Thunder River Rapids Incident Coronial Inquest Findings

[DaptoFunlandGuy]

1 hour ago, webslave said:

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

I'm really taking this to the ludicrous extreme here, and don't seriously believe it (although i don't really know what to believe anymore) but if you had seen so many 'safety' issues brushed under the rug, why would you bother, when you know 'save 30% on our power bill' would be a slam dunk win?

47 minutes ago, webslave said:

More modern automated systems would have made the number of people working on it all but irrelevant.

Honestly though - 'more modern' is the wrong term for this. The technology for this to be a safe system existed in the 90s. Intamin's rapids ride (and i'm using Wonderland as an example here) had continuous load stations just like TRRR did when it was first built.

Wonderland's turntable was also switched off, I believe sometime in the late 80s or early 90s, and airjacks were installed to physically hold the rafts in position for load, unload and despatch. A series of infra-red beams were installed from the bottom of the conveyor to the top, at unload, load, and despatch, and the PLC was capable of monitoring the position of the rafts.

Operators had manual control of raft release at load and unload, but the PLC controlled the conveyor, and wouldn't release a raft into the unload zone while it was occupied. Further, A despatch jack would hold a raft from despatching too closely after a raft had already been despatched.

Picture below: Airjacks (metal frame with timber planking) to the right of the raft, and the despatch sensor beam (bottom left) mounted on the steel railings immediately below the loaded raft.

I know for certain that the conveyor had a beam across it to track rafts nearing the unload point, but try as I might, I simply cannot locate a picture of it.

 

Tales from the Wonderland Maintenance Bay:

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We use to inspect the ride first up,. IE walk the channel to ensure all the weir boards were still in place. Check the vertical conveyors and then start the pumps. Then we would inspect all the boats and check air pressures, then hand it over to the operators. The main controls were to stop and start the turn table. the boat spacing was controlled by the PLC and the VSD running the conveyors, the operators could speed the turn table up if they had large gaps between boats or slow it down if boats were space too closely. And of course they had Estops.

I'm not sure if the water geysers were still operational but when we set them up I programmed two modes into the PLC, wet mode for summer and dry mode for winter. Wet mode was just that, YOU WILL GET WET. I still remeber when we commissioned the geysers, we had some of the office people to be the first round, and they got wet.

10 minutes ago, joz said:

 it's actually really disgusting that at the start of the inquest the park's lawyers tried to blame them.

As I mentioned earlier, the coroner made a point of stating right at the start that he found no fault with the ride operators. I agree totally disgusting, but very glad to hear they weren't faulted.

[DaptoFunlandGuy]

27 minutes ago, AlexB said:

I know for certain that the conveyor had a beam across it to track rafts nearing the unload point, but try as I might, I simply cannot locate a picture of it.

Ok, I think this is as good as I can get - this pic is near the end of the conveyor (the wonderland conveyor completely submerged before returning). The support rails on each side of the conveyor have uprights that are level with the channelboards. The indicated upright (and the upright opposite it) are the only uprights that are higher than the channel boards. Additionally, near the tip of the arrow is a white circle, and a white line leading up to it from the bottom. This is most likely a conduit and J-box containing the wiring for the infra-red beam.

And when it rains it pours - here's a second look - this is a still from a maintenance video taken standing in the unload zone trough (dry, obviously) showing the same (far side) upright with the sensor on it:

 

 

lol. Ok, I guess I got carried away 'in wonderland' but the point is, these automated systems weren't new. or modern. they just weren't reliant on operators to maintain total control over every safety aspect on the ride.

On quiet days, Wonderland could operate Snowy with ONE staff member, who was capable of parking the raft, supervising guests as they self loaded, despatching the raft, monitoring it throughout the watercourse, receiving it up the conveyor and parking it for unloading. I'm sure given recent events, if Snowy were still operating, a full review of operations procedures would probably have occurred...

(There is even a video of maintenance workers riding it - without anyone at the operator controls, although for obvious reasons I don't suggest this is a wise move)

[New display name]

3 minutes ago, AlexB said:

lol. Ok, I guess I got carried away 'in wonderland' but the point is, these automated systems weren't new. or modern. they just weren't reliant on operators to maintain total control over every safety aspect on the ride.

 

Of course they were not new and the TRR had them to turn off the waterfall, start the lighting effect in the cave and turn Henry the elephant's trunk on. 

[DaptoFunlandGuy]

7 minutes ago, Skeeta said:

Of course they were not new and the TRR had them to turn off the waterfall, start the lighting effect in the cave and turn Henry the elephant's trunk on. 

Any monkey can build an effect that triggers when the beam is broken. Effects triggers don't need to be built into the ride's PLC.

Which is why it's perfectly acceptable to let effects triggers rot on WWF - they don't compromise safety.

I'm still reading the report in parts. its going to take a while, but from what i'm reading, it sounds like the despatch control system they had installed was a simple timer that would only open the despatch gate every XX seconds (whether or not there was a raft present), rather than a block control system. This makes sense because of the stoppage procedures requiring the raft at the despatch gate to be tied to the dock and the emergency gate to be shut.

This was a measure put in place to space out the rafts, to prevent stacking in unload, the cause of the older (2001?) incident.

If, rather than a simple timed gate, they'd have implemented a block safety system (a very well established method of maintaining separation on an amusement ride) at that point, none of this would have happened.

[GoGoBoy]

This is what I've wondered all along -- why on earth was there not a basic block system installed with the same sensors you see on almost every water ride in the world. The conveyor would have just stopped moving once the stuck raft didn't pass the sensor in time. Surprisingly, this doesn't seem to have come up in any of the coroner's deliberations during the case? I know the water level sensor was mentioned. I guess it's more or less covered under the comments around lack of ride automation / engineering controls?

Edited February 25, 2020 by GoGoBoy

[rappa]

The persons that ‘should’ have been responsible at Dreamworld for safety of this ride had the same risk assessment training I have. 

They had more experience working with amusement rides than I have. 
Yet they failed to see ANY of these risks, let alone all of them and claim they couldn’t possibly have known/shouldn’t have had to know. 
 

Shame on them for their slackness and incompetence and disgraceful of them that they don’t take responsibility today. 
 

The actions of every person responsible for the management of ride operations and maintenance in that place were down right disgusting. 

Edited February 25, 2020 by djrappa

[RobMac]

Been painful to watch DW decline over the last 20yrs...corporate bankers generally don't make good theme park operators.

[Jamberoo Fan]

AMUSEMENT PARK REGULATION IN QUEENSLAND

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Compliance Monitoring and Engagement

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640. Mr. Michael Chan is the Director and Chief Safety Engineer, Engineering Unit for OIR, a position he has held since 2004. He is a Chartered Professional Engineer with more than 40 years’ industry experience. He is a Registered Professional Engineer with the Board of Professional Engineers Australia. Mr. Chan is also a member of Engineers Australia at the fellow grade and is an Honorary Fellow of the Safety Institute of Australia.

641. As the Chief Safety Engineer, Mr. Chan is responsible for the design registration of high risk plant and also provides technical advice to the plant item registration function. He manages the Engineering Unit at OIR, which consists of six Engineers. 

642. Recorded as assessments or advisories within the OIR case management system (CISr), OIR undertakes compliance monitoring and engagement both proactively and reactively. Assessments are conducted as workplace visits by inspectors to assess compliance with the relevant legislation, and may be planned proactively or as a response to a complaint or incident.

643. An advisory generally represents engagement activities undertaken to advise, inform and consult with the industry. This may include planned advisory interventions, industry forums or individual interactions between inspectors and workplaces.

644. Since 2002, OIR have conducted 8702 assessments pertaining to Theme Parks or amusement devices. Assessments have, on a yearly basis, increased from 547 to 697 a year (pre and post 25 October 2016).

645. A majority of these assessments were recorded as ‘proactive’ meaning that they were not linked to an event. Before 25 October 2016, OIR proactively inspected 4074 general amusement devices, and 2779 regional shows, school fete and festivals. ‘Reactive’ assessments, which are linked to an event or complaint prior to 25 October 2016, were carried out on 46 general amusement devices, and 43 regional shows, school fete and festivals.

646. In relation to Theme Parks, 111 proactive inspections were carried out at Dreamworld prior to 25 October 2016, with 20 reactive inspections recorded. Following the tragic incident, 134 proactive inspections were conducted at Dreamworld, with 10 reactive inspections being carried out. Prior to 25 October 2016, 101 proactive assessments had been carried out at Movie World, with 18 reactive assessments.

647. OIR have also carried out 4,830 activities pertaining to Theme Parks or amusement devices since 2002. A majority of these (74%) were site visits largely at regional shows, school fetes and festivals. Mr. Chan gave evidence that a total of 128 amusement device incidents were reported in Australia from 2000 to September 2018. The analysis of data showed over 96% of those incidents related to mobile rides; 4% related to fixed rides at Theme Parks.

648. With respect to statutory notices issued to Theme Parks or amusement devices since 2002 up until the tragic incident, Dreamworld received 34 notices, the highest for all of the Theme Parks, and the Ekka. Movie World and Wet N Wild for the same period, received no notices. Following the 25 October 2016, 17 notices were served on Dreamworld, with Movie World receiving two and Wet N Wild receiving one.

649. During the inquest, Mr. Chan acknowledged that the Regulatory framework in place at the time of the incident in relation to amusement devices effectively expected Theme Parks to have developed and implemented safety management systems, including maintenance, operation, training and emergency control, with the qualified engineering and other staff to action it.

Industry Guidance & Engagement Activity

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650. The OIR Chief Safety Engineer and Engineering Unit members meet with the major amusement device stakeholders (including Theme Park Operators) approximately twice a year, or as much as may be required due to emerging issues. An example would be a meeting which took place with staff at Movie World in 2015, following an incident involving critical bolt failures on the Green Lantern Ride.

651. As the Chief Engineer of OIR, Mr. Chan facilitated the development of the National Audit Tool for Amusement Devices in 2005. This Tool was intended to enhance the consistency and transparency of audit procedures for amusement devices, and covers all facets of maintenance and operation of amusement devices. Mr. Chan has also provided national training sessions on the application of the Audit Tool in Melbourne and Tasmania for WHS Inspectors from all Australian WHS regulators. The Tool has since been adopted by industry and all WHS Regulators around Australia.

652. Mr. Chan facilitated the development of a register as a database to record serious incidents involving amusement devices and enforcement notices issued by every Australian WHS Regulator on amusement devices. Since 2005, Queensland has been the custodian of the register, which is shared with all WHS Regulators in Australia. The data is collated and analysed annually and shared with industry stakeholders as performance graphs.

AALARA Forum

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653. Since 2003, OIR have been associated with the Australian Amusement, Leisure and Recreation Association Inc. (AALARA). As the peak national body representing the amusement, leisure and recreation industry of Australia, AALARA is responsible for safety, operations and management.

654. At the annual conference convened by AALARA, a regulators and stakeholders forum chaired by OIR, to discuss safety issues affecting the amusement device industry is conducted (e.g. the development and implementation of the National Audit Tool for Amusement Devices). OIR works closely with AALARA to identify safety concerns and also publishes OIR information sheets (i.e. new regulations) and alerts (relating to amusement devices safety) on their magazines.

Annual Amusement Device Stakeholders Forum

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655. Commencing in 2003, OIR hosts an Annual Amusement Device Forum, which includes Theme Park representatives, industry engineers and Interstate Regulators. The information presented canvas various topics, including recent safety incidents and issues with amusement devices, as well as learning the outcomes resulting from OIR audits of amusement rides, revision of the Australian Standards and design registration requirements.

