create back draft ofwater and could cause issues with rafts. The item was marked as closed. VIII.
8. DWORLD 04-15-08: In terms of the labelling of all control buttons, it was noted that progress had been made. As such, the item was marked as partially completed. IX.
9. DWORLD 04-15-09: The video monitor had been replaced and upgraded. The action item was marked as compete.X.
10. DWORLD 04-15-10: Areas of elevation highlighted. Item marked as complete.XI.
11. DWORLD 04-15-11: All emergency stops accented with red colour. Item marked as complete.XII.
12. DWORLD 04-15-12: In relation to the life ring at the base of the conveyor, the Australian Standard was researched by Dreamworld staff and it was found that there was none applicable. As such, no action was deemed to be required.XIII.
13. DWORLD 04-15-13: In relation to the chlorine storage behind the raft ride, it was noted that the water conditions had been improved. The recommendation in terms of the need for additional signage was to stand.
14. DWORLD 04-15-14: It was noted that the TRRR was pumped down two times a year to examine the condition of the trough. Item was therefore marked as complete. 

533. In addition to the above, JAK also recommended that evacuation procedures be re-evaluated on rides where more ‘specific evacuation procedures’ are called for, which included the TRRR. The Dreamworld Board response to this recommendation was that ‘specific ride evacuation procedures are in place for these rides…’ 

534. A document titled, ‘Information for JAK’, which was dated 4 November 2004, appears to outline the planned improvements to be carried out for various rides. In relation to the TRRR, the following actions were listed:

• Dual unload gates; 
• Raft rotate feature;
• Timed dispatcher;
• Handgrips;
• E/Stop – 2 pumps?
• Conveyor stop?

535. It seems these were the actions Dreamworld intended to take or were considering carrying out in relation to this ride. No further information was provided as to why these actions had been included, and whether they were actioned.

536. A spreadsheet listing all of the audit items and recommended actions as suggested by JAK in relation to each ride, was maintained by Dreamworld, with the status of each item updated at various intervals. A spreadsheet from 24 April 2006, suggests that all of the outstanding action items for the TRRR, as listed above, had been completed except for the rebuilding of the timber load and unload stations, which was in progress at the time.

July 2006 – Inspections

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537. Prior to a safety audit being conducted at Dreamworld in 2006, it appears that quotes were sought from JAK and David Randall and Associates (DRA).

538. On 25 January 2006, a quote was provided to Mr. Bob Tan by DRA in relation to Safety audits of Dreamworld, which would be ‘looking at compliance to both AS3533 and the current Workplace Health & Safety Legislation’. DRA, at that time, conducted audits for Warner Village Theme Parks, and had developed a checklist from AS3533 requirements, which covered the following elements:

• Maintenance schedules compared to the manufacturer’s requirements and AS3533;
• Operations manuals compared with the manufacturer’s requirements;
• Attendance at the daily inspections to ensure standardisation of procedures and training of staff;
• Observation of Operators to ensure compliance with operation procedures;
• An inspection of the ride to identify any areas of statute non-compliance, i.e. guarding, structural integrity etc; and
• Riding on the device to ensure clearance zones are observed, etc.

539. From previous experience at Warner Village Theme Parks, DRA suggested that it would take three days to thoroughly audit the large rides, with the smaller rides (such as the children’s train) taking up to a day to complete. The proposed completed report by DRA was to include an executive summary, the results of the audit and an action plan to remedy areas of non-compliance ranked according to their risk. The risk assessment method utilised had been adopted from AS4360.

540. A scope of work was provided by JAK canvassing largely the same areas as was the case in 2003. Ultimately, a decision was made to once again engage JAK. Documentation provided suggests that further inspections were carried out at Dreamworld between 12 and 26 July 2006. On this occasion, a full independent safety audit of the Park was commissioned, which included an ‘overall assessment of ride equipment, appropriateness of internal maintenance and engineering procedures, as well as, the safety of operations’. In addition, emphasis was to be placed on the electrical area of the Park with a Professional Electrical Engineer attending as one of the qualified inspectors. It is important to note that in the scope of work provided by JAK, whilst it explicitly included ‘visual loss prevention and safety evaluation of all Amusement rides’, as well as a ‘visual safety evaluation of associated ride and attraction maintenance support facilities’, and ‘visual evaluation of ride operations and maintenance procedures as related to safety and operational standards’, the applicable Australian Standards (especially AS3533) are not cited, nor is any specific clarification provided as to what standard (if any) such an evaluation was to be conducted.

541. With respect to the TRRR, the following issues were highlighted in Chapter 15 of the Final Report:

1. DWORLD 06-15-01: Recommended that all access to boarding the ride by guests have accessible safety requirement signs.
2. DWORLD 06-15-02: Recommended that all objects, such as fans, theme pieces, lighting that could fall on guest pathways be secured with a safety cable to ensure single point failure will not allow to land on or swing into guests.
3. DWORLD 06-15-03: Recommend the placement of additional signage within the rafts stating the need to keep arms and legs within the raft at all times to ensure that all riders see decals. It was noted that this was a repeat recommendation.
4. DWORLD 06-15-04: Control panel noted all buttons and indicator lights are properly labelled on day of audit.
5. DWORLD 06-15-05: Noted that the cameras in station area are not secured by secondary point. Recommended that all overhead objects be secured to prevent single point failure that could result in fall onto guests or employees.
6. DWORLD 06-15-06: Noted actuator button not labelled. Recommend that all Operator buttons be clearly labelled.
7. DWORLD 06-15-07: Recommend that the area under the lift hill be cleaned out and a handrail be replaced on the far side of the work area under the lift as it was severely corroded..
8. DWORLD 06-15-08: Recommend tightening the connector at the bottom of the motor unit. The current connector shown was loose at the time of inspection.
9. DWORLD 06-15-09: Recommend opened electrical box and wiring be repaired or removed to prevent electrical shock.
10. DWORLD 06-15-10:  Recommend the steel box tube located at the top of the lift hill in the access walk be secured to ensure it does not move out into the lift hill, or is loose to fall onto the feet of employees using the walkway.
11. DWORLD 06-15-11: Recommend the Park have a certified diver available onsite to allow for immediate maintenance and inspection of the underwater items on the water attractions.
12. DWORLD 06-15-12: Recommend installation of pipe supports for the PVC pipe under the pedestrian bridge over the rapids ride.
13. DWORLD 06-15-13: Recommend removal of all old bridge bolts from pedestrian bridge of the ride.
14. DWORLD 06-15-14: Recommend regular review of the pedestrian bridge plank bolts to make sure they are installed and holding the planks in position properly. The bolts should be galvanised or stainless.
15. DWORLD 06-15-15: Conveyor – Recommend the UHMW plastic be chamfered at the end to reduce the chance for catching the lift chain boards while sliding on the plastic.
16. DWORLD 06-15-16: Conveyor - Recommend reduction in the amount of grease being used on the lift hill bearings.
17. DWORLD 06-15-17: Recommend the access gate to the lift hill of the ride be installed with a latch of some nature which cannot be opened by a standard guest.
18. DWORLD 06-15-18: Recommend installation of a diagonal support behind the guide-way column in the rapids trough. The current column is loose at the anchor bolts and should be braced to reduce movement on impact from a raft at this location.
19. DWORLD 06-15-19: Recommend the light attached to the bridge just past the load station be secured using through bolts and a backing plate rather than lag screws.
20. DWORLD 06-15-20: Recommend review of the anchor bolts for the weir in the water channel to be sure they are secure and tight to the channel bottom.
21. DWORLD 06-15-21: Recommend review of the old column supporting the old Sky Link deck above the ride, as it has a large amount of corrosion..
22. DWORLD 06-15-22: Recommend repairs to the rock work at the entry to the tunnel on the right side.
23. DWORLD 06-15-23: Recommend review of the interior rock work in the tunnel of the ride as it has many cracks. A regular review of the condition should be made and a determination made what the useful life of the rock work is according to the installation.
24. DWORLD 06-15-24: Recommend ALL logs and branches found within the tunnel area of the ride be secured to the deck so they cannot enter the trough of the ride.1075
25. DWORLD 06-15-25: Recommend all old posts and stands along the trough sides be removed.
26. DWORLD 06-15-26: Recommend review of the air exhaust coming out in the tunnel passing under the mine ride.
27. DWORLD 06-15-27: Recommend review of the corrosion on the columns supporting the tunnel roof and the mine ride, located adjacent to the rapids trough.
28. DWORLD 06-15-28: Recommend review of these open bulb type fixtures in areas above the guest ride.
29. DWORLD 06-15-29: Recommend installation of or painting of the depth at the edge of the dock.
30. DWORLD 06-15-30: Noted sharp edge of roof below head height on the non-station side of the trough. Suggest that this be marked or removed to ensure no impact to the head of employees.
31. DWORLD 06-15-31: Noted appropriate signs and response equipment to deal with chlorine storage area. Suggest measured introduction of chlorine into the Rapid Ride based on size and dosage necessary to maintain proper levels.

September 2009 – Inspections

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542. From 21 to 30 September 2009, Ocean Embassy (Formerly JAK Leisure Company) conducted safety audits of the rides and attractions at Dreamworld. During this audit, personnel spent 12 days on-site, observing and accessing the procedures and conditions of the Park, as well as interviewing various staff at different levels.

543. Records suggest that the scope of work of the audit conducted in 2009 were intended to be a ‘follow-up’ and not a full independent safety audit. As such, the audit consisted of conducting visual loss prevention and safety evaluations of all amusement rides, attractions, associated buildings and facilities, review of the audit items carried out in July 2006, as well as a full safety audit of a number of rides, which included the TRRR. The specific issues cited for the TRRR were, ‘manual handling issues with raft arrivals and handling; operational system in supervisor and operator competency training methodologies’.