Functional Safety Forum

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656. On 9 August 2016, OIR held a Functional Safety Forum, which included Theme Park representatives, functional safety engineers and Interstate Regulators. The forum focused on the validation procedures for safety controls systems of plant (i.e. what the validation process includes, engineering qualifications required, and the OIR auditing process).

Published Guidance Material

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657. The following Safety Alerts have been published by OIR as a consequence of a number of incidents involving amusements rides:

• 2009 Safety Alert – Risk of being hit by moving parts of an aerial amusement ride;
• 2010 Safety Alert – Inflatable water balls;
• 2013 Safety Alert – Safety of amusement rides;
• 2015 Safety Alert – Re-design of rider restraint systems on amusement devices; and
• 2015 Safety Alert – Setting up and dismantling of amusement rides.

658. Post the tragic incident, OIR have published a number of Safety and Incident Alerts, including: 

• 2017 Incident Alert – Child injured after jumping castle became airborne;
• 2017 Safety Alert – Uncontrolled starting of amusement device; and
• 2018 Safety Alert – Inflatable water balls – electrical equipment near water.

659. Provided by Safe Work Australia as information for the public, nine packages of national guidance material to support the WHS Act 2011 and the WHS Regulations 2011 were published on the OIR website. Of the nine packages, one was the relevant Amusement Devices General Guide.

60. For guidance on complying with obligations under the WHS Act, industry participants may refer to the ‘Managing risks of plant in the workplace – Code of Practice 2013’. The Code was established under s.274 of the WHS Act and may be used in proceedings as evidence of whether or not a duty or obligation under the Act has been complied with. The Code provides advice on the safe use of plant and references technical standards that provide guidance on the design, manufacture and use of certain types of plant. For amusement devices the Code references Australian Standard AS3533.1 – 2009: Amusement Rides and Devices for design, manufacture and use.

Enforcement & Sanctions

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661. OIR enforces compliance with obligations owed under statutory regime consistent with guidance published in the Safe Work Australia National Compliance and Enforcement Policy.

662. Enforcement responses include the issuance of statutory notices requiring contraventions be remedied, unsafe activities prohibited and unsafe equipment not be used. In addition, enforcement may involve monetary fines, prosecution of offenders through the judicial system, and revocation or alteration of licenses issued by the regulator.

Compliance Notices

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663. OIR introduced an Enforcement Note in March 2012. This instructed inspectors on the use of prohibition notices under s.195 of the Act, when resolving contraventions relating to plant without design registration.This Note was subsequently withdrawn in December 2015, and appropriate instructions were issued to Inspectors supported by training in the use of the s.191 Act.

Investigations

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664. Records suggest that there have been 68 comprehensive investigations undertaken by OIR at the Theme Parks.

Prosecutions

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665. In 2016, a prosecution was commenced by OIR against one of the major Theme Parks for failing to adequately assess the hazard of metal fatigue, which resulted in one patron sustaining a minor laceration to the forehead. The company received a penalty of $25,000, with the ride being subsequently dismantled and removed from service.

666. In 2017, the prosecution of two matters relating to amusement rides were decided:

• The first matter involved an inflatable jumping castle, which was dislodged. A penalty of $15,000 was imposed.
• The other matter involved a worker who was fatally injured when dismantling an amusement ride. The company received a penalty of $80,000.

667. From June 2011 until the fatal incident in October 2016, OIR had undertook nine investigations involving amusement devices at shows and school fetes. As of October 2016, eight had been finalised with one matter before the court (this has since been finalised).

668. OIR reports that seven matters were successfully prosecuted with penalties ranging from $500 to $40,000 and four of the seven penalties were in excess of $25,000. These prosecutions involved fracture and head injuries where the rider was ejected from the amusement device, and in one case, a worker sustained crush injuries when trapped by moving machinery.

Regulatory Focus on Mobile Amusement Rides

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669. Prior to the tragic incident at Dreamworld in 2016, OIR’s efforts to monitor compliance for amusement devices had been focused on amusement devices at major agricultural shows, local carnivals and school fetes. This was due to the mobile nature of the amusement devices at these events, in addition to their frequent erection and dismantling. Furthermore, due to the transient nature of the operations, it was reported to be difficult to regulate without significant resource allocation.

Previous Notifications Made to OIR in Relation to the TRRR by Dreamworld

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670. OIR records clearly show that since the approval of the design of the TRRR on 14 August 1987, there have been no notifications made by Dreamworld as to the ride being altered or modified as part of the design registration process.

 

 

CLASS 2 RIDES INSPECTION & REGISTRATION

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671. From 1999, all data records relating to plant item registration were stored by OIR electronically in the Plant Admin System. Records relating to the TRRR since this time confirm that the requisite renewal applications were submitted up until 2015.

672. In 2015, OIR undertook a review of the processes that supported plant item registration, as plant and financial records were identified as requiring a significant cleanse. After the due date for the registration renewals of 31 January, there were a number of business processes to be completed before the list of plant owners with outstanding registration renewals could be compiled. Approximately, 2,400 renewal applications are made each year via hard copy application forms, rather than electronically. These forms are manually entered into the system via an online portal by a third party contractor. In February, invoices for registration fees are issued for those with unpaid renewal applications received between 1 December and 30 January.

673. Records suggest that in 2016, approximately 5,400 renewal forms were sent out, which covered 30,000 pieces of plant in Queensland.

Dreamworld’s Compliance with the Requirement for Renewal of Plant Registration

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674. Following the introduction of the harmonised legislation in 2012, particularly s.241 of the Regulations, it does not appear that there was a conclusion reached amongst Dreamworld’s management as to how compliance for the renewal of plant registration would be achieved. Legal representatives for Ardent Leisure advised OIR during the audit process undertaken as a result of this tragic incident that the following ‘system’ approach was adopted to the requirement for a ‘competent person’ by Dreamworld, which encompassed the following:

- Our Chief RPE Bob Tan who oversaw the system (a veteran Amusement Park RPE of 28 years’ experience).

- Maintenance and inspection regimes based around:

-  OEM recommendations

- Trend analysis

- Industry advice

- Regulatory bulletins and documents

- A tiered approach to on-site engineering personnel undertaking inspections (e.g. qualified trades, Team Leaders, Supervisors and Senior Managers – all of whom are trained and assessed as competent to undertake maintenance tasks, including annual maintenance inspections).

- Periodic inspections intervals based on modern and more current condition monitoring equipment for acute failure detection.

- Use of local and international audit professionals to audit all facets of:

- Management policy

- Compliance with local laws, standards, industry bulletins etc.

- Document control

- Training and competence

- Accuracy of inspections

- Change management policy

- Ride operation

- Technical integrity

- This systematic approach assists with:

- Compliance with the national regulators auditors tool

- Compliance with OEM inspection

- Fitness for purpose on all repairs/inspections 

- An auditable system of non-routine defects

675. Whilst Mr. Tan was never RPEQ certified, there seems to have been an assumption made within Dreamworld that his ‘expertise’ was sufficient to certify the rides for annual registration renewal. In relation to the required annual inspection of the amusement devices pursuant to the Regulation, Mr. Tan was aware that this had to be done by a ‘competent person’, however, this did not mean an RPEQ. After the changes to the Regulations were made in 2012, Mr. Tan stated that despite conversations with Mr. Deaves, there was no conclusion reached within Dreamworld as to how the annual inspections conducted would comply with the new requirements. Accordingly, the same process was followed through the annual and periodic inspections of the amusement devices at Dreamworld by members of the E&T Department. He stated during the inquest that it was not his responsibility to action the annual renewal applications for plant registration, as this was a matter for the Safety Department. Rather, Mr. Tan was involved in the initial registration, as this was a more rigorous process, including close communication and coordination with the manufacturer.

2016 Dreamworld Plant Registration

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676. On 16 December 2015, plant registration renewal forms for the 2016 registration period were sent to Ardent by a third-party processing provider. Payment for registration of 25 amusement devices were made by Ardent on 25 February 2016, however, no completed registration applications were received.

677. On 29 July 2016, OIR sent correspondence to Dreamworld reminding them of the requirement to renew registrable plant by a competent person, per the requirements of the Regulation. It was noted that the application for renewal of the amusement devices was incomplete, and all of the amusement devices at Dreamworld were unregistered. A 28 day period from the date of the letter to complete the registration renewal process was provided.

678. On 11 August 2016, OIR Chief Engineer, Mr. Chan, with OIR Principal Advisor, Mr. Terry O’Sullivan from the Engineering Unit, met with Mr. Deaves and Mr. Hutchings to discuss plant item registration requirements under the Regulation for amusement devices at Dreamworld. The purpose of the meeting was to discuss ss.240 and 241, in particular the requirement of a competent person to conduct annual inspections on registrable amusement devices. According to Mr. Chan, Mr. Deaves and Mr. Hutchings explained that whilst Dreamworld had implemented comprehensive maintenance, inspection and testing regimes on all amusement rides at the Park, they had not engaged a registered professional engineer to conduct annual inspections pursuant to the requirements of s.241 of the Regulations. As such, Dreamworld were not able to register their amusement devices.

679. Mr. Deaves and Mr. Hutchings proposed that Dreamworld be exempt from needing to engage a registered professional engineer under s. 241(5)(b) of the Regulation, and in lieu OIR accept that an effective ‘in house maintenance and inspection system’ had been implemented. Mr. Chan claims that he advised them that such a proposal was not acceptable pursuant to the Regulations, and that the annual inspection must be performed by a suitably qualified and experienced person and not by a ‘in-house maintenance, inspection and testing system’.

680. On behalf of Dreamworld, Mr. Thompson subsequently sent a letter to OIR via email on 16 August 2016, stating the following:

At the time of renewal, Dreamworld was of the belief that compliance with s241 of the Regulations (2011) had been achieved. Our continuous maintenance programme utilises inhouse professional Engineers and a range of external professional Engineers to undertake the required annual inspections. It was felt that this combination of engineering expertise was sufficient to meet the definition of “competent person”.

Since this time, we have held in-depth discussions with OIR Chief Engineer Michael Chan regarding the definition of “competent person”. In particular, our current combination of Engineers lacks the registered professional engineers (RPE) certification and hence does not meet the definition of competent person.

We acknowledge this technical non-compliance and have been working quickly to identify an appropriate RPE who can undertake the necessary inspections and sign-off. Our RPE can commence the inspections in early September and have them concluded by the end of September (there are some 35 amusement devices in the Dreamworld fleet).

Accordingly, we would respectfully ask for an extension of time to undertaken these assessments in order to comply as quickly as possible with s.241. In the meantime, our continuous maintenance programme provides many layers of safety inspection to ensure the on-going safety of all patrons. …

681. During the inquest, Mr. Thompson claimed that he had been provided with the initial correspondence from OIR by Mr. Deaves. There was some subsequent discussion between himself, Mr. Deaves and Mr. Hutchings as to which Department within Dreamworld was actually responsible for ensuring the plant remained registered. In relation to the letter that was sent to OIR under Mr. Thompson’s hand requesting an extension, he claims that Mr. Hutchings had in fact drafted that letter following discussions about the registration requirements with Mr. Deaves.

682. Following receipt of the request for an extension, Mr. Chan discussed the matter with Ms. Johanna Sutherland from the Licensing and Advisory Service Unit, OIR.  He recommended that the extension be granted on the basis that ‘on my knowledge of Dreamworld’s maintenance, inspection and testing regime and that a delay of a few months for a professional engineer to progressively conduct annual inspections will not introduce significant risks to Dreamworld’s continued operation’.  During the inquest, Mr. Chan clarified that whilst he did not have detailed knowledge of the maintenance of individual rides at Dreamworld, he had previously had discussions with Mr. Deaves, with whom he had a long standing professional relationship, about the existence of their inspection and testing program, and this was the basis of his recommendation.

683. Dreamworld were subsequently granted an extension until 30 September 2016, to inspect and assess their plant items for the purpose of the registration renewal. 

684. On 29 September 2016, a further email was sent by Mr. Thompson to Mr. Chan advising that whilst Dreamworld had been able to engage someone to inspect the smaller rides, they had struggled to find a “competent person” to inspect the ‘Big 9 rides’.A further extension until 1 December 2016, for compliance with s.241 of the Regulation was requested. It was noted in the correspondence that the TRRR had been inspected by this date by a “competent person”.Mr. Chan recommended that the further extension sought by Dreamworld be granted on the basis that it would allow the Park to continue its business with some of the ‘unregistered’ amusement devices in operation whilst others ceased for the engineer to conduct the required inspections. 

685. In August 2016, Mechanical Registered Professional Engineer (RPEQ), Mr. Tom Polley from Tom Polley - Machinery Inspection Services, was engaged by Mr. Deaves to carry out Class 2 Annual Inspections on rides at Dreamworld, including the TRRR. Initial correspondence sent to Mr. Polley from Mr. Deaves states the following:

… Our business has been having discussions with WPH&S about the competent person and accountabilities under the regulation for annual inspections.

The preferred model for us would be to make the business as an entity accountable for the auditing of the appropriate professionals required to ensure safe operation of equipment.

As you know the Queensland regulation is written and at this time does not allow for this option. In order to maintain plant registration we are required to have our rides inspected before the end of September. Is this a service you could provide for us in the time frame available.

Attached is a list of equipment. Many of the rides are small and our documentation is good….

686. Mr. Polley, who has experience in the amusement ride industry since 1992, agreed to conduct inspections for the Class 2 rides on 12 September 2016, charging a rate of $1200 per day. He indicated that he would need to inspect the ride and view documentation. Mr. Polley was subsequently provided with plant registration numbers for some of the rides by way of a spreadsheet. He did not request to see, and was not shown, the current Certificate of Registration for each item of plant he was asked to inspect.

687. Mr. Polley states that he requested from Mr. Deaves and Mr. Cruz maintenance documentation of all the Class 2 Rides for the past 12 months, in order to assist him in completing his inspections and subsequent reports. He claims that during conversations as to these documents, he was advised that Dreamworld had been focusing on getting their maintenance documentation up to an acceptable level for the Class 5 rides, which are the bigger thrill rides. As such, he was told that there was no maintenance documentation available. He subsequently requested from Mr. Cruz records as to the annual inspections conducted previously.

688. In relation to the TRRR, Mr. Polley claims that he did not receive any completed maintenance documentation or log books, rather he was provided with a blank Daily and Annual Inspection Schedule via email. Mr. Polley was advised that there had been no issue with the TRRR for the past 12 months, and that there was no current maintenance documentation due to the effort being put into the Class 5 rides.

689. According to Mr. Cruz, Mr. Polley was provided with the ‘entire maintenance program’, for each of the rides he was asked to inspect. At inquest, Mr. Cruz clarified this to mean a copy of the preventative maintenance checklists for the daily, weekly and monthly inspections, leading up to the annual shutdown. He does not recall providing Mr. Polley with maintenance records, including downtime reports. At Mr. Deaves request, Mr. Cruz accompanied Mr. Polley around each of the rides as he carried out his inspections and outlined the daily inspection checks undertaken for each ride.

690. In relation to the TRRR, Mr. Cruz gave evidence that the only information he provided Mr. Polley was the preventative maintenance checklists.

691. On 29 September 2016, Mr. Polley attended Dreamworld and conducted a visual inspection of the TRRR, which was limited to the mechanical and structural aspects of the ride, and did not include the electrical or operational systems.

692. Despite being the Ardent Group Safety Manager, Mr. Hutchings had no involvement with engaging Mr. Polley.

Certificate Issued for TRRR

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693. An Annual Mechanical and Structural Inspection Certificate/Report 39/16 (the Certificate) was subsequently issued by Mr. Polley for the TRRR, which was dated 17 October 2016. This certificate states that no faults were found with the following:

• Operational history since the last detailed inspection;
• Log book; and
• Inspection, including accessible critical components.

694. The following recommendation and faults were found with the TRRR: 

• Recommendation 1: Anti Roll Back Gate – Consideration should be given to introducing a scheduled inspection in the Daily Pre-Service Inspection for the anti-roll back gates as the top gate remained open when it should have automatically closed.
• Fault Found 1: Anti-Roll Back Gate – The top gate automatically closing mechanism is not working and must be repaired.

695. The Certificate notes that: 

Statement

A visual inspection of the device (including a specific inspection of visible mechanical and structural critical components) has been completed. This inspection did not include an electrical inspection. In my opinion, this device was mechanically and structurally safe to use at the time of inspection provided the above Recommendation is appropriately considered and the above Fault Found is repaired.

696. Mr. Polley claims that despite a lack of maintenance documentation, he was able to conduct a visual mechanical and structural inspection of the TRRR, based on ‘my observations of issues like oil leaks, wear, cracking, and signs of corrosion, together with assertions given to me by park maintenance personnel that there had been no mechanical or structural issues with the ride in the past 12 months’.

Draft Report for all Class 2 Rides

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697. On 24 October 2016, Mr. Polley sent via email, a draft report to Mr. Deaves and Mr. Cruz with general findings following the annual inspections carried out of all of the Class 2 devices.

698. The draft report outlines generally the applicable OIR legislative framework for amusement device registration. The following limitations of Mr. Polley’s annual mechanical and structural inspections are stated as follows:

- Visually inspecting accessible mechanical and structural components and accessible critical components of individual devices in the presence of Dreamworld technical staff for: o

- Cleanliness including fluid leaks; o

- Wear; o

- Cracking;

-Signs of corrosion; and

- Signs of buckling, permanent deformation, paint cracking, paint flaking or other indications of stress beyond the yield point.

- Perusing a selection of computerised and hard copy maintenance records for individual devices.

- Visually observing electrical issues, however, my annual inspection did not include a detailed electrical inspection. Of note, a detailed electrical inspection should be carried out by a qualified electrical person.

Of note, my annual inspection did not extend to:

• Assessing the competence of technical and operational staff to run the devices;
• A full audit of pressure equipment against the design registration and plant registration requirements of Schedule 5 of Work Health and Safety Regulation 2011, nor did it extend to a full audit against the inspection requirements of AS 3788-2006, Pressure equipment-In-Service equipment; and
• An assessment of bolting hardware and bolting techniques used in critical bolted connections. 

699. In relation to General Findings of the Annual Inspections, Mr. Polley noted that a daily inspection schedule was available for most devices, with a yearly inspection schedule available for some. Furthermore, processes were in place and had commenced for reviewing and updating current inspection schedules for the Class 2 devices, as had been done on the higher class rides.

700. Mr. Polley noted a number of Recommendations in his Draft Report, including the following: 

• Inspection schedules: The organisation should continue, on a risk assessment basis, reviewing all inspection schedules. All devices should have a daily and annual inspection schedule and an analysis should be undertaken to determine the need for any weekly, monthly, three monthly and six monthly scheduled inspections or any other special inspections not based on calendar parameters.
• Documentation following Servicing, Repair and Maintenance: The organisation should introduce a formal procedure for checking all documentation is in order prior to returning a device back to normal use following servicing, repair or maintenance.
• Class of Device: As part of the review of all inspection schedules, the organisation should establish the current Class 2 for the rides inspected is correct in accordance with the Classification requirements of Australian Standard AS-3533.1. The organisation should also record the parameters used to establish the class of ride. 
• Dead Man controls: On a risk assessment basis, each device should be assessed on the need for Operator dead man controls and if required, modifications should be introduced on a priority basis as determined by the risk assessment. Appropriate testing requirements should also be introduced as required.

701. In conclusion, Mr. Polley stated that: In my opinion the organisation will have an acceptable maintenance regime in place once it satisfactorily addresses the Recommendations above including the upgrade and implementation of all inspection schedules for the Class 2 devices.

702. Individual certificates were subsequently provided for each of the Class 2 Rides.

703. At the time of the incident, Dreamworld had engaged Pitt & Sherry, a Specialist International Engineering company, to carry out inspections on the major thrill rides. Representatives from the company were on-site inspecting other rides the day of the tragic incident.

704. Records from OIR confirm that the registration process for all of the amusement devices were completed by 24 January 2017.

 

OIR INSPECTOR AUDITS OF DREAMWORLD PRIOR TO THE INCIDENT

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705. Between 2002 and 25 October 2016, the Regulator conducted a number of compliance activities for Dreamworld and WhiteWater World, which consisted of:

• 38 investigations (interventions with duty holders in response to a notifiable incident, complaint or request for assistance);
• 111 assessments (interventions with duty holders to monitor compliance and record enforcement actions, and in response to a notifiable incident);
• 36 notices (records of the issue of statutory notices to duty holders); and
• 10 advisories (records of inspector interactions with duty holders where there is no anticipation of any compliance action being taken).

706. Principal Inspector Ian Baker, who has been employed by OIR for over 26 years and involved in the inspection of high risk plant at Amusement Parks since 1990, notes that he has always had a productive and professional relationship with Dreamworld. He notes that in his experience, the safety practitioners and Engineering Management at the Park have always been receptive to advice and suggestions made by OIR in relation to any safety matter. He has undertaken numerous site visits to Dreamworld, which were both reactive and proactive, estimating that on average he has attended site approximately once a month. Prior to 2014, Mr. Baker recalls that when he attended site, he used to have extensive contact with Mr. Tan. The last time he attended site for an OIR audit was 3 March 2016.

707. During the inquest, Mr. Baker stated that he had never seen the Operator Procedures nor any documentation in relation to repairs and alterations of the TRRR. He had also not inspected the conveyor of the TRRR during a safety audit at Dreamworld. When shown photographs of the trough of the ride, including the end of the conveyor and steel support railings at the unload area, Mr. Baker acknowledged that there was a ‘nip point’ and that he would have been ‘concerned’ had he observed the area in this manner. He noted that when OIR Inspectors were attending site to carry out a safety audit, they weren’t closely examining the construction and integrity of the amusement device unless a specific complaint had been received. Furthermore, there was no concentrated effort to determine whether a piece of plant had been modified or altered without notification made to the Regulator.

708. In relation to the actions taken specifically for the TRRR by the Regulator prior to the incident, the following was noted:

• 18 November 2003: Two assessments were undertaken as part of a major audit program coordinated by Inspector Ian Baker, for which the TRRR was considered by three inspectors. Notebook recordings of the findings made for these assessments state that this was a large plant audit for which the Theme Park was viewed during a walk around. The TRRR was physically inspected, as was documentation pertaining to the ride. It was noted that ‘no breach of the WH&S Act could be identified’.
• 12 October 2014: A Hazard Specific Workplace Assessment was conducted by Inspector Ian Baker (35774) which was in response to an un-notified incident on 7 October 2004, where rafts collided in the unloading area and a female guest fell into the water as she was disembarking from the raft. The site visit took 1 ½ hours. Notebook recordings of the findings of investigators state that, ‘assessment re safe load & unload procedures. E-Stop fitted at debarkation point. CCTV to monitor point. Electronic stop & release system is being upgraded. 2nd gate option currently being investigated’.

709. Records provided by Ardent Leisure confirm the OIR safety inspections conducted in 2003.Prior to the audit of Dreamworld, meetings were conducted with Inspectors from OIR in order to establish the parameters of the pending audit.