544. A fee of $26,200 (US$) was payable for this work and the provision of the final report.

545. With respect to the TRRR, the following issues were highlighted in Chapter 15 of the Final Report:

1. DWORLD 09-15-01: Verbiage on the official safety notice at the ride is repeated in the theme signs, which is acceptable if all official notices are in standard format on the red background signs and placed to ensure guests have access to read them prior to boarding.
2. DWORLD 09-15-02: Recommend that all objects such as fans, theme pieces, lighting that could fall on guest pathways be secured with a safety cable to ensure a single point failure will not allow it to land on or swing into guests.
3. DWORLD 09-15-03: It was noted that the buttons and indicators on the control panel at the main Operator’s booth were properly labelled on the day of the audit.
4. DWORLD 09-15-04: The ‘emergency shutdown’ procedure posted at ride. During an emergency, it was recommended that a simpler automatic process should be considered. Recommend that the safety system be updated to ensure correct steps are taken by a single emergency button, which will ensure the appropriate timing and sequence.
5. DWORLD 09-15-05: Noted that cabinets at the panel area are in disarray and cluttered.
6. DWORLD 09-15-06: Recommended immediate discontinued use of fan in queue area as it is rusted and corroded.
7. DWORLD 09-15-07: Monitor at the Operator panel does not appear to be an outdoor, mountable monitor, and should be replaced or at least secured to prevent falling.
8. DWORLD 09-15-08: Recommended all overhead objects, including cameras, be secured to prevent single point failure.
9. DWORLD 09-15-09: Noted that there was damaged and inconsistent application of safety decals on all ten rafts in the station. Recommend all decals be replaced and ongoing program to ensure proper decals are in place.
10. DWORLD 09-15-09(2): Noted non-skid finishes on entry to following boats has worn beyond its useful life on a number of rafts. Recommend a nonskid be applied to essential areas of loading.
11. DWORLD 09-15-10: A number of rafts were seen to have Velcro seat belts worn beyond useful life.
12. DWORLD 09-15-11: Recommended program instituted to check all life ring units and other such preservers around the bodies of water in the Park on a regular basis to ensure they are appropriate for planned use of rescue. Recommend research be undertaken to ensure compliance to Australian Standard of water safety.
13. DWORLD 09-15-12: Recommend review of the corrosion on the gates in the upper pump pool.
14. DWORLD 09-15-13: Recommend installation of retaining clips on the grate at the end of the walkway above the pump pool and conveyor to hold gate section in place.
15. DWORLD 09-15-14: Recommend replacing the boot material around the slide boot on the lift hill emergency stop box.
16. DWORLD 09-15-15: Recommend review of the corrosion in the service area by the pump motors.
17. DWORLD 09-15-16: Recommend replacing the wooden members of the roof under the lift hill chain during the chain change out. The wood has significant rot and should be replaced as soon as budget allows.
18. DWORLD 09-15-17: Recommend the heat tape used on the motors be installed permanently or that a switch box be installed to control the operation and protect against shock.
19. DWORLD 09-15-18: Recommend the mount bolts for the motors are Ultrasound tested to verify condition on a regular basis if not currently done.
20. DWORLD 09-15-19: Recommend review of the underside of the main bridge crossing over the ride. The bridge was scheduled for replacement in a year or so.
21. DWORLD 09-15-20: Recommend installation of safety cables to prevent the single point mount or attachment from breaking – lighting.
22. DWORLD 09-15 -21: Recommend the landscape hanging into the ride be monitored by the landscapers and trimmed as necessary.
23. DWORLD 09-15-22: Recommend installation of a board at the lower third board level in order to keep boats from getting caught under the upper two boards – in cave.
24. DWORLD 09-15-23: Recommend using shorter tire pieces to keep them better attached to the wood supports.
25. DWORLD 09-15-24: recommend the chlorine response kits are checked on a regular schedule and the paperwork is checked for readability.
26. DWORLD 09-15-25: Recommend review of the boat maintenance area and how it is utilised for the work process on the boats during normal operation.It was suggested that a lift unit or rail system could be installed to assist in the movement of the boats within the area.

546. Further supplementary comments were provided by the auditors, which were detailed in a separate report. In relation to the TRRR, the following was recommended:

•  Noted that the manual handling and turning of units as they enter the unload area on a relatively unstable waterway presents operational and safety issues in preventing guests or staff from stumbling or falling. It was noted during the audit that unload Operators were handling the rafts in a consistent manner in accordance with procedures.
• Suggestions to solve the instability of the units were:

- A rotating system commonly used on other raft rides to allow continued movement of units and to provide a stable surface for units to rest upon during the load and unload process.

- Queuing of boats in the load/unload area and loading/unloading in mass and then dispatching with spacing. This would require a belt system to be speedy and steady enough to handle.

- Indexing the units on a stable surface – suggested to be the safest option.

• It was recommended in report that control system be reviewed and consideration be given to updating, especially in relation to the emergency shut down procedure.

 

March 2013 – Inspections

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547. From 17 February until 2 March 2013, Ocean Embassy conducted safety audits of the rides and attractions at Dreamworld. The scope of work intended to be the subject of these full safety audits where outlined by Mr. Bob Tan in a document dated 4 June 2012, and largely consist of those previously provided by JAK. It appears that three companies were approached to provide a quote on the proposed scope of work, however, only two responded. Ultimately, Ocean Embassy was selected to conduct the audits. The cost for this service was $30,200 (US$).

548. With respect to the TRRR, the following issues were highlighted in Chapter 15 of the Final Report:

1. DWORLD 13-15-01: Recommended evaluation of allowing Bats within the tunnel of ride. Also, review of concrete ceiling inside the ride.
2. DWORLD 13-15-02: Recommend bolts on weir log be changed or secured so it will not be sticking up and result in impact with boat tube.
3. DWORLD 13-15-03: Recommend general clean-up in the pump pit area of the ride.
4. DWORLD 13-15-04: Recommend fire extinguishers be placed in compliance with the Dreamworld requirement for inspection every 6 months.
5. DWORLD 13-15-05: Recommend the themed wood and items on the loading deck of the ride to be repaired, changed out and removed.
6. DWORLD 13-15-06: Recommend labelling of the gate and E-stop buttons of the ride, located at the far end of the boat dispatch fence. Ride control buttons should be labelled and identified as to action and/or function.
7. DWORLD 13-15-07: Recommend repainting of the EXIT and ‘arrow’ on the walkway from the ride to better identify the exit pathway and direction.
8. DWORLD 13-15-08: Suggest removal of chlorine kit at the back of the TRRR.
9. DWORLD 13-15-09: Noted roof deterioration with pieces of roof falling off. Recommend review of queue structure and roof for repair.
10. DWORLD 13-15-10: Noted emergency light failed the power test. Recommend review of all emergency lights in queue and review of testing method and frequency.
11. DWORLD 13-15-11: Noted rusted and corroded fan in queue area. Recommended discontinued use of fans in this condition.
12. DWORLD 13-15-12: Noted cameras in station do not have safety cable to prevent single point failure.
13. DWORLD 13-15-13: Noted ‘emergency shutdown’ procedure posted at the ride. Recommended that during an emergency, a simpler automatic process should be considered. Recommend that the safety system be updated to ensure correct steps are taken by a single emergency button, which will ensure the appropriate timing and sequence.
14. DWORLD 13-15-14: Noted Operator panel – the labelling was ‘worn and difficult’ to read, Recommend replacement of faded labels.
15. DWORLD 13-15-15: Expired registration is posted at ride and should be removed - not required.
16. DWORLD 13-15-16: Poor housekeeping in control panel area. Recommended that it be kept in good order and better practices be enforced.
17. DWORLD 13-15-17: Noted damaged and inconsistent application of safety decals on rafts. Recommend all decals be reviewed and replaced as necessary. Further recommended that there be an ongoing program to ensure proper decals are in place.
18. DWORLD 13-15-18: Recommended program instituted to check all life ring units and other such preservers around the bodies of water in the Park on a regular basis to ensure they are appropriate for planned use of rescue. Recommend a reaching hook be placed near such bodies of water and that an inspection program be implemented on all water-safety equipment with proper tags and records.
19. DWORLD 13-15-19: Safety cable to be installed for overhead speaker at front of ride.

549. A spreadsheet was maintained recording each of the recommendations made by JAK/Ocean Embassy and Dreamworld’s response, including whether the task had been completed or whether the risk was acceptable and no further action needed to be taken. The recommendation suggesting a simpler automatic shutdown process for the TRRR was recorded as ‘risk acceptable’.

Comments about JAK / Ocean Embassy Safety Audits

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550. The safety audits conducted by JAK Leisure Company/Ocean Embassy, whilst seemingly thorough, were largely focused on the aesthetic issues associated with rides and attractions at Dreamworld, rather than a proper safety assessment against the applicable Australian Standards (AS-3533). This limitation was known and recognised by Dreamworld in supporting documentation provided during the course of the inquest hearing, whereby it was noted that,

An external audit is performed every 3 years by JAK. Reviewing the value of this audit. Much time is being spent on aesthetics per the external audit when more pressing issues need to be addressed. The difficulty with JAK audit is they are based internationally and are not aware of the Australian Standards which are usually different to international standards. Is there an Australian body that does a similar audit/review? Based on price, being coming for 8 years. There are Australian companies that do the same thing.

551. During the inquest, Mr. Hutchings acknowledged the concern held in relation to the fact that the audits by JAK were not being conducted to the Australian Standards.

552. The reoccurring nature of the recommendations made by JAK, particularly given the cost of the reports, was also raised by Dreamworld staff in the E&T Department following the 2013 audit. It was noted that:

Issues

An analysis of each JAK survey identifies common issues and recurring recommendations for each ride. So much so, the survey report from 2013 is substantially similar to that of previous surveys. Given that each JAK review costs circa $60K, it is debatable whether a future JAK survey (scheduled for 2016) represents ongoing value for money. This issue has generated discussion amongst the Dreamworld Safety and Engineering Departments as to what other options are available to improve safety outcomes and ensure value for money.

Most preferred option

Whilst various options are available, the most preferred option would involve a twofold approach focussing on improving existing systems as well as an external auditor subjecting the rides/systems to an Australian Standard 3533 audit.

…

AS3533 Audit – as of 2012, the new nationalised safety legislation requires all amusement devices to be inspected and accredited against AS3533. Whilst this could be done with inhouse expertise, the preference is to utilise independent expertise. (JAK are not able to undertake specific AS3533 audit, as they predominantly reference American and European standards). However, a variety of local or international auditors could perform this task…

553. Unfortunately, despite repeated attempts during the course of the coronial investigation to contact and obtain information from Mr. Gilbert and JAK Leisure Company/Ocean Embassy, no response was ever received. It is not entirely clear, therefore, the actual extent of JAK’s involvement with Dreamworld, the scope of the brief or the intended limitations of the advice provided. This is further exacerbated by the limited and ad hoc nature of the documentary records retained, a significant number of which were only provided whilst Court was sitting, rather than beforehand.

554. That being the case, given the qualifications of Mr. Gilbert and Mr. Hehn, which were known prior to engagement with the company, as well as the superficial nature of the audits conducted, as was recognised by Dreamworld, it seems obvious that the safety advice provided was not intended to be a substitute for a thorough hazard assessment of the amusement rides, as was stipulated pursuant to the Standards.

555. Furthermore, some of the recommendations made by JAK, which may have pertained to safety, such as the labelling of the Main Control Panel buttons and the E-Stop at the unload area, which were raised in previous years, were not actioned by Dreamworld. In 2013, the Main Control Panel at the loading area when considered by JAK appeared as below:

556. The Main Control Panel on the date of the incident, appeared as follows:

557. Mr. Naumann, the Maintenance Planner for Dreamworld at the time of the incident, acknowledged during his interview with OIR, that the recommendations made by JAK, particularly as to the labelling of the control panel and E-Stop at the unload area at the TRRR, should have been actioned during the annual shutdown of the ride, however, were not carried out.1150 He could not offer an explanation as to why this hadn’t occurred.

558. The E-Stop at the unload area at the time of the tragic incident, appeared as below:

559. Despite the recommendations made by the external auditor that the ride control buttons, including the E-Stop, should be labelled and the action identified, in a response provided to OIR by Ardent during the course of their investigation into the circumstances of this tragic incident, they maintain that ‘the emergency stop button at the unload platform of the TRRR was clearly marked on 25 October 2016’.1152 This is clearly not the case.

Edited February 25, 2020 by Jamberoo Fan

[Levithian]

  On 25/02/2020 at 1:10 AM, webslave said:

Maybe I'm still missing it here (and if so I apologize), but I'm not seeing anything in paragraphs 128-130 that indicate that they considered a drop in water level had anything to do with operating the conveyor.  They seemed totally focused on rollbacks and stranding of a raft at the bottom of the conveyor, rather than water level and stranding at the top of the conveyor.  Taking that entire section as a whole the only time they talk about water level monitoring is in reference to efficiency rather than safety.

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Its because you keep reading in point form. Go back and read the whole testimony. It shows a discussion on conveyor safety occurred and the front end of the conveyor wasnt considered for upgrade. How do you know the risk was even considered? Because the employee notes that the intended upgrades being completed now would provide monitoring or all alarms, all water levels and the pump loads. 

What the report is saying is the employee identified a possible risk, was not tasked with mitigating that risk, but still put forward a proposal to Upgrade the control system to mitigate that risk.

It goes on to state that it was his view that this could be performed to enhance safety and save the company money. 

It states that these issues were put forward to the engineering supervisor via email. 

Section 135 confirms these discussions and acknowledges Mr Ritchie raising the danger and putting forward additions to the planned works. It literally says the engineering supervisor agrees with his proposal for additional works but that it could not be completed at this stage, and to focus on the upgrades to the bottom.

Further to this, in section 139 , later discussions about this additional works were had with the company (PFI) during a site visit in August 2015. This means the discussion and the proposal put forward by Mr Ritchie occurred prior to this and tha the engineering manager deemed them important enough to raise with pfi. Even if by his own account this was informal, but by later admission, this is largely how much of their work was planned. Voiced rather than documented.

Futhermore, scroll down to section 144 and have a read how eerily similar the log ride operation was. In 2013 pfi was tasked by the same engineering manager with performing an upgrade that included water level monitoring on the log ride.

It goes on to show from records that the engineering manager identified this risk, how important water level management was, and that he personally viewed the ride operation, was made aware that boats could crash into each other and deemed an upgrade was required to stop this from happening. 

So, the same engineering manager raised the very same issues back in 2013 and proposed they be addressed by upgrades to control systems to monitor water levels, and even proposed that a block system needed to be in place to stop boats coming off and crashing into each other. He tasked pfi with planning and quoting this upgrade which was performed.

The whole cost of implementing all these systems was $16000. 

Why were these same issues not investigated with the river rapids ride? The engineering manager states that even though significant upgrades were performed to the log ride, no risk assessment was ever completed either. Not before or afterwards.

WTF?! It speaks to management performing works and making changes without proper planning or analysis. 

So yes. The report finds the water level is of primary importance and that an automated control system should be in place to halt the ride and operation of the conveyor in the event it occurs. They are not talking about indicator lights being installed if water level monitoring was installed because they already found warning lights signifying the pump stoppage on the control panel were an inadequate control system. Further to this point, talk of a safety interlock being installed for the conveyor is exactly what you are querying. An interlock shuts off power to a device and it cannot be restarted or reset until the issue is rectified. It means it has the ability to stop it being restarted in the event of a failure which would address a situation like the 2014 incident where the operator was dismissed from occurring. 

We can argue sensors vs conveyor and how it would be implemented all we want but the report says it best really. 

They knew the rafts can hit. They knew the rafts could be lifted and even flipped. They knew the water level was critical for the ride to function. They knew people were not capable of managing the risk on the ride and had fired an employee to the fact. They knew all this from in house incidences and experiences and did little to mitigate or exclude the risk of injury or death and are entirely to blame for the tragedy. 

Edited February 25, 2020 by Levithian

[webslave]

  On 25/02/2020 at 2:50 AM, red dragin said:

A dozen things could have been changed, any one of which could have stopped this incident. But none of those were implemented. 

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Exactly, that's what I'm getting at here.  Some would have even been more effective than others.  What's clearly apparent is;

- The initial design of the ride had significant flaws.
- The documentation of that construction was likely deficient or never existed.
- The system for identifying safety hazards with the ride had significant flaws.
- The process of maintaining the ride was flawed and/or incorrectly carried out.
- The inspection regime for the ride had significant flaws.
- The regulatory oversight of the ride was manifestly inadequate.
- The training of ride operators was poorly documented, and generally poorly undertaken.
- The overall condition of the ride plant was poor.
- Modifications had been made to the ride that are unlikely to have been made, documented or assessed in a competent manner.
- The method of operating the ride was an anachronism.
- The process for evaluating safety incidents was very poor.
 

  On 25/02/2020 at 2:57 AM, Skeeta said:

You're throwing in hypothesis that didn't happen and I'm stating the facts in this case. Skeet is not a what if person.

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  On 25/02/2020 at 2:57 AM, Skeeta said:

Do you think if the pump didn't stop and the water level didn't drop the raft would have still flipped in this case?

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C'mon buddy, you're a smart dude.  We're both playing what-if here because it's the only thing we can do.  You clearly asked me what-if the pump didn't stop and the water level didn't drop as if it's some sort of validation that all of this rests on a water level sensor (the original contention I'm arguing against).  What I've shown you is that the same what-if is valid far beyond that one factor.  I'm not saying you're wrong about a water level sensor preventing this, I'm simply saying that it's not the only thing.

[Jamberoo Fan]

HISTORY OF EXTERNAL SAFETY AUDITS AT DREAMWORLD

DRA Safety Management Audits

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560. In 2013, DRA Safety Specialists were first engaged by Ardent Leisure through Mr. Hutchings, to conduct audits of the Work Health and Safety Management Systems (WHSMS) in place in all of its businesses, including Dreamworld, having regard to the National Self Insurance WHS Audit tool (based on AS 4801). The Managing Director of DRA, Mr. David Randall, who is a certified practicing engineer and a globally certified OHS auditor, states that these audits involved a ‘systematic examination of the WHSMS against defined criteria in the National Self Insurance WHS Audit Tool, to review its effectiveness in managing health and safety in the workplace and ensure it achieves the organisation’s policies and objectives in that regard’, which is done by looking at the procedures and processes set up to manage an overall health and safety program. This auditing process is different to that of a workplace inspection to detect specific deficiencies, failures or hazards in particular processes or areas.

561. Whilst DRA were also engaged by Dreamworld to consider two specific instances on rides involving the Cyclone Rollercoaster and the Log Ride, they were not involved in the inspection of any specific ride from a safety or operational perspective. Mr. Randall confirmed that the TRRR was not specifically inspected or part of the audits conducted.

562. Following DRA’s first WHSMS audit in 2013, annual audits were scheduled and performed in February 2014 and July 2015 for the purpose of determining whether the WHSMS had been properly implemented and maintained, and to monitor the process of the implementation of recommendations made. Subsequent consultancy visits were also undertaken to further assist with implementation in October 2014, November 2014, January 2015, April 2015, December 2015, April 2016 and August 2016.

563. According to Mr. Randall, the safety management system at Dreamworld was below industry standards when compared to Village Roadshow Parks, however, was above others. He describes Village Roadshow’s safety management system and the recording for the maintenance of their rides as ‘strong’, and he intended to try and assist Dreamworld to achieve a similar standard. During the inquest, Mr. Randall stated that after his audit at Dreamworld, he identified the need for a ‘very strong safety maintenance system’ to be put in place, as well as a ‘good maintenance engineer’ to establish the systems required.

564. Following on from Mr. Randall’s recommendations, it appears that Mr. Deaves was promoted to General Manager of Engineering, with Mr. Tan being moved to Special Projects. In relation to Mr. Tan, Mr. Randall stated during the inquest that, ‘he is a very capable engineer, but the systems that I desire and require for me to be able to certify a ride weren’t there.’

February 2013 Audit

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565. The first audit conducted by DRA at Dreamworld took place over four days in February 2013. It involved a desktop audit of Dreamworld’s WHSMS, along with a review of Departments, including Operations and Maintenance, which included an evaluation of checklists, worker competencies, risk management documentation for particular rides, as well as a pre-start inspection of the newest ride, the Buzz Saw.

566. The Executive Summary of the findings highlight the following matters:

• The safety management system was originally located on Lotus Notes, which was no longer supported and had limited access throughout the Park. The documents had recently been transferred into a common drive whilst they were being reviewed and updated to current legislative requirements. In essence, there was no documented Safety Management System in operation within the Park.
• The rides and attractions were being well maintained with competent staff, however, there was no documentary evidence to support this process.
• The Safety Unit was noted to be very operational in that most of the day was involved in hands-on activities from conducting inspections to providing training, with little available time for strategic development of the Safety Management System.
• The implementation of Figtree, as a platform for risk management, was praised as an excellent platform for managing the risks within the Park incident reporting. However, managers were required to finalise incidents open for their departments to ensure it reflected the current status of the Park.
• It was noted that emergency procedures were well managed, with staff participating in evacuation drills, attending training annually with procedures reviewed regularly.

567. The areas for improvement were listed as follows: 

• Safety Management System: The SMS has not been reviewed for a long period of time and is currently not compliant with the Harmonised Legislation. Procedures do not clearly identify the reference against which the document seeks compliance nor does it clearly define responsibilities for the implementation of that procedure.
• Document Management System: There is no document management system to manage version control, develop approval work flows etc. The current process is to use a common drive for storing the data in Word and Adobe Acrobat, which is inaccessible to most staff.
• Ride and Attraction Documentation: Although the rides and attractions appear to be well inspected and maintained, there is no evidence that the inspections comply with the manufacturer’s requirements or AS3533, there has been no formal risk management process applied to the rides and competencies of staff to inspect and maintain the rides has not been demonstrated etc.
• Engineering Training Records: There is little to no evidence of department induction, work at height, confined space training, competency to operate high risk plant and equipment and records of licenses etc. With the appointment of the new Engineering Manager and administration staff member, the program is being resurrected and will require significant resources to bring it back to compliant levels.
• Lock-out Tag-out Procedure (LOTO): The blue tag system allows maintenance staff to work on equipment while it is operational without a competent person at the control panel. All rides and attractions must have the controls locked out to prevent the inadvertent starting of that equipment while persons are in the ride envelope which will require a complete review of the LOTO procedure and some modification to Ride Operator consoles.
• Job descriptions/KPI’s: Significant review of job descriptions will be required to ensure that the essential and desirable skills of that role have been clearly identified, and the quantifiable safety responsibilities where applicable are detailed for the role. Performance evaluation reviews are ad hoc and safety key performance indicators are in their infancy for General Managers. Hence, there is no clear understanding of who is responsible for certain safety activities and no measure of performance to those activities.
• Consultation: This is in regards to the purchasing of new attractions, the purchasing of plant and chemicals within departments whereby there is no formal process to ensure stakeholder involvement.
• Electrical compliance: Compliance with the Electrical Safety Regulation 2002 is being readdressed with safety switches being performance tested after a five year absence from testing, and electrical equipment in Maintenance Workshops scheduled for testing and tagging after not having been tested since 2011.