710. Commencing on 18 November 2003, 24 inspectors from OIR attended Dreamworld to conduct the safety audit. This lasted four days, with each group of Inspectors being accompanied by a Dreamworld team member, Mr. Bob Tan, Mr. John Angilley, Mr. Steve Corrie and Mr. Russell Reed. I note in the submissions from the OIR, referring to their document relating to that inspection, there is a reference to electrical GPO’s needing to check inside the pump area of the Rapids ride. The OIR goes on to mention that at the time of the inspection, “the support rails were placed as close as possible to the end of the conveyor; thereby limiting the gap and potential to identify any nip point which may have been evident at the time.” I do not accept this submission. The OIR concede in their submission that Inspector Baker “had not personally looked at the TRRR as a safety audit or for safety aspects of it. On all occasions that Mr. Baker went to Dreamworld, he did not see the TRRR not operating and the water drained from the system.”

711. I find this admission alarming. Especially when considered against the evidence of the independent engineers, and indeed the findings of the inspectors from OIR who attended the scene after the accident, who all agree that the placement of the support rails in proximity to the end of the conveyor created an obvious nip point, as did the spacing between the rails of the conveyor, in contravention of the Australian Standards, and an extreme danger to the passengers in the rafts.

712. I find that had the TRRR been inspected, in its design, condition and layout at the time of the fatal incident, by a properly qualified engineer this serious and highly dangerous situation would have been prevented and the ride closed. Especially against a background of constant breakdown of the water pumping system in place causing regular and frequent drops in the water level, a situation well known to the owners and Operators of the ride as well as inspectors from the OIR.

713. The OIR were also involved with the amusement industry in assisting and consulting extensively with industry stakeholder groups to enhance safety of amusement rides. The Engineering Unit has, over the last 14 years consulted with industry, Engineers Australia and has been responsible for establishing the National Work Health and Safety (WHS) Regulators Group.

 

OIR TECHNICAL ADVICE ABOUT THE INCIDENT

Technical Advice - Principal OIR Adviser (Mechanical), Mr. David Flatman

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714. Principal Workplace Health & Safety Adviser (Mechanical), Engineering Service Unit, Mr. David Flatman provided a detailed report in relation to this incident for the purpose of providing advice to the Legal Unit of OIR. He attended site on a number of occasions, and provided an opinion as to what the contributing factors and likely causes of the incident may have been, as well as the safety issues associated with the maintenance and inspections of the ride. Only relevant technical information as to the incident and cause is detailed below.

715. Mr. Flatman, who is now the Chief Advisor for Engineering Services, Specialised Health and Safety Services with OIR, had almost 10 years’ experience as a Principal Inspector at the time of the tragedy.In this role, he provided technical support to the inspectorate, legal and prosecutions units within OIR, as well as external advice to stakeholders in relation to plant safety. He held engineering roles prior to his employment with OIR.

Inspections and Testing

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716. Mr. Flatman attended the scene on a number of occasions and was involved in the re-enactment testing undertaken. Relevantly, he noted the following:

• The ride appeared to be in generally poor condition, with significant corrosion evident throughout the steel components of the ride and concrete degradation in two of the tunnels.
• Testing in an attempt to reconstruct the incident demonstrated that the rails near the unload area were approximately 300 mm below the water surface during operation. It also showed that the conveyor can cause a raft to bounce when it is pushed back into the conveyor and the conveyor turned off.
• The tests also showed that the water level dropped by approximately 400 mm in 40 seconds when the south pump is turned off. The operating water level was 2.26 m, which dropped to 1.83 m when only the North pump was operating.

717. Mr. Flatman’s findings as to the sequence and likely cause of the incident largely accord with that of Senior Constable Cornish. In summary, he finds that the incident was primarily due to the second raft being forcefully driven towards and colliding with the stationary leading raft while the leading raft’s forward movement was obstructed on the rails.The leading raft was grounded on the rails near the unloading area as a result of the southern pump failing and causing the water level to drop below the rails. It is likely that the leading raft was obstructed by the cross brace between the rails in the vicinity of the unloading area. The second raft was then driven into the stationary leading raft by positively engaging with the slats on the conveyor. This resulted in both rafts rising up at their point of contact. The motion of the conveyor caused the rear of the second raft to be drawn down into the gap between the rails and the conveyor fatally injuring four passengers. 

718. In terms of the contributing factors to the incident, Mr. Flatman identified the following:

• Stationary raft – listed as a significant contributing factor, given the collision would not have occurred had this raft not been grounded on the rails near the unload platform.
• Gap at the end of the conveyor – the geometry of the gap between the head of the conveyor and the steel rails was sufficiently large enough to allow the second raft to be drawn in by the motion of the conveyor. Measurements by Mr. Flatman indicate that the gap between the rails and the conveyor shaft were 760 mm, with the gap from the rails to the wooden slats was 390 to 460 mm.  Given the measurements of the rafts and the tube diameter, it was found that the tube could easily fit into the gap if it was pushed back. The gap at the head of the conveyor between the slats and the rails is small enough to allow the slats on the conveyor to bite onto the tube and draw it into the gap. 

• Missing slats – measurements taken by Mr. Flatman of the gap created by the missing slats on the conveyor were 770 mm, with the width of the gap between the small wooden pads on the conveyor being 1255 mm. This created a void large enough to allow the 1650 mm diameter of the raft plug to drop down and positively engage with the slats on the conveyor. Mr. Flatman notes that ‘when a raft was positioned on the conveyor in such a way that resulted in the slat being located under the middle of the plug, the resulting seesaw effect could cause the rear of the plug to tip downwards into the void and positively engage with the adjacent slats on the conveyor. In addition with the conveyor running the missing slats created alternating large and small gaps that could bite into a raft tube and increase the likelihood of a raft being drawn in the gap at the head of the conveyor. The missing slats is considered to be a significant contributing factor to the incident’.
• Bowed slats – Some of the slats on the conveyor were observed to be bowed upwards approximately halfway along their length by approximately the thickness of the slats (50 mm). This increased the bite on the tube and may also have caused the slat to bow further outwards when loaded against the tube of a stationary raft, increasing the tendency for the tube to be drawn into the gap between the conveyor and the rails.
• Gap between rails – the distance measured by Mr. Flatman of the rails in the vicinity of the unload platform was 1250 mm, which is similar to that between the small wooden pads on the conveyor. The distance between the cross rails was 1270 mm. This created a void large enough for the plug in the leading raft to protrude into and positively engage with the cross brace preventing it from moving along the rails. The likelihood of this occurring is increased if the raft was misaligned towards one side on the rails, so as to prevent the plug from being supported by both the rails. This can be worsened if the rails were located towards one side of the channel rather than in the centre. Measurements taken during inspections show that the rails in the vicinity of the second cross brace were located off centre towards the northern side of the channel. 
• Low air pressure – Mr. Flatman theorizes that the low air pressure in the tubes may have contributed to the incident by reducing the support provided by the tube and allowing the plug to protrude below the slats or rails and into the voids. It could have also contributed to the incident by allowing the tube to deform and be drawn into the gap between the conveyor and the rails. 
• Low water level – Mr. Flatman found that the low water level was a significant contributing factor to this incident, as it caused the leading raft to become grounded on the rails. 
• Pump failure – CCTV confirm that the incident was initiated by the south pump failure that caused the water level to drop below the rails and resulted in the leading raft being grounded on the rails. Testing confirmed that when one pump stopped, the water level dropped below the rails in approximately 40 seconds. 
• Seat belts - Mr. Flatman notes that the seatbelts in place, which were made of Velcro, were unable to restrain the passenger when the raft was tilted upwards and shaken during the incident. Had the seatbelt been secured with a positive locking mechanism, such as a buckle, it may have prevented the person falling into the conveyor. 
• Operator procedures – it is noted that the procedures, which require the unload Operator to contact the Main Operator before activating the emergency stop, prevented the conveyor from being stopped prior to the rafts colliding, which may have limited the severity of the incident. 
• Operator tasks – had the main Operator not been distracted by the task of explaining and removing passengers from the load area, he may have activated the emergency stop in time to prevent the incident. In addition, Mr. Flatman notes that it is difficult for a busy Operator to identify the low water level in the space of 35 seconds between rafts when they rely solely on a visual check of the water level. 
• Operator experience and training – one of the Operator’s had only been trained on the day of the incident. It is unclear whether the unload Operator had been trained in the use of the E-Stop and detection of the low water level. 
• Ride Layout – It is likely that the layout of the loading and unloading platforms resulted in the load Operator at the loading platform facing away from the Unload Operator while he was talking to guests. Had he not been distracted by this task, and the orientation of the loading platform was such that he could clearly see the Unload Operator and conveyor, he may have activated the emergency stop in time to prevent the incident. Mr. Flatman is of the view that had there been an additional Operator or deck hand available at the time of the incident, they may have been able to attend to guests and allow the Load Operator to focus solely on the operation of the ride. This may have allowed him to identify the potential collision and activate the emergency stop in time to prevent the incident or respond to the unload Operator’s attempts to gain his attention. Mr Flatman notes, however, that these are administrative controls, which are not the best way to prevent incidents and should only be utilised after more reliable control measures, such as engineering controls, are considered. 
• Control markings – The controls at the unload platform, including the emergency stop control, were not labelled. This lack of marking would have made it harder for an unfamiliar Operator to locate it in the case of an emergency.

719. In Mr. Flatman’s opinion, the three most significant contributing factors to the incident were:

1. Stationary rafts on the rails;
2. Missing slats on the conveyor; and
3. Operator training

Control Measures

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720. Mr. Flatman also briefly considered various control measures, which could have been implemented to avoid the incident. Specifically, he cited the following measures:

• Conveyor modifications: the missing slats on the conveyor could have been replaced, which would have reduced the likelihood of a raft being forcefully driven into another by positively engaging with the slats, and reduce the possibility of the slats biting into the tube and drawing a raft down into the gap at the end of the conveyor.
• Stationary raft monitoring: Installation of a stationary raft monitoring system at the head of the conveyor similar to that at the foot of the conveyor. The stationary raft monitoring system could be integrated with the ride control system so that it could automatically stop the conveyor, pumps and close the jacks to prevent additional rafts from being dispatched in the event a raft becomes stuck near the head of the conveyor for any reason.
• Operators: Improve Operator training by explaining the position and operation of the emergency stop controls. Increase the period of time a new Operator spends with an experienced Operator when learning to operate a ride. Emergency drills could be conducted to ensure the competency of Operators in such a situation. Mr. Flatman notes s. 36 of the Work Health and Safety Regulation 2011, which requires that the other control measures, such as engineering controls, should be implemented first, with the residual risk then controlled by administrative controls. 
• Modifications to rails: The rails could have been modified by adding an additional rail midway between the existing rails. A centre rail would reduce the depth the plug could protrude below the top surface of the rails and most likely prevent it from positively engaging with the cross brace.

Ride Modifications

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721. The TRRR had undergone a number of significant modifications since its initial construction and design registration in 1987, registration number E1624. The TRRR was initially listed as a Class 2 amusement device.

722. There were no records of the modifications included in the design registration documents held by OIR. It is therefore unknown if the modifications were designed by a competent person in accordance with relevant technical standards, or if the design of the modifications were verified by a third party RPEQ. In accordance with s.244 of the Work Health and Safety Regulation 2011, the alterations to design registered plant must also be registered when they may affect health and safety. Whilst a number of the alterations were likely to have occurred before 2011, similar provisions were in place at the time.

723. Mr. Flatman is of the view that the removal of the slats on the conveyor was a major contributing factor to the incident. Markings on the channel floor in the vicinity of the unload area near the head of the conveyor indicate that the rails may have been altered. Details as to these modifications are unknown. It is possible that the markings may be left over from the turn table system that was previously removed from the ride. He is of the view that the removal of the conveyor slats was a significant modification to the ride, and the regulator should have been notified.