568. In summary, the audit of the Safety Management System at Dreamworld received a final score of 41.7%, which was low and predominantly due to the lack of an up-to-date, easily accessible document controlled Safety Management System that sets the framework for compliance to the legislative requirements. A score of 75% is seen as fully compliant with such requirements. At inquest, Mr. Randall noted that a compliance mark about 75% was required under the audit tool for self-insurance. 

569. In relation to the comment made in the Executive Summary as to the fact that there was no evidence that the rides complied with AS-3533 and no formal risk management process applied to the rides, Mr. Randall told OIR investigators that the reason he had included this was that it had become evident after the first audit that there were no records for the amusement rides to be able to demonstrate compliance with the manufacturer’s requirements or AS3533. In July 2015, Mr. Randall recommended that a junior engineer be appointed to complete a full ride audit every two months, which could be verified by an external specialists.

2014 Audit

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570. Between 24 and 28 February 2014, DRA attended Dreamworld to conduct a Management Systems Audit, using the National Self Insurers Audit Tool V2.1. The audit was conducted in conjunction with the Safety Department, and included interviews with various Departmental Managers and Supervisors.

571. The following comments were made in the Executive Summary as to the findings of the audit:

• The current Safety Management System was out of date, fragmented and requiring significant resources to bring it up to current legislative standards. The previous year had been spent developing a platform to house and manage the Safety Management System documents along with the purchase of a product, which can be used as a guide in the development of the procedures. It was noted that significant resources will be required to update and review all the policies and procedures and transfer them into the Oracle Document Management System.

572. The strengths identified during the audit were listed as follows:

• Training; 
• Electrical - Significant work had been undertaken by the Engineering Department, and electrical tagging and testing had been systemised, although non-compliances were identified within the Audit; 
• Contractor Management – Significant work had been undertaken to ensure all contractors engaged onsite have been inducted and have provided details of their relevant insurance policies and safe work methods before commencing work; 
• Incident/Hazard Reporting – Figtree usage is improving across all departments, which is now providing useful data for quarterly reports;
• Consultation – Significant work had been undertaken to improve consultation across the Park with regard to the introduction of new equipment, attractions and procedures. Change management documentation is in the process of implementation; 
• Job Descriptions/KPI’s – A review of job descriptions indicated that essential and desirable skills of the role have been clearly identified, and management staff now have a safety KPI linked to their pay.

573. The areas for improvement were similar to that stated in the 2013 audit, and included the following:

- Safety Management System – Safety Direct is now available in Oracle and includes a safety management plan for its effective implementation. Significant work will be required to implement the SMS, which will require the Executive Leadership Team to determine which procedures have priority for implementation. 

 - Rides and Attraction Documentation – Although significant work had been undertaken by the Engineering Manager to collate all the documentation for rides in an electronic format and make it available for staff, the following issues were still found to have existed:

• Inspection checklists for each ride have not been formally compared to the manufacturers requirements, and during the audit, where differences have been noted there is no evidence to support the change in inspection. 
• Standard operating procedures for daily and weekly inspections have not yet been developed and hence there is no consistency in the inspections performed by maintenance staff. 
• There are limited records of competency assessments of engineering staff to perform the daily and weekly inspections, and what does exist is an assessment against an inspection sheet rather than a standard operating procedure. 
• The existing lock-out tag-out system still relies on an administrative control i.e. tag, to prevent the operation of a ride whilst a maintainer is in the ride envelope. 

- Corporate Risk Management – Consideration of generating a corporate register which records all issues raised through internal and external audits. A single register will enable management to prioritise the risks and allocate resources accordingly.

- Training Plan/Records – A majority of the training was undertaken within departments and training records held at this level. There is no electronic Learning Management System which would enable the recording of training against each individual. 

- Hazardous Chemical Management – Without purchasing controls on chemicals, chemical registers are out-of-date which places the organisation at risk. 

- Lock-out Tag-out: This system needed to be revised as a matter of priority to ensure that it achieves the single aim of ensuring staff entering the ride envelope cannot be struck by a ride.

574. In summary, the audit on this occasion had a final score of 46.1%, which was noted to only be a ‘marginal improvement’ on that achieved in 2013. It was suggested that the recommendations of this report be placed into a Corporate Risk Register, prioritised and allocated to Managers for implementation, following which significant improvements will be made.

575. Mr. Randall claims that the 46.1% score obtained on this occasion following the audit surprised him as he had expected a far greater improvement in the 12 months with the implementation of the recommendations made in 2013. It was his understanding that this limited improvement was due to resources within the Safety Department at Dreamworld. Mr. Randall expressed concern to the Board as to the lack of improvement, following which additional staff were added.

Consultancy Visits 2014

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576. In late 2014, DRA conducted their first consultancy visit at Dreamworld whereby document management systems and document control structures were discussed with Management before a meeting held with the Safety Executive Committee. It was determined that the executive team would determine a suitable document management system for the storage of all Dreamworld documentation, and the Safety Department would be in charge of managing the updating of the procedures.

2015 Audit

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577. On 13 and 14 July 2015, Mr. Randall from DRA conducted a Safety Management Systems Audit on Dreamworld, using the National Self Insurers Audit Tool. Given the limited timeframe, the audit focused on those criteria that did not gain a score of 3.0 in the last audit conducted in February 2014.

578. It was noted in the Executive Summary that significant improvements had been made with the implementation of the Safety Direct Management System, Liferay, a new LMS and the expansion of MEX ops. These introductions would allow for significant improvements in the automation of the safety management functions over the next 12 months to two years. Furthermore, a restructure of the Safety Unit at Dreamworld has enhanced services provided to the Departments. The Engineering Department had also made significant inroads into upskilling their staff and ensuring that training records were available for the inspection of rides. Full risk management reviews of the major attractions had also been commenced.

579. In addition to the strengths listed in the 2014 audit, the following further positives were also noted:

• Safety Management System – now readily available online to all staff.
• Risk Management – Quarterly inspections of departments, the development of corrective action registers for each department along with the development of a static risk register for each department has improved the risk management practices across the property.
• First aid management – is now approaching best practice with excellent facilities, highly trained staff and a comprehensive First Aid Procedures Manual.

580. The areas for improvement largely mirrored that of the 2014 audit with the removal of the Safety Management System and Ride documentation. The additional area of concern was Emergency Management, which it was noted were out-of-date and did not accurately reflect the procedures undertaken within the Park for emergency situations.

581. In summary, the audit in 2015, yielded a final score of 61.6%, which was a significant improvement from the previous year. It was noted that with the imminent implementation of LMS, Liferay and the enhancement of MEX ops, significant automation of the safety functions could be achieved making the SMS resilient to change in staff. Furthermore, with Departmental Managers having clearly defined responsibilities, which are documented in the annual Safety Plan, safety will become a standard part of business rather than an ‘add on’.

Consultancy Visit - April 2015

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582. In April 2015, a further consultancy visit took place whereby the status of the recommendations from the audit conducted in January 2015 was reviewed with the continuous improvements within the Engineering Department and contract management noted.

Further action in relation to the Emergency Procedures for rides were identified, which primarily involved the development of suitable picture based procedures to deal with all emergencies.

583. In relation to the Engineering Department, the following was noted:

• A review of work undertaken by the engineer on the documentation for the Wipeout and Buzz Saw clearly showed that significant work had been completed to ensure the rides could be inspected systematically to best practice standards based on manufacturers, Australian standards, ride bulletins and experience. This process was to continue with all high risk thrill rides being completed as a matter of priority, with one ride being completed per month.
• On the daily and weekly inspection sheets, the types of lubricants to be used for greasing to be included, as well as the tools required to complete the inspection. 
• Supervisors to ensure all maintenance staff have completed the competency to operate the rides, as daily and weekly inspection procedures are developed.

584. DRA recommended that ‘management consider engaging an external consultant to manage the AS3533 compliance issue associated with the introduction of new rides as part of the design registration process’.

585. In terms of change management, DRA recommended that consideration be given to rotating Ride Operators during a shift, to ensure they remain vigilant when undertaking their functions.

Consultancy Visit - December 2015

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586. In December 2015, a further consultancy visit took place where the progress of the implementation of the recommendations from April and July 2015 were considered.

587. In terms of actions undertaken, the report highlighted the following:

• Picture based emergency procedures had been developed for the five major rides by the Engineering Department.
• A lubricant register for each ride had been developed.
• A change management form in Safety Direct was available for use by staff. 
• All corrective actions identified in the Safety Management System Audit conducted in July 2015 have been included in a corrective action register.
• Engineering were continuing to make progress with improving the documentation and systems of work related to ride operation and maintenance, with items that remained un-actioned detailed in an action plan.

588. In addition to a range of recommendations made about issues such as Hazardous Chemical Management, Emergency Procedures, Contractor Management and the Safety Management Plan, DRA also outlined the requirements of annual ride inspections per the OIR Regulations. The requirements of Form 8 and ss. 266 and 267 of the Act were explained. It was recommended that the following take place:

• Consider re-assigning the task of annual registration to the Engineering Department given they are deemed the person in control of the plant.
• Ensure an annual statement is obtained from either an external RPEQ Engineer or an internal competent staff member to state that the ride is safe for operation, the completed National Audit Tool for Amusement Devices would be sufficient to satisfy this requirement.

Consultancy Visit - April 2016

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589. In April 2016, a further consultancy visit took place whereby a review of the progress of previous recommendations from prior consultancy visits and audits were considered.

590. The report prepared noted the following items of significance:

• Work had been ongoing in updating emergency procedures and ensuring Warden’s boxes in each of the zones were fitted with suitable equipment.
• The annual inspection requirements for each of the attractions will now be completed by an external provider.

591. It was noted that ‘given the transition in the Safety Managers role, it is understandable that many of the issues raised in the December report are yet to be formally addressed.’ Furthermore, the corrective action register was said to have listed all of the recommendations from previous audits, however, should be extended to include all from external/internal reports to ensure that there is a current log of risks available for review.

592. Relevant issues considered with further recommendations made were identified as follows:

• The corrective action register in Safety Direct to be used as the major tool for monitoring the implementation of the recommendations for those elements in the audit that were identified as below a score of 3.0.
• Locate resources within each department to ensure the requirements of the chemical management system are implemented prior to the November audit.
• In relation to emergency procedures, conduct a desk-top and other drills of key emergency procedures prior to the November audit with evidence of the drill outcomes available.
• The need for a comprehensive training needs analysis for each department, as this was one of the major non-conformances in all of the previous audits.

593. In April 2016, DRA were also requested to conduct a review of the Log Ride incident where a male patron was injured falling from the ride.The purpose of the review was to provide a further opinion as to the investigation process and findings to date, to compliment that already undertaken internally and by the Regulator, in order to ensure the safe reopening of the ride.

594. In addition to the further controls recommended for the ride, which included extra CCTV cameras and automatic audio safety warnings at critical points on the ride, DRA suggested that a ‘full documented risk assessment of the ride be conducted’, which was intended to provide evidence of Dreamworld’s primary duty of care, that both the current and proposed risk control measures are reasonable and have a timeframe for implementation which is reflective of the risk posed.

 

Edited February 25, 2020 by Jamberoo Fan

[diesal11]

So at what point did the main operator actually hit the primary E-Stop? The documents timeline doesn't specify and also seems to imply it wasn't pressed until after the rafts collided?

[webslave]

  On 25/02/2020 at 3:02 AM, Levithian said:

How do you know the risk was even considered? Because the employee notes that the intended upgrades being completed now would provide monitoring or all alarms, all water levels and the pump loads. 

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I agree that it's one possible reading of it, but could we agree that it's not the only plausible reading of it?  As I said, you can infer a connection between the two but there's nothing in that section that actually puts the two items together.  If your reading of it is correct then certainly it would be a clear statement that the park knew of a safety problem related to the water level concerning the conveyor and didn't rectify it.  I do note however that since the document doesn't say that it's likely that he can't back up that assertion.  It's not in the risk assessment, and paragraph 128 specifically notes that the risk they were working on didn't concern the risk of collision at the top of the conveyor.  If your reading that a water level sensor was to be installed for some sort of safety purpose (ie; to mitigate a risk), then what risk were they trying to mitigate?

  On 25/02/2020 at 3:02 AM, Levithian said:

Section 135 confirms these discussions and acknowledges Mr Ritchie raising the danger and putting forward additions to the planned works. It literally says the engineering supervisor agrees with his proposal for additional works but that it could not be completed at this stage, and to focus on the upgrades to the bottom.

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This section specifically states that he didn't feel the additional work concerned safety, which would actually support my reading of this rather than yours.  It does not say that Mr Ritchie raised any danger with regard to the water level.

 

  On 25/02/2020 at 3:02 AM, Levithian said:

Futhermore, scroll down to section 144 and have a read how eerily similar the log ride operation was. In 2013 pfi was tasked by the same engineering manager with performing an upgrade that included water level monitoring on the log ride.

It goes on to show from records that the engineering manager identified this risk, how important water level management was, and that he personally viewed the ride operation, was made aware that boats could crash into each other and deemed an upgrade was required to stop this from happening. 

So, the same engineering manager raised the very same issues back in 2013 and proposed they be addressed by upgrades to control systems to monitor water levels, and even proposed that a block system needed to be in place to stop boats coming off the conveyor and crashing into each other. He tasked pfi with planning and quoting this upgrade which was performed.

The whole cost of implementing all these systems was $16000. 

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I think that you may need to consider the very important differences here.  He had identified that the speed of the logs as they traversed the drop could reach 70km/h and in the event that the water level at the bottom of that had fallen presented a hazard where one log could collide with another at a high rate of speed.  This is quite distinct from TRRR where the concern was not collision at a high rate of speed.  The concern at TRRR should have been capsize, entanglement and drowning, but again there's no evidence that I can see here that made the connection for them between low water level and the conveyor.  This is in contrast to the Log Ride where the connection had clearly been made.  I know your line of thinking here is "if he thought this up on the log ride, why not on TRRR?" but it's not borne out in the report, and on logical grounds seems implausible given the quite different risks.

  On 25/02/2020 at 3:02 AM, Levithian said:

WTF?! It speaks to management performing works and making changes without proper planning or analysis. 

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Abso-bloody-lutely! That's why I don't think you can just infer that they somehow had made the link between low water level and the conveyor.  If there was any evidence they had made this link the report wouldn't just hint at it - it would have said so.

  On 25/02/2020 at 3:02 AM, Levithian said:

They knew the water level was critical for the ride to function.

...

They knew all this from in house incidences and experiences and did little to mitigate or exclude the risk of injury or death and are entirely to blame for the tragedy. 

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The water level was indeed critical for the ride to function - without water they couldn't cycle the ride.  Is it proven, however, that it was unsafe to operate the conveyor with anything other than a full water level?  Is that even true for that matter?  After all, provided you don't have a raft bottomed out at the top you can still operate the conveyor.  Furthermore, one of these in-house incidences and experiences you refer to actually occurred with a full water level.  Not only would that incident not have told you that the water level is safety-critical, it's actually likely to have lead you further away from that notion.

The truth is that they knew or should have known that it was unsafe to operate the conveyor unless they were confident that there was nothing obstructing the transition at the top of the conveyor into the trough.  What they knew or should have known is that one of the potential causes (not the only cause) for an obstruction is low water level causing a raft to bottom out in that location.

Personally, it kills me that a relatively simple system such as a beam at the top of the conveyor (prior to transition) couldn't have been used to stop the conveyor any time a raft made it to the top with a deadman's run button provided to the unload operator to jog the conveyor.  It's a winner for me because you can help protect against this incident, other incidents that have been like it previously, and also against incidents where you might have a person fall into the trough at unload and be at risk of being hit by a raft that enters the trough.

[New display name]

  On 25/02/2020 at 3:05 AM, webslave said:

C'mon buddy, you're a smart dude.  We're both playing what-if here because it's the only thing we can do.  

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Not the same.   I asked you in relation to the accident.  You're what if had nothing to do with the day and I think we are fighting 2 different fights here.

[webslave]

  On 25/02/2020 at 3:36 AM, diesal11 said:

So at what point did the main operator actually hit the primary E-Stop? The documents timeline doesn't specify and also seems to imply it wasn't pressed until after the rafts collided?

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  Quote

477. Testing of the E-Stops at the TRRR by investigators following the tragic incident, in the presence of Dreamworld staff, confirmed that none of the E-stop’s had been activated at any time during the course of the incident.892 CCTV footage of the incident also confirms this finding.

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  On 25/02/2020 at 3:43 AM, Skeeta said:

Not the same.   I asked you in relation to the accident.  You're what if had nothing to do with the day and I think we are fighting 2 different fights here.

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I think you'll find mine were phrased pretty similarly, except there were more of mine.  Again, I'm not saying that you're wrong here - I'm just saying there's far more to it.

[Levithian]

 

  On 25/02/2020 at 3:05 AM, webslave said:

 What I've shown you is that the same what-if is valid far beyond that one factor.  I'm not saying you're wrong about a water level sensor preventing this, I'm simply saying that it's not the only thing.

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Im thinking were the disagreements are coming from is maybe because the mechanical side of the findings ia really two part. If you view it like this, it kinda clears things up a bit.

As far as safety goes, the water level is the primary factor. You cannot dispute this and its why there is even talk of a level system control. Mitigate the water level problem and the entire safety risk is removed. This is agreed upon by investigators, both engineers and the police. 

Secondary, and the other major factor is the conveyor continued to run in this state. These are the main contributing factors that pose a continual risk at all times across years and were not mitigated, ever. This means there has always been these underlying risks in its operation that should have been addressed over its 30 years. 

In addition to these, the state of the conveyor, in regards to slats, etc and the gap between the rails in the trough and the front of the conveyor were highlighted, along with the inadequate e-stop placement/system as major contributing factors to this incident occurring. That is it is specific in this incident only and deemed that addressing either the state of the conveyor or the gap between the rails and the conveyor would have likely meant this incident would not have occurred. Again, this specific to this incident. 

Its why the report noted earlier comments by bob tan about rafts flipping over completely. The underlying issues with the ride since its commissioning were still there. 

Its why the report makes mention of even if these specific contributing issue were addressed or the factors had not occurred, there was still an underlying unacceptable risk that needed addressing which could cause further incidences different to this one which killed people. 

[diesal11]

  On 25/02/2020 at 3:47 AM, webslave said:

477. Testing of the E-Stops at the TRRR by investigators following the tragic incident, in the presence of Dreamworld staff, confirmed that none of the E-stop’s had been activated at any time during the course of the incident.892 CCTV footage of the incident also confirms this finding.

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So how did the conveyer even stop then? The ride op claimed to have pressed the button 2 or 3 times, did he press the wrong one?

EDIT - Found it towards the end:

  Quote

1019. It is evident from the CCTV footage that at the time of the incident, Mr. Nemeth remained at the Main Control Panel. Having noticed that the water level had dropped significantly, Mr. Nemeth advised the guests he had loaded that they would need to disembark. It is not clear when he initiated the shutdown sequence of the ride, particularly whether this was before or after the rafts collided and/or he had contacted the control room. There is no way to ascertain with any certainly as to whether he did and if so precisely when Mr. Nemeth may have pressed the conveyor stop button. He claims he pressed it multiple times but nothing happened. Testing following the incident by investigators found no issue with the operation of that particular control button. From the CCTV footage, the conveyor can be seen to commence a slow stop approximately 11 seconds after the rafts have collided. It seems in all likelihood, given the events that followed, that Mr. Nemeth may not have pressed the conveyor stop button until the rafts had collided or moments beforehand.

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How awful for him, ridiculous that this wasn't foreseen given that the Main panels conveyer stop button takes 8 seconds, which is controlled by a primary ride op who has their attention constantly switching between loading guests and controlling the entire ride.

Edited February 25, 2020 by diesal11

[Jamberoo Fan]

HISTORY OF EXTERNAL SAFETY AUDITS AT DREAMWORLD

DRA Safety Management Audits

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Dreamworld’s Response to DRA Audits

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595. Following each audit and consultancy visit, a final report was produced by DRA, which would outline the findings made and recommendations. Mr. Randall presented his findings for each of the DRA reports to the Ardent Leisure Board by way of an Ardent Safety Committee meeting. To assist in the ongoing implementation of the recommendations following the audits, a Risk Register and Action Log was developed in December 2014, which was to be maintained by Dreamworld Safety staff.