Previous Incidents on TRRR

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724. Mr. Flatman considered the previous incidents that had occurred on the TRRR. In relation to the incident that occurred in 2001 involving Ms. Lynd, he notes that no engineering controls were implemented to prevent this incident from reoccurring, which did not involve the water level dropping. He notes that modification of the control system to detect a stationary raft between the unload area and the head of the conveyor would have been preferable. Clearly, there was little learning from previous incidents.

725. Mr. Flatman notes that despite the 4 incidents involving the TRRR taking place in the vicinity of the unload area near the head of the conveyor, upgrades were carried out to the beginning of the conveyor in 2016. He expresses the view that the greater risk was clearly at the head of the conveyor near the unload area.

Maintenance and Inspections

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726. The information available to Mr. Flatman suggests that there was periodical and routine maintenance performed on the ride. This consisted of daily, weekly, monthly inspections, as well as annual shutdowns. In addition, maintenance was performed during ride breakdowns to return the ride into operation.

727. Mr. Flatman refers to AS-3533.2 Amusement Rides and Devices, Part 2: Operation and Maintenance which requires that rides undergo major inspections. This is a requirement in addition to the annual inspections. It is likely that the annual shut downs did cover some of the requirements for a major inspection.

728. During the inspections of the ride carried out by OIR, the following faults were identified: 

• Missing slats from the conveyor;
• Excessive corrosion;
• Crumbling concrete;
• No guarding at the foot of the conveyor, rail system and pump outlets;
• No water back flow prevention;
• Water running over electrical components; and
• Unidentified controls including emergency stop controls

729. The inspections carried out by OIR showed that the maintenance performed on the TRRR was insufficient to prevent significant corrosion occurring or water running over the electrical components in the pump enclosure. The maintenance activities appeared to ensure that the ride remained in operation rather than keeping it in good condition. Mr. Flatman is of the opinion that more should have been done to prevent and rectify the excessive corrosion and to ensure that the pump motors and electrical components were kept as dry as possible. He is of the opinion that due to the faults identified, the ride was unsafe to operate and a more rigorous maintenance regime should have been implemented. 

730. In considering the inspection conducted by Machinery Inspection Services (Tom Polley) in September 2016, Mr. Flatman notes that ‘a visual inspection carried out of visible parts only of the TRRR is not a detailed visual examination and is likely to lack sufficient detail to accurately form the opinion that the ride is mechanically and structurally safe to use for the next annual period when many structural components on the ride are submerged in water’ (pg. 24, 25).

731. Mr. Flatman is of the view that the faults identified by Mr. Polley that is the presence of corrosion and the critical bolted connections on the ride, were not contributing factors to the incident.

732. A number of the issues raised in previous risk assessment audits of the TRRR were present at the time of the incident, particularly the lack of control identification labelling, corrosion and the emergency stop procedure. Mr. Flatman notes that this clearly shows that the issues have been ongoing and have not been adequately addressed.

Conclusions

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733. By way of summary, in Mr. Flatman’s opinion, the most likely cause of the incident was due to the second raft being forcefully driven by the conveyor towards and colliding with the leading raft, while the leading raft’s forward movement was obstructed against a cross brace on the rails. The space caused by the missing slats on the conveyor allowed the raft to enter the gap at the conveyor head and rails. The motion of the conveyor drew the rear of the second raft and three passengers into the gap. The conveyor continued to run for approximately 19 seconds during this time, with the raft shaking vigorously and the fourth passenger fell from his seat into the gap.

734. The incident was initiated by a sudden drop in water level as a result of the south pump stopping, due to a fault. In Mr. Flatman’s opinion, monitoring the water level may have prevented the incident.

735. Mr. Flatman notes that despite previous incidents on the TRRR, at the time of the tragic event, there was a heavy reliance on administrative controls, rather than engineering control measures, to manage the evident risks and ensure the safety of the ride, which is unacceptable. He notes that there was little learning from previous incidents on the ride.

 

The coroner has no power to fine anyone. They only make recommendations. The only action will be industrial, as in, business/company related if the OIR (office of industrial relations) decides there is enough evidence to prosecute. So dreamworld may cop a fine, but not individual people.

 

OIR TECHNICAL ADVICE ABOUT THE INCIDENT

Technical Advice - OIR Principal Inspector, Mr. Ian Stewart

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736. Mr. Stewart, Principal Inspector with OIR, was requested to attend and assist with the OIR investigation into this tragic incident. He has extensive practical industry experience and as an investigator considering health and safety issues, with formal trade qualifications and experience, a certificate in Competency Engineer – Inspection of Machinery, and a graduate diploma in Occupational Health and Safety.

737. Mr. Stewart attended the scene on a number of occasions in October and November 2016, and considered various relevant documentation associated with the ride. As a result, he prepared a memorandum of his findings in relation to the causal factors of this fatal incident. The relevant findings of this report are outlined below.

Issue 1 - Reliance on Administrative Control in Emergency Situations

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738. Mr. Stewart noted that the safe operation of the TRRR primarily relied upon administrative controls, which are outlined in the operating procedures developed for the ride. These controls require the Operators to have an understanding and ability to observe and respond to situations, including emergencies, as and when they arise, including:

• The controls used to operate the ride.
• Ensuring adequate water level.
• Preventing raft collisions.
• Monitor guest’s behaviour to ensure they stay in the rafts when required.
• Loading and unloading guest’s onto and off the rafts.
• A section of the ride traverses and is monitored solely by the operator at the Main Control Panel observing CCTV monitors, in conjunction with other tasks.
• Maintaining order and sorting guest’s waiting to ride and those exiting the ride.

739. In relation to the tasks being performed by the Level 2 and 3 Operators prior to the fatal incident, which may have contributed to the delay in becoming aware of the developing emergency situation, Mr. Stewart notes that:

• Tests runs of the ride following the incident demonstrated that it was difficult to identify that the south pump had stopped solely by observing any change in noise levels. The north pump continuing to operate generates sufficient noise levels as a possible indicator to Operators that a pump had tripped.
• The Ride Operators rotate positions between the ‘Load’ and ‘Unload’ stations periodically while the TRRR is in operation.

740. Having considered the functions required of the Level 3 Operator whilst manning the TRRR, Mr. Stewart notes that a majority would have had Mr. Nemeth facing away from the Main Control Panel and the unload area where Ms. Williams was located.

741. The applicable Australian standards (AS-3533 series & AS/NZS 4024), provide guidance as to ‘Operator Information Handling Limitations’. AS/NZS 4024.1901:2014 – Safety of Machinery Part 1901, and describe situations and tasks that may impact negatively on the Operator’s ability to respond effectively in emergency situations, where the number and/or complexity of concurrent tasks is excessive. At Appendix A ‘Application Guide’ of this Standard, the following guidance is provided:

A.2 Attention

In many situations, e.g. those involving a human operator in a human-machine system, the person can be viewed as a single channel processor with capacity to process information from no more than a few sources at a time.

Attention is normally confined to two main sources, the internal world i.e. thoughts and sensations from the body, and the external world. Since attention can be described as a limited resource, there may be competition among attentional resources. For example, an operator who is occupied with thoughts or decision making may suffer attentional deficits regarding events happening in the outside world. A consequence of the design of human-machine systems is that it is essential not to overload the attentional resources of the operator.

742. Mr. Stewart identified a number of tasks performed administratively by the TRRR Operators to control ‘high risk’ situations, which he is of the view should have been controlled and/or minimised by appropriate ‘engineering controls’, namely:

• Monitoring and prevention of rafts colliding in the unloading area; and
• Water level monitoring.

743. Additionally, the following components of the ride were in Mr. Stewart’s opinion, deficient at the time of the incident, and are likely to have limited the Operators ability to respond effectively to prevent this tragic incident from occurring:

• Ride operating controls.
• Marking of controls.
• Ride operating procedures.
• Testing of emergency procedures, including how often the testing should be done.

744. Mr. Stewart outlines details of the past incidents from 2001-2014, which had occurred on the TRRR. He questions why, given the circumstances of some of these incidents, particularly that involving Stephen Buss, as to why a risk assessment process resulting in the installation of suitable engineering controls, was not carried out. Mr. Stewart notes that the design of an amusement device should include features (higher order controls, such as engineering controls) to protect guest’s, Operators and equipment when a failure occurs. In Mr. Stewart’s view, these earlier incidents on the TRRR, therefore, should have alerted Dreamworld to the fact that the current administrative controls were not effective in preventing incidents involving serious risks, such as rafts colliding in the unload area. Mr. Stewart considered what a risk assessment of the TRRR could have considered, based on the applicable legislation and regulations, noting that any such reassessment or review should have thoroughly reassessed the methods of control of the risk with a focus on implementing appropriate higher order controls, such as engineering controls.

745. In Mr. Stewart’s opinion, the previous incidents on the TRRR on 18 January 2001, 7 October 2004 and 2 November 2014 where rafts collided in the unloading area, should have caused Dreamworld to thoroughly assess the control of the risk by installing suitable engineering controls. He notes that engineering controls are preferred over administrative controls as outlined in WHS Regulation 36, and s.4 of the OIR, How to manage work health and safety risks – Code of practice 2011.

Issue 2: Limitations of the Ride Emergency Controls, Systems and Procedures
Provided for the Operator to Respond to Emergencies 

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746. Mr. Stewart notes that the prevention of the fatal incident was solely reliant on the Ride Operators observing and responding to: (a) Rafts colliding in the unloading area; and (b) Water level drop.

747. In this regard, Mr. Stewart raises concern as to the limitations of the ride controls and procedures as are required to be used by the Operator. He notes that controls should be marked such that the Operators can easily identify the control, the equipment involved and task the control performs. This becomes particularly important in an emergency situation when Operators may panic and/or hesitate in deliberating a course of action.

748. Section 210 of the WHS Regulation specifically requires the marking of operational and emergency stop controls. Mr. Stewart notes that the control panel at the main load section on the TRRR does not comply with WHS Regulation as the controls are not clearly marked.

749. Section 211 of the WHS Regulation pertains to Emergency Stops. Mr. Stewart notes that the conveyor emergency stop located at the unload area is an essential control as it is the only way for this to take place, and should have been clearly marked ‘Conveyor Emergency Stop’. He opines that this may have prompted the Unload Operator to activate this stop, had she been trained accordingly. 

750. In relation to the Operator Procedure in effect, Mr. Stewart notes that in his view, there was an inordinate amount of material and information to absorb in a short time, and also to become competent in. He is of the view that a longer period of supervised training would have been appropriate. However, he finds that irrespective of the sophistication in the training provided, the risks associated with rafts colliding and/or the water level drop are significant, such that administrative controls, including Operator monitoring and controlling them is not an appropriate control measure.

751. Mr. Stewart also notes that regardless of the sophistication of plant, equipment and means of controlling emergency situations, it is common practice within the Amusement Park industry to perform periodic emergency drills. No emergency drills were conducted for the TRRR. He is of the view that these drills may have assisted in preventing the incident, however, could not have been used in lieu of appropriate engineering controls to minimise the ‘high risk’ issues associated with the ride.

Issue 3 - Monitoring and Prevent of Rafts Colliding in the Unloading Area

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752. In Mr. Stewart’s view, rafts impacting each other in the unloading area, is the primary risk to the health and safety of patron’s riding the TRRR, specifically referring to the previous 2001 incident.He notes that when the conveyor continues to operate after this occurs, the following raft could then be driven by the conveyor into the stationary raft where there is a risk of serious injury or death due to crushing, entrapment and/or drowning. In Mr. Stewart’s opinion, these previous incidents should have caused Dreamworld to assess and control the risk prior to the fatal incident.