596. It appears that the Safety Department were the custodian of the DRA audit reports. The recommendations, however, were shared with various Departmental Managers, including the Operations Department, so that corrective actions could be addressed.

597. According to Mr. Hutchings, Mr. Davidson was aware of the DRA findings and recommendations. He notes that not all of the recommendations made were implemented as it was ‘purely a constraint issue’. Regardless, it is clear that with the improved auditing scores, gradual improvements were being made by Dreamworld.

598. During the inquest, Mr. Randall stated that, ‘I firmly believe had we gone through that process and had another, you know, three months, that some of these issues that have caused this event would have been identified and rectified’.

Dreamworld Safety Auditing Strategy FY15

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599. In May 2014, Mr. Deaves in consultation with Mr. Hutchings drafted a Dreamworld Safety Auditing Strategy for 2015. This document notes that the annual DRA audits, which is described as providing a comparison between the safety management systems as against the national self-assessment audit tool, have highlighted the absence of a formalised document control system. Whilst some improvements were noted in the 2013 and 2014, in order to improve the scores of the audits, it was proposed that the following strategies be implemented:

• Auditing strategy: It was proposed that the money spend on auditing ($14,000) be used to engage DRA as a consultant to assist in completing the work required, as identified by previous audits.
• Document control: It was noted that the Ardent IT Department had been working on a group wide document control solution for some years. Recently, a small module was made available to the Dreamworld Safety Department in order to deposit and manage Park wide safety policies and procedures. In order for the system to be complete, it was noted that a module was required for each major Department.
• Engineering: Whilst it was noted that the preventative maintenance, inspection and training regimes had evolved over the operating life of the Ardent Theme Park Division, there was no formal evidence of compliance with the current system. As such, it was suggested that the following points for compliance be reviewed:

- OEM Inspection and servicing requirements, including safety alerts and service bulletins.

- Applicable Australian Standards compliance.

- Queensland Regulation compliance assessed against the National audit tool.

- Consolidation of historic information from JAK, DRA and internal audits. It was noted that this review would likely ‘detail a large amount of recommendations that are currently not performed or partially performed’.It was recommended that a junior engineer be recruited to undertake the following tasks:

- Review each device and consolidate the information in the document control centre for retrieval by all relevant staff.

- Assess the relevance of each task, negotiate with OEM on variations. - Manage change documentation.

- Develop training plans and assessment tools based on the final service requirements.

600. Upon completion of the proposed review, it was further submitted that the process and inspection regime be independently verified for compliance, as this would provide a ‘base line for any engineer’s inspection to work from which is not an annual requirement of the Queensland regulation’. 

601. It appears that in April 2014, steps were taken to have the above proposal discussed between Mr. Deaves, Mr. Hutchings and Mr. Davidson. According to Mr. Deaves, this meeting took place whereby resourcing to assist Engineering in carrying out further audits on amusement rides was discussed following the identification of gaps in the safety systems management. This proposal was agreed to and further administrative support, as well as junior engineer, Mr. Cruz were subsequently hired to undertake the tasks as listed.

 

Edited February 25, 2020 by Jamberoo Fan

[Levithian]

  On 25/02/2020 at 3:38 AM, webslave said:

I agree that it's one possible reading of it, but could we agree that it's not the only plausible reading of it?  As I said, you can infer a connection between the two but there's nothing in that section that actually puts the two items together.  If your reading of it is correct then certainly it would be a clear statement that the park knew of a safety problem related to the water level concerning the conveyor and didn't rectify it.  I do note however that since the document doesn't say that it's likely that he can't back up that assertion.  It's not in the risk assessment, and paragraph 128 specifically notes that the risk they were working on didn't concern the risk of collision at the top of the conveyor.  If your reading that a water level sensor was to be installed for some sort of safety purpose (ie; to mitigate a risk), then what risk were they trying to mitigate?

This section specifically states that he didn't feel the additional work concerned safety, which would actually support my reading of this rather than yours.  It does not say that Mr Ritchie raised any danger with regard to the water level.

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No it doesnt. It says that Mr Ritchie agree that the current proposed upgrades required addressing now, thats all.

He goes further to state that additional changes were intended to be completed after these immediate upgrades, but acknowledges this was only in discussion. 

He felt strongly enough about the additional upgrades to include them in his proposal and actually says the upgrades would improve safety, so how can you say he felt otherwise?

The inquest finds that such measures should have been implemented and that if any risk analysis had been performed they would have been highlighted.

Mr Ritchies proposal should have been enough to trigger investigation. The engineering supervisor agreed the additions were warranted, and thats basically as far it went. 

The issue of ride operation and low water level danger needs no addressing because everyone, right down to dreamworld, their policies and the ride operations manual ALL agree it is. You cannot say it is or isnt implied, when it has been outlined how important it is. It causes a ride safety stoppage and the conveyor is manually halted and immediate assistance is required. This is why the employee was fired in 2014 because it explicitly states that the conveyor cannot be restarted during low water levels like what follows a pump failure, and that operators are not permitted to restart pumps without seeking approval. 

He did both of this and was fired. 

So, knowing all this, if a skilled, engineering employee creates a proposal seeking to address monitoring of water levels and implementing an automatic control measure; do you think this is done because it is a critical risk already highlighted and understood, or do you think there is still some conjecture as to if he felt the water level was a safety risk at all and just proposed the additions for seemingly monetary value?

Even if you want to argue he had no idea, someone above did or should have. And if they didnt, the person above them should have. The proposal shouldnt have been ignored, it should have been followed up and investigated. The engineering manager even agrees this should have happened and this is simply just another example of the opportunity dreamworld had to address a critical flaw in the rides operation which was mismanaged.

Which is what the report finds.

Edited February 25, 2020 by Levithian

[webslave]

  On 25/02/2020 at 3:52 AM, Levithian said:

As far as safety goes, the water level is the primary factor. You cannot dispute this and its why there is even talk of a level system control. Mitigate the water level problem and the entire safety risk is removed. This is agreed upon by investigators, both engineers and the police. 

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I know the report has that in there, and strictly speaking you're right that it would have prevented this incident, but it doesn't (as you put it) make it such that the entire safety risk is removed.  We know from the 2001 incident that water level was not a factor, and accordingly I don't see how anyone could make the case that the water level fixes the safety issue.  Assume for a moment that in the year 2000 a water level interlock was installed; would the 2001 incident have occurred?  Evidence suggests it would have.

If you look at the reference to Tan's email of 13 November 2014 (see paragraph 268) you'll note he describes the problem as allowing rafts to bank up at unload (which makes sense because he's talking about the 2001 incident which didn't involve the water level).  What's interesting though is paragraph 269:

  Quote

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...

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I think the Coroner might have gotten this wrong.  I don't believe Mr Deaves is talking about the Texas incident at all, or at least if he was I don't believe Tan's reply was actually about that.  I believe Tan's reply was actually about the Buss incident, which had occurred only a week prior and indeed included the factors he highlighted.  What's interesting here is he specifically notes that he stopped and restarted a pump which was against procedure (ie; he's casting that as a negative action) and that stopping the conveyor was something against procedure (ie; he's casting that as a negative action) which presumably was because of the risk of capsize to the raft at the bottom of the conveyor.  For reference, he's the low air procedure:

  Quote

3.4.5 Loss of Air Pressure (Low air alarm)

(i) Stop dispatching
(ii) Contact a Supervisor via control stating ‘Rapid Ride – Code 6’
(iii) Press Emergency Gate Button
(iv) 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
(v) Tie the front raft to the deck railing at the end of the dispatch control panel area
(vi) Insert dispatch isolator key
(vii) Retrieve all rafts in circuit
(viii) Unload guests (only if safe to do so)
(ix) 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
(xi) Await further instructions from a Supervisor
(xii) Record downtime

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Meanwhile, here's the procedure in case you lose a pump:

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3.4.3 Shut Down Operation

(i) Press Emergency Gate Button
(ii) Press Conveyor stop
(iii) Press Emergency stop
(iv) Remove dispatch isolator key
(v) Contact control on 325 stating ‘Rapid Ride – Code 6’ and advise why shutdown was initiated e.g. loss of power to conveyor
(vi) Direct Load operator to attend the bottom of the conveyor
(vii) If a deckhand is present direct them to attend the queue line and advise guests of delay as per 3.8.5
(viii) Count how many rafts are retrieved (from conveyor to dispatch control panel area)
(ix) Await further instructions from a Supervisor
(x) Advise guests of an operational delay as per section 3.8.5
(xi) Record downtime

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As an aside what's missing from that procedure is the south pump:

  Quote

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 no emergency stop for the South pump, or one that stopped both pumps simultaneously.

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So, looking at Tan's comments about procedure it's fair to say that Buss stopping a pump was incorrect for the low air scenario.  But, at that point when he stopped the conveyor Buss was following procedure... eventually (since he's now doing Shut Down Operation).  Restarting the pump was also incorrect.  This is a bit of a problem though, because I can see how they will have been more than willing to allow themselves to look solely at the employee not following procedure as the issue rather than examining the rest of it.  I didn't find anything in this section that indicated that they saw the risk of running the conveyor when you had a raft trapped at the transition point.  Moreover I certainly don't see anything there that would suggest he knew of the risk of operating the conveyor with low water level.

The item going in-favour of them knowing of this risk is that in the case of the Shut Down Operation procedure pressing Conveyor Stop sits at item #2 (after the emergency gate preventing accidental dispatch), but as to whether conveyor stop is that high on the list because they know of the risk with low water level versus simply because they want to prevent a bankup at unload (which we actually know they are aware of) is debateable.

[Jamberoo Fan]

CHANGES AT DREAMWORLD FOLLOWING THE INCIDENT

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602. Material provided by Ardent Leisure during the inquest proceeding notes that a number of significant changes were made at Dreamworld following the tragic incident. The need for such changes to be made were expressed by Mr. Hutchings during an Ardent Leisure Board meeting, which took place on 7 December 2016, where he ‘expressed his desire to replace human behavioural controls with engineering or monitored solutions’. He further highlighted his intention to improve hazard identification and associated documentation. Below is a summary of the review, auditing and changes implemented since this tragic incident.

603. Shortly following the incident, Pitt & Sherry Operations Pty Ltd, an Australian Engineering firm with expertise in amusement devices and moving plant, were engaged by Ardent Leisure to inspect and assess the Amusement Devices and relevant associated components at Dreamworld and WhiteWater World. The scope of the work was to:

• Conduct a general safety review, utilising a team of engineers (Structural, Mechanical and Electrical and Control) including providing signoffs as part of a 3-Tier Review; and
• Conduct Annual Inspections on all Amusement Devices.