753. Reference is made to the previous engagement of suitable persons to install appropriate controls to minimise a similar risk at the beginning of the conveyor. Accordingly, suitable technical standards, appropriate monitoring equipment and competent persons were known to Dreamworld prior to the fatal incident.

Issue 4 – Water Level Monitoring

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754. Mr. Stewart notes the layout of the TRRR, specifically the use of the water pumps, which ensure that an artificial stream is provided so that the rafts can float. Hazardous situations may be created when one or both pumps fail. In particular, when one pump fails, the water, which normally covers the raft catch rails located at the unload area, drops, which doesn’t allow sufficient buoyancy for the rafts to float, and as such, they rest on the rails. Occurrences where the pumps have tripped causing a subsequent loss of water were not uncommon on the TRRR. However, in the week prior to the incident, the pumps had tripped more frequently.

755. Mr. Stewart notes that water level monitoring equipment, which was capable of stopping the conveyor when the water level dropped, would have cost around $2000 - $3000 if it had been included in the earlier upgrade work. He further highlights that consideration had been given to having this type of monitoring implemented by Dreamworld in 2016, demonstrating that this risk had been identified earlier, and was known.

Issue 5 – Gap at the End of the Conveyor at the Unloading Area

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756. The width of the gap at the unloading end of the conveyor on the TRRR is sufficient to allow a raft to be drawn into it, creating the risk of death or serious injury associated with entanglement or entrapment of persons on the raft.

757. It does not appear that any risk assessments were conducted by Dreamworld in relation to this gap, which may be somewhat hidden during the normal operation of the ride by the water.Mr. Stewart expresses the view that this hazard would not have been obvious to the casual observer, and therefore, detailed research and observation would have been required to identify and control the hazard.

758. In relation to the standards applicable to conveyors, Mr. Stewart specifically refers to AS/NZS 4024.1201:2014 Safety of Machinery Part 1201: General Principles for Design – Risk Assessment and Risk Reduction, which provides examples of hazards, hazardous situations and hazardous events. Moving elements with the potential to draw in, as was the case for the conveyor on the TRRR, is specifically cited.

759. AS/NZS 4024.3610:2015 Safety of Machinery Part 3610: Conveyors – General Requirements, at point 1.5.21, defines a ‘nip point’, which is:

The point at which a moving conveyor element meets a fixed or moving element, so that it is possible to nip, pinch, squeeze, entangle or entrap parts of the human body.

760. Relevantly, at Point 2.13.2 – Hazardous Situations and Parts Requiring Safeguards of this guidelines, it further states that:

1.13.2.1 General

Safeguards shall be designed to prevent –

(a) Persons reaching into the danger zone or other body parts becoming caught or entangled;

(b) Conveyed materials accidentally falling or being projected into persons;

(c) The hazard from the failure of a component;

(d) Contact with a danger point (i.e. nip or shear points) on the conveyor.

1.13.2.2 Shear points and nip points

All accessible shear and nip points which create a risk to health or safety shall be safeguarded in accordance with this Standard or the AS 4.24.1 series, except for belt conveyor applications in accordance with AS/NZS 4.24.3611

NOTES

…

2. Shear and nip points are created where the gap between any moving part of the conveyor and any fixed equipment is greater than 5 mm and less than 120 mm.

1.13.2.3 Rotating parts

All exposed rotating shafts or other parts shall be guarded, unless the design risk assessment indicates there is no unacceptable risk to health or safety.

All exposed projections, gaps, shafts couplings, collars or similar shall be guarded.

761. At AS/NZS 4.24.3612:2015 Safety of Machinery Part 3612: Conveyors – Chain conveyors and unit handling conveyors, it notes that:

TABLE 2.1 – TYPICAL HAZARDS ASSOCIATED WITH CHAIN CONVEYORS AND UNIT HANDLING CONVEYORS

762. Accordingly, Mr. Stewart notes that the gap on the conveyor on the TRRR varies from 500 mm to around 1 metre at the unloading end of the conveyor. As this is greater than 120 mm, this technical standard does not consider it a hazard. However, he noted the following: 

• AS/NZS 4024.3610:2015 primarily considers the movement of productand materials and not persons.
• A risk assessment should have been conducted following the modification/s that appears to have created this gap.

763. In addition to the risk posed by the gap at the end of the conveyor and the unload area rails, the following further hazards were also observed:

• • Gaps between the slats in the conveyor system were excessive, such that a person may fall and/or get out of the raft due to skylarking and panic, and could fall through the conveyor resulting in injury or death due to crushing, shearing and/or drowning.
• Lack of maintenance and excessive corrosion negatively impacting on structural integrity and impacting on patron and worker safety.

764. In terms of the risks associated with the conveyor, Mr. Stewart notes that reinstating the slats and extending the raft catch rails would have minimised the risk of a raft or person’s whole body falling through the gap, however, a sufficient gap may have remained that there would still be a risk to body parts, such as arms and legs. Had an appropriate SIL 3 rated engineering control been installed to monitor and control the risks associated with raft collision and maintain correct water level, this would have removed the threat posed.

765. Mr. Stewart is of the view that there was information readily available to Dreamworld to identify the potential hazard created by the large gap at the end of the conveyor.

PROHIBITION NOTICE – ARDENT LEISURE

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766. On 8 November 2016, following the tragic incident, a Prohibition Notice (‘the Notice’) was issued to Ardent Leisure by Principal Inspector, Mr. Ian Stewart, pursuant to s. 195 of the Workplace Health and Safety Act 2011. This Notice precluded the operation of the TRRR until a serious risk to health and safety emanating from an immediate exposure to a hazard associated with a person being entangled in moving conveyors or submerged obstacles was rectified. The basis for the view held by Mr. Stewart was listed as follows: •

• The width of the gap between the end of the conveyor and the steel catch platform, which is sufficient to allow a raft to be drawn into it creating a risk of death or serious injury. •
• Insufficient controls are in place to prevent a raft from entering the unloading station whilst another raft remains in the area between the end of the conveyor and unloading deck. This creates a serious risk of death or serious injury associated with entanglement or entrapment. •
• Where a person falls from a raft there is limited access for effective emergency response.

767. The Notice states that in its current state, the TRRR was not able to be put back into service at any time, and poses an imminent risk to person’s health and safety from exposure to the hazards cited above.

 

REGULATORY RESPONSE FOLLOWING THE INCIDENT

2016 Audit Campaign

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768. Commencing on 29 October 2016 and concluding on 2 December 2016, a compliance and audit program of Queensland’s six largest Theme Parks, including Dreamworld, was undertaken by OIR. The audit team consisted of a Director, Operations Manager, Engineers, and a number of Senior and Principal Work Health and Safety and Electrical Safety Inspectors. Assistance was also provided by other jurisdictions, with Engineers and Work Health and Safety Inspectors from WorkSafe Victoria and SafeWork South Australia.

769. OIR described this audit as ‘comprehensive’, and included over 90 audits conducted using the National Audit Tool for Amusement Devices, which involved a desktop review of the ride followed by on-site testing and verification. Specifically, Inspectors reviewed the documentation for each ride in relation to plant and design registration, maintenance and operating manuals, instruction and training of Operators, annual inspections by competent persons, repairs and alterations, critical components and associated non-destructive testing, emergency plans, asbestos, noise and electrical hazards and risks. The site verification process involved Inspectors observing the operation of the ride, talking to the Ride Operators and other relevant persons, and assessing the actual operation of the ride against the systems outlined in the documentation provided. In addition, engineers were also engaged to review the current risk assessment documentation for each ride and provide support to Inspectors through technical assistance during the site verification.

770. The OIR Public Swimming Pool Checklist was used for those Theme Parks, which operated water based rides. Key elements, which were addressed in the audit tool, included: administration, general supervision, first aid, facility design, water features and technical operation.

771. As a consequence of the audit, 96 Individual Assessments were completed, 14 Improvement Notices and three Prohibition Notices, which related to amusement ride the Buzzsaw at Dreamworld, were issued. 

772. Twenty-four audits were conducted for Dreamworld, with a focus on the ‘Big 9 Thrill Rides’. Eight notices were issued in total.

773. In a Theme Park Report 2016, OIR outlined the findings of the audits conducted. Relevantly, the following recommendations were made:

• OIR to review and comment as necessary on the reports prepared by external engineers Pitt & Sherry on all amusement rides at Dreamworld.
• Facilitate a forum with stakeholders in the amusement ride industry to discuss current legislative requirements, policy decisions, audit tools and relevant issues in the first half of 2017.
• Conduct proactive audits on fixed amusement rides by 30 June 2017, to ensure compliance with relevant Work Health and Safety Laws.
• Conduct annual inspections of fixed amusement rides each year following the initial six monthly audits listed above.
• Conduct proactive audits to ensure that all plant at major Theme Parks is registered as required.

2017 Audit Campaign

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774. A second major compliance program was undertaken between 12 October 2017 and 17 November 2017, involving the six major Theme Parks. The process of assessment for this audit was broadened to include a review of the overall safety management system and hazard specific systems of each person conducting a business or undertaking. Existing assessment tools, such as WHS Regulators National Audit Tool for Amusement Devices, were modified for use at Theme Parks and incorporated input from five OIR specialist units. Furthermore, industry stakeholders, including AALARA and the Australian Workers Union, as well as business owners, were consulted for the purpose of the audit program and advised of the process and tools to be used.

775. As a result, 102 Individual Assessments were completed, 16 Improvement Notices and three Electrical Safety Notices were issued during the campaign. The major non-compliance issues identified were those relating to annual inspections of registered plant. Other issues that were identified include the following:

• Falls from height;
• Fuel dispensing in close proximity to electrical equipment;
• Electrical installations and maintenance; and
• The ‘test and tag’ procedure for specified electrical equipment on rides.

776. An additional 22 issues were identified by inspectors during the audits and were immediately rectified therefore not attracting a non-compliance notice.

777. A number of audit tools were used for the purposes of the campaign, including:

• Theme Park Systems Assessment;
• Hazard management systems assessment;
• Onsite verification;
• Waterslide inspection guidance and checklist; and
• Theme Park audit survey.

778. OIR note that they, ‘will continue to support the major Theme Parks to enable improved safety outcomes for workers and the general public. Businesses are also encouraged to work together to improve safety within their industry. OIR have increased the level of enforcement activities on the Theme Park industry by verifying effectiveness of training for operation of amusement rides, including emergency procedures; and conducting random auditing of the design of new or modified amusement rides’.

779. A Draft Project Closure Report was prepared by OIR detailing the findings of the 2017 audit report.

Best Practice Review of OIR

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780. The Best Practice Review (BPR) was commissioned by the Queensland Government following this tragic incident and another fatality at an Eagle Farm worksite in October 2016. This tragedy raised particular concern as to the regulation of safety matters in Queensland.

781. Relevantly, the BPR and its recommendations considered: 

• The appropriateness of OIR’s Compliance and Enforcement Policy;
• The effectiveness of OIR’s compliance regime, enforcement activities and dispute resolution processes;
• OIR’s effectiveness in relation to providing compliance information and promoting work health and safety awareness and education;
• The appropriateness and effectiveness of the administration of public safety matters by OIR; and
• Any further measures that can be taken to discourage unsafe work practices, including the introduction of a new offence of gross negligence causing death as well as increasing existing penalties for work-related deaths and serious injuries.

782. The general findings of the BPR recognised that there was an ongoing need for OIR to improve the human capital, systems and processes in place, particularly in relation to the inspectorate, investigations and prosecutions. A re-balance of priorities in favour of ‘hard’ compliance work, as opposed to capacity building areas, with a view to increasing ground visibilities and activity of the inspectorate was recognised as necessary.