604. Following the above inspections, Pitt & Sherry issued an Annual Inspection Certification Letter for those devices found to comply with s.241 of the Regulations and AS3533.3. Corrective actions identified were outlined in reports provided for each ride.

605. In addition, Leisure Technical Consultants (LTC) were also engaged by Ardent Leisure to conduct its own Functional Tests and Peer Review of Pitt & Sherry’s findings. These findings were outlined in detailed reports, which contained 160 recommendations and observations as to Corrective Actions. LTC found that the inspections conducted by Pitt & Sherry had been to a high standard.

606. The Engineering Department worked closely with Pitt & Sherry and LTC to facilitate their inspection of rides at the Park, and to complete remedial works on the matters identified by the Consultants.

607. In 2017, Pitt & Sherry were engaged by Ardent Leisure to conduct additional inspections and audits at Dreamworld and WhiteWater World to assess the work conducted in response to the Corrective Actions, as implemented by Dreamworld Technical Services.

608. In 2018, Ardent Leisure engaged Chapalex Pty Ltd, a company specializing in the integration of safety and risk management principles and practices into existing operational frameworks, to assist in gaining ‘an understanding of the current status of work health and safety operating systems, policies and practices at Dreamworld and WhiteWater World’. Chapalex agreed to allow the Director, Mr. Phil Tanner, to undertake the role of Director of Safety at Dreamworld, WhiteWater World and Skypoint from 1 July 2018. Mr. Tanner was responsible for identifying opportunities to enhance the Park’s existing WHS practices.

609. Whilst not exhaustive, other pertinent changes made throughout the Theme Park following the incident, include the following:

- Dreamworld staff were required to review applicable operating procedures for rides and attractions at the Park, in consultation with Pitt & Sherry to ensure that any modifications arising out of the reviews undertaken were incorporated into the Operating Procedures.

-  Refresher training was provided to Ride Operators before the rides at the Park were reopened to the public.

- SP Solutions, external consultants with expertise in assisting companies identify, assess and control risks, were engaged to conduct workshops with Dreamworld staff and assist them in conducting risk assessments on rides at the Park.

- A Memorandum Creation Procedure was introduced in the Operations Department, which requires consultation with the Attractions and Entertainment Manager, as well as a final sign off by either the Attractions Manager or General Manager of Park Operations, before it is disseminated to staff. According to Mr. Fyfe, following the incident, there is now a focus on ‘risk assessment’ and widespread consultation when creating memorandums.

- The configuration and members of the Safety Department were significantly changed to include an Engineering Safety Advisor, Safety Training Advisor, Environment Advisor and a Senior Safety Advisor.

- A number of safety initiatives were also introduced at the Park, including:

- Emergency management plans - sets out the Park-wide response to various emergency situations, including for particular rides.

- Scenario drills – a program was developed to be conducted on rides at the Park in consultation with Pitt & Sherry. Engagement was also commenced with the Queensland Fire and Emergency Services, QPS and OIR.

- Park-wide Evacuation Drills – introduced to provide training to staff as to how to proactively respond to emergency situations.

- Incident Controller – a revised incident controller structure was implemented to provide situational leadership.

- Park-wide audio system – enable more effective coordination of evacuation and personnel management during an emergency.

- A review of the health care able to be provided by the Park Health Facility was undertaken with necessary improvements actioned to achieve best practice.

- An analysis was undertaken as to the scoping and resourcing requirements of establishing an in-house Park training academy to canvas the operation of the Parks, with accredited training programs recognised Australia wide.

- A review was undertaken of the Ride Induction Training Program provided to new employees with improvements made.

- Implementation of new data management and IT Systems at the Park, which includes a new safety management system that consolidates previous systems into one single platform to control safety risks. A new document management system was also introduced, which efficiently and effectively tracks, manages and stores documents across all Departments. 

610. Ardent Leisure have also developed a hazard and operability study (HAZOP) model for identifying and evaluating issues, which may present to staff, guests and rides at the Park. This risk assessment tool is intended to be the basis for any changes to the Regulatory regime in place in Queensland in response to this incident.

 

AMUSEMENT PARK REGULATION IN QUEENSLAND

 

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611. The responsibilities of the Regulator for Amusement Park rides in Queensland is identified in the Work Health and Safety Act 2011 (WHS Act) and Work Health and Safety Regulation 2011(the Regulations), which commenced on 1 January 2012. The implementation of this legislation gave effect to the national framework of model work, health and safety laws under the agreement of the Inter-Governmental Agreement for Regulatory and Operational Reform in Occupational Health and Safety. OIR are also responsible for administering the Electrical Safety Act 2001 and the Electrical Safety Regulation 2013 in conjunction with the Electrical Safety Office (ESO).

612. In administering this legislation, OIR is responsible for ‘monitoring and enforcing the primary objectives of the WHS Act and ES Act to protect workers and other persons from harm to their health, safety and welfare through the elimination and minimisation of risk arising from work or from particular types of substance and plant’.

Brief History of WHS Legislation - Past Decade

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613. In 2011, the Workplace Health and Safety Act 1995 and the Workplace Health and Safety Regulation 2008 was repealed. The previous regulatory regime included a number of requirements relevant to amusement park rides in Queensland, such as general requirements for registrable plant and registrable plant design. 

614. Plant design registration has been a feature of WHS legislation in Queensland for many years. It was intended to be a mechanism to ensure that the design of an item of plant had a verification statement confirming that it meet the technical standards and engineering principles appropriate for the plant.

615. In 2011, a nationally recognised set of model occupational health and safety laws were made to harmonise the different Australian jurisdictions. This model was adopted in Queensland in 2011, and commenced on 1 January 2012.

616. When Queensland adopted the model WHS laws in January 2012, it delayed the commencement of the five yearly renewal cycle for registration of items of plant and preserved the existing annual registration cycle due to operational and systems considerations. This is further explored below.

2011 WHS Act – Regulator Responsibilities

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617. The WHS Act imposes a range of duties on persons and owners of plant (amusement devices), which are relevant to the design, maintenance and provision of safe plant. In discharging these responsibilities, OIR, as the Regulator of Amusement Parks, have three distinct functions:

• Administrative;
• Compliance monitoring and engagement; and
• Enforcement and sanctions.

Administrative Functions as of October 2016

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618. The statutory regime administered under OIR includes requirements for plant registration and plant design registration, with certain classes of amusement devices requiring registration design and item registration. This has been a feature of the legislation in Queensland for many years, and was intended to check that the design of an item of plant had a complied with the published technical standards and engineering principles applicable to the plant.

Plant Design Registration

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619. Pursuant to s.259 of the Regulations, registration for plant design for a device is a one-off process, unless the design is altered or modified. Plant design registration requirements are generally consistent across all Australian jurisdictions.

620. There are currently 15 types of plant requiring design registration, which includes items such as amusement devices, cranes, lifts and pressure equipment. In particular, design registration for amusement devices is covered by s.2.1 of AS3533 – Amusement Rides and Devices.

621. The registration process consists of verification through several steps:

• Initial application consisting of design plans, technical standards and the assessment carried out by an independent competent person (a registered professional Engineer). 
• Verification by the OIR Engineering Unit, which may include additional requests for information to address discrepancies. 
• Should the Engineering unit remain concerned, an audit against the design and application is undertaken to ensure requirements are met. 
• Design registration is only certified if the plants design satisfies this process and registration fees are paid.

622. Under the Regulations, the design verifier must be a competent person and must not have been involved in the production of the design or engaged by the design company at the time it was developed. A competent person for design verification, under s.252 of the Regulations, means a person who has the skills, qualifications, competence and experience to design the plant or verify the design. For Queensland, this means a suitably qualified and experienced RPEQ.

623. Items of plant requiring design registration under s.243 the Regulations are coordinated by the OIR Engineering Services Unit. When Theme Park Operators are planning to install new amusement devices, OIR’s Chief Safety Engineer will provide input to ensure health and safety legislation and Australian Standard requirements are met.

624. The OIR Engineering Services Unit provides advice and strategic leadership on plant-related safety matters under the WHS legislation, as administered by OIR. This includes providing engineering support to the OIR investigation team when the incidents they are investigating involve the operation of plant, which include amusement devices.

Plant Registration Renewal

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625. Separate to the design registration of a piece of plant, items of plant are then required to have their registration renewed annually. The OIR Licensing and Advisory Services unit co-ordinates the items of plant requiring registration under s.246 of the Regulations. The registration involves a yearly application for plant registration, either lodged online or via a hardcopy using the requisite application form. A processing fee is applicable, following which a certificate of registration is provided.

626. For registration renewal of plant, the Regulator is not required to inspect the plant or verify any element of its safety as part of the process. Accordingly, the requirement to register items of plant is ‘an administrative transaction between the person with management or control of the plant (e.g. the plant owner) and the regulator’. The duty to inspect the plant rests with the plant owner and the registered professional engineer.

627.The registration of plant items provides OIR with a database, which records all of the location and owner details of plant items in the event that this information needs to be accessed following a safety concern.

628. For operational and OIR reasons, at the time of the national harmonisation in the work health and safety laws in 2012, Queensland did not move to the five yearly renewal cycle for plant registration provided under the model WHS laws. It seems that the primary reason for the delay in Queensland moving to the five year renewal period was the ‘significant upgrade it would require to the Office of Industrial Relation’s information technology system’.

629. Current plant item registration requirements continue to differ amongst the States with annual registration renewal required in Queensland and NSW, with five year renewal for Tasmania, South Australia, Northern Territory, the ACT and the Commonwealth.

 

 

Edited February 25, 2020 by Jamberoo Fan

[webslave]

  On 25/02/2020 at 4:11 AM, Levithian said:

He felt strongly enough about the additional upgrades to include them in his proposal and actually says the upgrades would improve safety, so how can you say he felt otherwise?

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For a few reasons (my bolding):

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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.

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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.

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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’. 

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He did not consider, however, that the state of the control panel adversely affected the safety or operation of the ride.

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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.

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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.

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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.

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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.

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Where is he saying that the main control panel upgrades are to improve safety?

  On 25/02/2020 at 4:11 AM, Levithian said:

skilled, engineering employee creates a proposal seeking to address monitoring of water levels and implementing an automatic control measure; do you think this is done because it is a critical risk already highlighted and understood, or do you think there is still some conjecture as to if he felt the water level was a safety risk at all and just proposed the additions for seemingly monetary value?

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I think the parts I've provided immediately above should answer this for you.  Just in case you're unaware, Mr Ritchie was a supervisor in E&T (Electrical) and was a qualified electrician.  Is he the guy who you'd think would be concerned with water levels and risk of such?  And even if he was, based on the report what confidence do you think I should have in the competence of these people?  He's the same guy who felt that just resetting power to the pump drive to fix it was good enough and didn't cause any risk should it cause further faults!  On the basis of a statement from him that a pump fault does not constitute a risk how do you justify your belief that he would have concerned himself with monitoring water level?