783. Overall, the BPR made 58 recommendations, with the following three relating to public safety, specifically requiring the introduction of regulatory amendments to improve amusement device safety:

- Recommendation 41: The WHS Regulation 2011 be amended to require that:

• Mandatory major inspections of amusement devices, by competent persons, are conducted;
• Competent persons are nominated to operate specified amusement devices, and
• Details of statutory notices are recorded in the amusement device log book and made available to the competent person inspecting the amusement device.

- Recommendation 42: OIR in consultation with relevant stakeholders, determine the level of competency required for the inspection of specified types of amusement devices, and the level of competency required for the operation of specified amusement devices (including the potential need for formal licensing arrangements to apply in respect of certain categories of device), and that the WHS Regulation 2011 be amended accordingly.

- Recommendation 43: The WHS Regulation be amended to require, for Operators of amusement devices, a similar regulatory approach to that taken for Operators of facilities which use, generate, handle or store hazardous materials. That is, for Operators and facilities whose amusement devices collectively present a high risk, require preparation of a safety case (which includes a WHS System) and application of a licensing regime. For Operators and facilities whose amusement devices collectively present a medium risk, require preparation of a WHS management system and application for a lower level licensing regime.

784. It was noted in the BPR that for older amusement devices poor mechanical integrity and a lack of modern safety control measures were a concern. Although annual inspections are mandated under the WHS Regulation, this requirement falls short of a ‘major inspection’, which should include the examination of all critical components of the device, as well as a check of the effective and safe operation of the ride by a competent person with formal engineering qualifications and experience. OIR indicated that they were in discussions with the engineer’s professional body (Engineers Australia) to reactivate the National Engineers Register for in-service inspection of amusement devices. A proposal is also to be made to the Board of Professional Engineers, Queensland to set up a similar register.

785. It was recognised that the level of risk to the public from amusement devices is comparable to that of facilities, which use, generate, handle or store hazardous materials. Accordingly, it was acknowledged that a similar regulatory approach may be necessary for Operators of amusement devices where the collective risk for those devices exceeds certain thresholds. 

786. In August 2017, the Queensland Government considered the recommendations of the BPR and supported the recommendations made regarding amusement devices. OIR has consulted with a range of peak bodies and individuals following the release of the BPR.

787. On 31 August 2017, two meetings were held with show circuit representatives and the major Theme Parks to discuss the BPR recommendations in relation to amusement devices. The Honourable Grace Grace MP, who was the Minister for Employment and Industrial Relations, Minister for Racing and Minister for Multicultural Affairs at that time, attended part of the meeting with the Theme Park representatives.

788. Following these meetings, the Amusement Device Working Group of industry stakeholders was established and met on 27 September 2017 to discuss the BPR recommendations.

789. A draft of proposed regulatory amendments was developed by the Office of the Queensland Parliamentary Counsel during early 2018. On 11 May 2018, the Amusement Device Working Group met to discuss the proposed amendments to the WHS Regulation.

790. I accept that the recommendations of the BPR have been accepted and are being put in place. Once in place, the OIR should conduct a further audit to determine all recommendations are in operation and are achieving the best results possible.

OIR Plant Inspectors (Amusement Devices) Subgroup

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791. The effectiveness of the compliance campaigns on amusement devices has been improved through the implementation of regular training updates for OIR inspectors conducting the audits. In June 2017, a subset of the OIR Plant Network Group was established. The Amusement Device Inspectors function to provide specialist support to the audit programs for both fixed and mobile amusement devices. These specialists possess a high level of understanding of the plants, as well as knowledge of the National Audit Tool for Amusement Devices and the AS3533 series of standards.

792. The members of the amusement device sub-group are provided with the relevant training and experience sharing opportunities by the OIR Engineering Unit. This sub-group act as a repository of amusement device-related information, audit issues or operational procedures to be shared with other inspectors (who may at stages be auditing amusement devices). The sub-group members support the mentoring and training of inspectors for amusement device auditing, and meetings are held prior to the commencement of audits at Theme Parks or regional shows.

Plant Item Registration Working Group

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793. Convened in November 2016, the Plant Item Registration Working Group aimed to examine the current administrative, system and compliance activities undertaken throughout the plant registration life cycle. The working group considered the following: 

• The feasibility of compliance audits for registered plant for high risk plant owners, e.g. those registrable plant items with additional specific regulatory requirements; and
• Constraints of the existing plant system and possible enhancements to ensure the plant registration life cycle is administered effectively.

794. As a result of the working group, a number of system enhancement and process improvements were made, namely: • Improvements to invoicing and journaling functions to reduce manual intervention required for reconciliations; • Inclusion of audit trail and notes functionality to better maintain information on customer transactions; and • Changes to field functionality to make the system data easier to interpret for internal staff.

795. Although the administrative registration scheme for plant does not replace or relieve a duty holder of the regulatory requirements regarding plant use, maintenance and inspection data gathered through the registration process can be used to assist compliance of high risk plant, including amusement devices.

796. OIR has initiated a two phase audit program for plant item registration:

• Phase 1: physical inspection of items of plant that are not re-registered in the new registration period, to ensure that unregistered plant are not in operation. These audits are carried out by the regional inspectorate supported by the engineering unit. Statutory notices are to be issued if an unregistered plant is found to be in operation.
• Phase 2: desktop audit of registered plant items to confirm the required design registration, maintenance and inspection records are available and are compliant with the Regulation.

797. Upon implementation, 70 plant item registrations per year will be randomly selected for desktop audit, until the introduction of the new Regulation is in force and a safe case system implemented.

Amusement Devices Stakeholders and Regulators Forum

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798. OIR held an amusement devices stakeholders’ forum in Brisbane during February 2017. Subsequently, in May 2017, OIR chaired the Amusement Devices Stakeholders and Regulators Forum, as a part of the annual conference organised by AALARA.

 

PROPOSED REGULATORY AMENDMENTS

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799. Following the tragic incident, a number of changes were made to the WHS Act and the Regulations.

800. In December 2016, ss. 2, 272A and 279A of the Regulations were amended to retain the existing annual plant item registration and renewal arrangements until 1 January 2019. This amendment was made through the Work Health and Safety and Other Legislation Amendment Regulation (No.1) 2016 (SL No. 229 of 2016), which was made by Governor in Council on 7 December 2016, and notified on the Queensland legislation website on 9 December 2016.

801. At the time of the amendments, the removal of plant registration was being considered as part of the Council of Australian Governments (COAG) review of model WHS laws. Maintaining the annual registration for two further years (through the amendment to the Regulation) was intended to minimise the disruption for businesses until the Government considered the recommendations arising from the COAG review. The effect of this amendment was that owners of registrable plant, including certain amusement devices, were required to continue renewing registration annually.

Draft Further Amendments to the Regulations

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802. Following the BPR, further proposed amendments to the Regulations were drafted to reflect the recommendations made, namely:

• The introduction of major inspections of amusement devices;
• That competent persons be nominated to operate specified amusement devices and details of statutory notices are recorded in amusement device logbooks; and
• A requirement for Theme Parks to prepare a safety case and the application of a licensing regime.

803. The first consultation draft of the new Regulatory provisions were circulated to stakeholders on the Amusement Device Working Group on 2 August 2018. Following on from feedback provided by the Group, a further amended draft was prepared in November 2018.

804. By way of an overview as to the proposed changes to the regulatory environment should the Regulation amendments be enacted, the amusement devices at Major Amusement Parks, as defined in the Regulation, would still need to be registered/renewed until such time as a license is granted to the Park. On granting the license, it is proposed that the amusement device would be covered by a safety case prepared by the Park, and therefore the device would not need to be registered separately. The systems for inspection, maintenance and testing of amusement devices at Major Amusement Parks would be audited by the Regulator as part of monitoring compliance with the proposed Major Amusement Park license and safety case system. Registration for amusement devices at workplaces other than licensed Major Amusement Parks would remain the same.

Major Amusement Parks and the Proposed Safety Case Licensing System

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805. Through the introduction of Part 9A.3 of the draft amendments to the Regulations, it was proposed that a safety case and license regime be established for Major Amusement Parks, requiring a comprehensive and integrated approach for managing safety at the Parks.

806. The Major Amusement Parks which would fall within this regime are:

• Aussie World;
• Dreamworld and WhiteWater World; 
• Sea World;
• Warner Bros. Movie World; and
• Wet ‘n’ Wild.

807. From a declared date, a Major Amusement Park will have:

•  Six months to provide the Regulator with a safety case outline. This outline is required to include a written plan for preparing a safety case about the amusement devices at the Park, including key steps and timelines, methods and resources to be used, details as consultation with workers, draft emergency plan and how the case will address annual and major inspections, maintenance and testing of devices, instruction and training to Operators, log books and how the effectiveness of the safety case will be monitored.
• Two years to provide the Regulator with a safety case and apply for a Major Amusement Park license. A Park can continue to operate amusement devices during this period. The license will be for the operation of the amusement devices at the Park.

808. As part of the proposed safety case regime, Major Amusement Parks will be required to prepare a written presentation addressing the following: •

• Identify potential hazards and incidents involving amusement devices at the Park;
• Carry out a safety assessment for amusement devices at the Park;
• Implement control measures designed to eliminate or minimise the risk of an incident occurring;
• Prepare an emergency plan and implement it if an incident involving an amusement device occurs; 
• Implement a safety management system for amusement devices at the Park; and
• Consult with workers, for example, in relation to the emergency plan, safety management system and preparing and reviewing the safety case.

809. A safety management system is a comprehensive and integrated system for managing all aspects of risk control in relation to potential amusement device incidents at the Park. It is intended to be the primary way in which it is ensured that incidents do not expose the people to serious risk to their health or safety.

810. It is proposed that once licensed, a Major Amusement Park will not be required to register its amusement devices as the Regulator will be aware of relevant information about the devices through the safety case. A license will be granted for a period of up to five years, and conditions can be imposed by the Regulator on the license.

811. Sections 608N, 608O and Schedule 18C of the proposed amendments specify matters which are required to be covered in the emergency plan and safety management system for amusement devices.

812. Major Amusement Parks will still be required to comply with specific regulatory requirements regarding amusement devices, for example, in relation to annual inspections, major inspections, Operator competency and log books.

Mandatory Major Inspections of Amusement Devices

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813. Through the introduction of s.241A and associated provisions, major inspections of amusement devices would be required to be conducted by, or under the supervision of, a competent person, who has the necessary skills. A competent person for amusement devices aside from inflatable devices, would be a registered engineer.

814. Such inspections, which are in addition to the existing legislative inspection and testing requirements already in place, are intended to ensure that a comprehensive check and test of the amusement device is carried out through an examination of the critical components of the device, as well as checking the safe operation of the device.

815. Major inspections would be required to be carried out every 10 years unless otherwise specified by the manufacturer of the device or a competent person, who previously inspected the device. The responsibility of ensuring such an inspection was carried out would rest with the person who had management or control of the device. By way of a transition, the next major inspection for a current amusement device would depend on the age of the device and whether it has already undergone a major inspection. For amusement devices that are over 10 years old and have not previously undergone a major inspection, the next major inspection must be carried out within 2 years of the new Regulation coming into effect.

816. Requirements to maintain log books (ss.242, 242A) are also to be introduced, which specify the details to be recorded.

Operators of Amusement Devices

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817. Under the proposed amendments, persons with management or control of an amusement device would be required to ensure that the device is only operated by a competent person. A ‘competent person’ is defined as a person who has acquired through training, qualification and experience the skills to carry out the task. The effect of this provision is that an Operator, after being provided with proper instruction and training in operating the device, would also have to be assessed and determined as competent to operate the device. A record of the worker having completed the necessary instruction is required to be included in the log book for the device.