  On 25/02/2020 at 4:11 AM, Levithian said:

Even if you want to argue he had no idea, someone above did or should have. And if they didnt, the person above them should have. The proposal shouldnt have been ignored, it should have been followed up and investigated. The engineering manager even agrees this should have happened and this is simply just another example of the opportunity dreamworld had to address a critical flaw in the rides operation which was mismanaged.

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I think the part you're missing here is that this was a proposal to clean up wiring at a main control panel that was a rats nest from an electrician.  I've seen no evidence it was ever presented as a safety-critical item, and haven't seen you quote any yet.  Do you know of any?

[DaptoFunlandGuy]

  On 25/02/2020 at 4:11 AM, Levithian said:

if he felt the water level was a safety risk at all and just proposed the additions for seemingly monetary value?

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Just on this monetary argument - I feel like a person working at the park, knowing that very little gets done unless it makes money, wouldn't you be inclined to push the cost saving factor as a way to get it approved?

[webslave]

  On 25/02/2020 at 5:07 AM, AlexB said:

Just on this monetary argument - I feel like a person working at the park, knowing that very little gets done unless it makes money, wouldn't you be inclined to push the cost saving factor as a way to get it approved?

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You might if you wanted to do it.  If it was for safety though, don't you think you might mention it at all?

[Original]

What struck me with this ride, with as complicated as it was to run why did DW only run it with 2 ops. We obviously know cost cutting. But it should have always at least had 3. One on the control panel watching CCTV and keeping an eye on the conveyor, one on load and one on unload. In the same way West has three people working in the stationary and four in peak periods, with the fourth person working as a grouper. And let's not forget West has someone in the turntable room. 

I always think if the ride had also had three people working along with more modern automated systems running would have gone a long way to prevent this. 

[webslave]

  On 25/02/2020 at 5:30 AM, Original said:

I always think if the ride had also had three people working along with more modern automated systems running would have gone a long way to prevent this. 

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More modern automated systems would have made the number of people working on it all but irrelevant.  Adding more people without better systems is unlikely to have prevented this, though.  

[Original]

Someone's sole job to watch the ride, especially the conveyor since a lot of emphasis was put on doing this, could have helped, they could have seen the raft stuck and started a shutdown of the conveyor until it could be moved. Not like how it was previously run, do your job of loading or unloading, plus watch over the main control panel or conveyor at the same time. 

Might as well tell MW they can cut back on their staff on West because its control system was completely upgraded recently. Really, no matter how modern and automated it might be, IMO someone should always have the sole job of watching the main control panel and CCTV of the ride. That would be my guess why MW has one person always stationed on the main controls of every major ride at their park and at SW too, especially if the ride is in constant operation like TRR was. I'd actually love to hear from previous VRTP employees who might have an idea exactly why their parks don't have their operators doing two high priority tasks at the same time.  

It would also follow the practice of most major parks I have seen. But then again its clear DW didn't like following the practices of every other major theme park operator in the world. 

[Jamberoo Fan]

AMUSEMENT PARK REGULATION IN QUEENSLAND

  Reveal hidden contents

Administrative Functions as of October 2016

  Reveal hidden contents

Safety Regulations for Plant

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630. The regulation of plant safety, which is separate to the requirements for plant design and item registration, has significantly changed in Queensland over the past decade.

631. Prior to the implementation of the national model WHS laws, there were general workplace health and safety obligations in the Workplace Health and Safety Act 1995 (repealed) on persons conducting business or undertaking; designers, manufacturers and suppliers of plant; erectors and installers of plant; owners of plant and persons in control of fixtures, fittings of plant in workplace areas. Generally, the obligations included providing and maintaining safe plant, ensuring the safe design of plant and to ensure the plant is maintained in a condition that ensures the plant is safe. The supporting Workplace Health and Safety Regulation 2008 (repealed) was limited to control of high risk plant by way of registration of plant items and plant designs based on the list of plant in the National Standard for Plant. No other specific safety regulations for plant existed at the time.

632. Practical advice on managing risks were provided in the former Plant Code for Practice, which included guidance on inspection programs, frequency and documentation. The former Code stated that plant should be serviced and maintained in accordance with the manufacturer’s specifications if applicable, and if not, in accordance with other proven and tested procedures.

633. The introduction of the national model WHS laws in Queensland in January 2012, provided more comprehensive regulatory provisions specifically related to the registration and maintenance of plant, including amusement devices.

634. The provisions relating to plant safety in the Regulations are contained within ss.204-213, and generally relate to the control of risks, proper use of plant, guarding, emergency stops and maintenance and inspection of plant.

635. Relevantly, ss. 210, 211 and 213 of the Regulations specifically state:

210 Operational controls

1. The person with management or control of plant at a workplace must ensure that any operator’s controls are

(a) identified on the plant so as to indicate their nature and function and direction of operation; and

(b) located so as to be readily and conveniently operated by each person using the plant; and

(c) located or guarded to prevent unintentional activation; and (d) able to be locked into the ‘off’ position to enable the disconnection of all motive power

Maximum penalty – 60 penalty units. …

211 Emergency stops

1. If plant at a workplace is designed to be operated or attended by more than one person and more than one emergency stop control is fitted, the person with management or control of plant at the workplace must ensure that the multiple emergency stop controls are of the ‘stop and lock-off’ type so that the plant cannot be restarted after an emergency stop control is reset.

Maximum penalty – 60 penalty units.

2. If the design of plant at a workplace includes an emergency stop control, the person with management or control of the plant at the workplace must ensure that –

(a) the stop control is prominent, clearly and durably marked and immediately accessible to each operator of the plant; and

(b) any handle, bar or push button associated with the stop control is coloured red; and

(c) the stop control cannot be adversely affected by electrical or electronic circuit malfunction.

Maximum penalty – 60 penalty units.

213 Maintenance and inspection of plant

(1) The person with management or control of plant at a workplace must ensure that the maintenance, inspection and, if necessary testing of the plant is carried out by a competent person.

Maximum penalty – 36 penalty units.

(2) The maintenance, inspection and testing must be carried out –

(a) in accordance with the manufacturer’s recommendations, if any; or

(b) if there are no manufacturer’s recommendations, in accordance with the recommendations of a competent person; or

(c) in relation to inspection, if it is not reasonably practicable to comply with paragraph (a) or (b), annually.

636. A ‘competent person’ for the purpose of s.213 of the Regulations is defined in Schedule 19 as, ‘a person who has acquired through training, qualification or experience the knowledge and skills to carry out the task’.

637. In relation to the control measures for amusement devices, ss.238-241 of the Regulations are applicable.

638. Relevantly, ss. 238, 240 and 241 of the Regulations provide:

238 Operation of amusement devices

(1) The person with management or control of an amusement device at a workplace must ensure that the amusement device is operated only by a person who has been provided with instruction and training in the proper operation of the device.

Maximum penalty – 60 penalty units.

(2) The person with management or control of an amusement device at a workplace must ensure that –

(a) the amusement device is checked before it is operated on each day on which it is to be operated; and

(b) The amusement device is operated without passengers before it is operated with passengers on each day on which the amusement device is to be operated; and

(c) the daily checks and operation of the amusement device without passengers are properly and accurately recorded in a log book for the amusement device.

Maximum penalty – 36 penalty units.

240 Maintenance, inspection and testing of amusement device

(1) The person with management or control of an amusement device at a workplace must ensure that the maintenance, inspection and, if necessary, testing of the amusement device is carried out –

(a) by a competent person; and

(b) in accordance with –

(i) the recommendations of the designer or manufacturer or designer and manufacturer; or

(ii) if a maintenance manual for the amusement device has been prepared by a competent person, the requirements of the maintenance manual.

Maximum penalty – 60 penalty units.

(2) A person is not a competent person to carry out a detailed inspection of an amusement device that includes an electrical installation unless the person is qualified, or is assisted by a person who is qualified, to inspect electrical installations.

241 Annual inspection of amusement device

(1) The person with management or control of an amusement device at a workplace must ensure that a detailed inspection of the device is carried out at least once every 12 months by a competent person.

Maximum penalty – 60 penalty units.

(2) An inspection must include the following –

(a) A check of information about the operational history of the amusement device since the last detailed inspection;

(b) A check of the log book for the amusement device;

(c) A check that maintenance and inspections have been undertaken under section 240;

(d) A check that any required tests have been carried out, and that appropriate records have been maintained;

(e) A detailed inspection of the amusement device to ensure compliance with the Act and this regulation (including a specific inspection of the critical components of the amusement device).

(3) The regulator may extend the date for an inspection by up to 35 days if an inspection is scheduled to coincide with the same event each year.

(4) If the date is extended under subsection (3), the new date is the date from which future annual inspections of the amusement device are determined.

(5) In this section – Competent person means a person who –

(a) In the case of an inflatable device (continuously blown) with a platform height less than 9m- has acquired through training, qualification or experience the knowledge and skills to inspect the plant; or

(b) In the case of any other amusement device –

(i) Has the skills, qualifications, competence and experience to inspect the amusement device; and

(ii) Is registered under a law that provides for the registration of professional engineers; or

(c) Is determined by the regulator to be competent person.

(6) The regulator may, on the application of a person, make a decision in relation to the person for the purposes of subsection (5), definition competent person, paragraph (c) if the regulator considers that exceptional circumstances exist.

(7) An annual inspection under an equivalent provision of a corresponding WHS law is taken to be an annual inspection for the purposes of this section.

639. The current Regulation requires that the inspection of an amusement device pursuant to s.240 is to be carried out by a registered professional engineer with the appropriate skills, qualifications, competency and experience. This is a reflection of the consensus reached during the development of the national model WHS laws, that a competent person to inspect plant should have academic or vocational qualifications in a relevant engineering discipline and knowledge of technical standards. At the time, Engineers Australia recommended that a professional engineer should be the person who is competent to inspect plant due to the complexity and high risk nature of the plant.

That's now just about 2/3 of the Queensland Coroner's Findings Of Inquest so far. Hope it is convenient for you all. I'll post the last third over the coming days. In the meantime, you can read the full report via @webslave's post.

Edited February 25, 2020 by Jamberoo Fan

[joz]

One of the things reading the report is jist how set up to fail the ops were. Their workload was pretty well maxed out when things were working properly, add to that a situation where there are multiple ways to respond so you have to diagnose the ride and keep it safe as well as do everything else. It wouldn't be so bad but DW knew that the ride ops were their control measure for a number of things.

 

The chat in here is about being cheap, while I've no doubt they were, to me the whole thing seems more like pure incompetence. The engineering let the ride ops down something fierce, and it's actually really disgusting that at the start of the inquest the park's lawyers tried to blame them.