818. The intent of these provisions is to recognise that different amusement devices require varying levels of knowledge and skill to operate the ride.

Amusement Device Log Books

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819. Pursuant to ss.242 and 242A of the proposed amendments, additional information would need to be recorded in the log book for an amusement device, including:

• The competency of the Operator of the device;
• The person who stores, installs, assembles, constructs, commissions, decommissions or dismantles the device being a competent person;
• Details about major inspections, including the name of the competent person who carried out the inspection, the date of the inspection, results of the inspection and recommendations of the competent person, and any components repaired or replaced during, or as a result of, the inspection;
• Details about major inspections, including the name of the competent person who carried out the inspection, results of the inspection and recommendations made, and any components repaired or replaced during or as a result of the inspection; and
• Relevant enforcement notices given for the device.

820. The log book is required to be available for inspection by a competent person carrying out a major inspection of the amusement device or an entity that has control or management of an event where the device is being operated.

Purpose of the New Proposed Safety Case Regime

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821. OIR maintain that the proposed safety case and licensing regime for Major Amusement Parks will involve an ongoing relationship between the Regulator and the Theme Park industry. It will require Major Amusement Parks to regularly review and update their safety case to ensure that safety is being systematically managed at the workplace. As safety cases are reviewed, updated and resubmitted to the Regulator for renewal of license application, OIR will have an ongoing role in working with the Major Amusement Parks, auditing compliance and performing the Regulator’s function.

822. During the inquest, Mr. Bradley Bick, Executive Director of WHS Engagement and Policy Services, OIR stated that the safety case regime was intended to ensure that there has been a systematic and comprehensive risk assessment undertaken on each of the rides at the Theme Park by the Operator, and that there is an overlaying safety management system in place, which verifies that the necessary controls are present and effective. With respect to major inspections, Mr. Bick stated that ‘there would be ongoing checks to make sure that operators were actually complying with that new regulatory requirement'.

823. Practically, whilst the implementation of the process for auditing, assessing and administrating the safety cases for Major Amusement Parks is still being determined by OIR, Mr. Bick stated that it is anticipated that upon a safety case being submitted, Mr. Chan and the Engineering Unit at OIR would be responsible for conducting the requisite assessment. Three additional positions within the Engineering Unit, which will possess engineering qualifications and be trained to undertake the requisite assessments under the new Regulations, are to be funded to facilitate this process. It is not envisaged that third party assessments of the safety cases will be undertaken at this stage.

824. At inquest, Mr. Chan acknowledged that the new safety case regime would involve the active auditing by the Engineering Unit within OIR of Theme Parks to ensure the proposed management maintenance programs and other areas detailed in the safety case were actually effective following implementation and had been suitably verified by a qualified external specialist as required.

825. In addition to the amended Regulations, OIR are also developing a Code of Practice for the industry in consultation with relevant stakeholders, including the Amusement Device Working Group, which will set a minimum standard for the operation of amusement devices.

826. On 21 March 2019, the aforementioned amendments to the Regulations as stipulated in the Work Health and Safety (Amendment Devices – Public Safety) were approved by the Governor in Council and commenced on 1 May 2019.

 

INDUSTRY RESPONSE & INFORMATION

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827. For the purpose of the coronial inquiry, various pertinent industry groups were invited to provide comment as to the incident and issues associated with the Regulation of Amusement devices in Australia and worldwide. Whilst most refused to provide any formal comment, below is a summary of the responses received.

Submission by the Safety Institute of Australia

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828. On 1 August 2018, Mr. Patrick Murphy, the Chair of the Safety Institute of Australia (SIA) provided a submission as to issues associated with the management, maintenance, safety risk assessment and training associated with fixed amusement rides, such as those found at Dreamworld, as well as the Regulatory environment.

829. The key issues identified by the SIA in relation to the aforementioned matters were as follows: 

(a) Issues pertaining to the adequacies of annual and longer term inspections and audits, and engineers signing off on the safety design of amusement rides, particularly in relation to the competencies of those professionals having to certify the safety of the ride. Safety covers all structural, mechanical and electrical/electronic aspects of the ride, and impacts on the effective life of the ride.

(b) Issues pertaining to the management of modifications to the manufacturer’s specifications, during or following installation to ensure compliance with local Standards or legislation. Such modifications have to be approved by a competent person consistent with the requirements in item (a).

(c) The role of Australian standards in a situation where rides are generally developed and manufactured overseas to overseas standards, in particular Europe and the USA.

(d) Issues pertaining to the adequacy of maintenance of the structural, mechanical and electrical/electronic aspects of the ride in terms of compliance with manufacturers’ and construction design specifications. Routine maintenance and environment has an impact on the effective life of the ride.

(e) Issues pertaining to the training and competency assessment of ride supervisors, operators and maintainers. This will include the adequacy of standard operating procedures relating to opening or closing a ride, normal operation and emergencies.

830. Generally, the SIA raised some concern as to the definition of a ‘competent person’ within the meaning of the Regulations and Australian Standards, as well as insufficient quality control on the application of the relevant definitions. It was noted that there was no formal mechanism to assess the competence of those engineers who elect to practice in Amusement Rides and Device-inService. Accordingly, an RPEQ could be deemed a competent person and sign off on the issues. Whilst s.241 (5)(b) defines a competent person, SIA noted that without a ‘clear understanding’ of how the Regulator decides on who is a competent person, the potential for confusion exists and could result in the inappropriate sign-offs on the operation and safety of amusement rides.

831. SIA also cited the current lack of competent professional engineers with experience in amusement rides, as well as a lack of process to try and ensure these numbers grow so as to ensure the necessary expertise is sustained. It was noted, however, that IEAust was convening a panel to examine the required competency standards for the amusement ride category.

832. SIA submitted that the Regulator should undertake spot checks of the annual inspections, particularly of high risk rides, to check the appropriateness and consistency of the sign-off, and whether the inspecting engineer/auditor(s) has an appropriate holistic plant design and operating verification process. It was also submitted that the Regulator require the inclusion of maintenance plans as part of the registration of amusement rides, particularly for high risk rides.

833. With respect to the Australian Standards, SIA was of the view that Standards Australia and the Regulators should consult to harmonise their requirements for design verification a large number of amusement rides in use in Australia are internationally manufactured.

834. With respect to the maintenance of rides, SIA noted that those older than 10 years will generally not have been designed to the current safety standards. In these circumstances, it is submitted that a competent person should be required to ensure that the risk management record for the ride identifies each of the risks, implemented controls and the residual risk to ensure that safety is maintained, so far as is reasonably practicable.

835. In relation to training of Ride Operators, SIA is of the view that in order for staff to maintain competency in operating a ride, they should be tested in emergency and evacuation procedures every six months, and Operators of high-risk rides should be routinely tested through simulations of emergencies.

836. The critical recommendations made by SIA are as follows:

1. The definition of a competent person in relation to amusement rides needs to be clarified to reflect the unique characteristics of amusement rides and their multi-disciplinary scope. This should be a joint activity between IEAust and the Regulators.
2. IEAust needs to consider planning for succession to the current small group of RPEs competent to assess amusement rides to ensure continuity and safety of rides.
3. The Regulators should audit the quality of sign-offs of ride designs, modifications and maintenance plans, and the adequacy of training and assessment of amusement ride supervisors, Operators and maintainers. This particularly applies for older rides.
4. For staff to maintain competency, they should be tested in emergency and evacuation procedures every six months, and Operators of high risk rides should be routinely tested through simulations of emergencies when the public is not on the ride.
5. The relevance of design aspects of A3533.1 is questioned, given that rides used in Theme Parks are manufactured in the EU or USA to standards pertaining in those countries. AS3533.2 and AS3533.3 still have an essential role.

OIR Response to SIA Submission

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837. OIR were asked to consider the submission made by SIA and respond to the recommendations made and issues raised.

838. A response was subsequently provided by Mr. Bradley Bick, the Executive Director, WHS Policy and Engagement Services in the OIR.

839. OIR’s response to the key issues identified by the SIA are as follows:

a) The lack of a formal mechanism to assess the competence of those engineers who elect to practice as ‘competent persons’ to approve the design of an amusement ride, conduct compliance checks, risk assess or perform and develop maintenance procedures and programs

1. The OIR does not have a role in assessing or regulating the competence of engineers in their capacity as professional engineers registered under the PE Act. This is administered by the Board of Professional Engineers of Queensland (BPEQ). There is a formal assessment regime used to assess engineers’ competencies against minimum requirements for engineers to gain registration as professional engineers in Queensland.

b) How does the Regulator determine who is a ‘competent person’, pursuant to s.241 (5)(b) of the Regulation.

1. Pursuant to the Regulation (s.241 (5)(b)(ii) & (i)) for amusement devices that must be inspected by an RPEQ, the person must also have acquired through training, qualification or experience the knowledge and skills to inspect the device. The Regulator does not have a legislated role to determine who meets the criteria under this section, as the knowledge and skill required will depend heavily on the particular type of device being inspected and its critical components.

c) The need for a holistic approach to be taken in certifying a ride as safe pursuant to the WHS Act 2011, which may necessitate the involvement of multiple person/s to ensure that all technical competencies associated with components of a ride are considered.

1. More than one competent person may be required to inspect the device, for example, a mechanical engineer and an electrical engineer may be required. The OIR understands it is routine for inspecting engineers to call upon people with specialist skills to assist when conducting annual inspections on amusement devices under s.241. The inspecting engineer maintains overall responsibility for the inspection of the amusement device including the work carried out by the assisting specialists.
2. During the inquest, Mr. Chan agreed that there needed to be a holistic signing off with respect to amusement devices. He acknowledged that as a mechanical engineer, he would not have the requisite training to consider all of the components of a ride, and may need to engage other external experts, such as non-destructive testing specialists or control systems, to consider certain elements and mechanisms.It would be likely that such specialists would need to be engaged externally.

d) The suggestion that the Regulator should undertake spot checks of the annual inspections, particularly of the high risk rides, to check the appropriateness and consistency of the sign-off, and whether the inspecting Engineer/auditors has an appropriate holistic plant design and operating verification process.

1. Audits of the major Theme Parks were undertaken by OIR in 2016, 2017 and 2018. These audits included checks that the annual inspection had been carried out by a competent person as required under s.241 of the WHS Regulation. The audits were conducted in accordance with the National Audit Tool for Amusement Devices by a multi-disciplinary team from OIR.
2. As part of implementing the recommendations about amusement devices made by the Best Practice Review of Workplace Health and Safety Queensland, a consultation draft of the proposed regulation was prepared. Annual inspections of amusement devices are an element of the safety case system proposed and Major Amusement Parks would be audited annually by the Regulator to check compliance. Mr. Chan acknowledged during the inquest, that this tragic incident had highlighted the need for the Regulator to do more to ensure compliance, with the development of Regulations requiring such action to be taken.
3. For amusement devices generally, the Regulator is also proposing that as part of the 2019 plant item registration renewal process, amusement device owners will be required to provide the name and details of the competent person who has undertaken the annual inspection of the device and the date of inspection. This information will enable the Regulator to confirm the person is registered as a professional engineer in Queensland. 
4. In addition, OIR has commenced recruitment for an additional 33 workplace health and safety inspectors, with three being placed as amusement device inspectors with engineering qualifications to assist in the regulation of the Theme Parks and amusement devices.

e) The suggestion that the Regulator require the inclusion of maintenance plans as part of the registration of amusement rides, particularly for high risk rides.

1. The proposed safety case and license regime for Major Amusement Parks will require detailed information on how amusement devices will be maintained, inspected and tested. This information would need to be provided to the Regulator in the license application. Matters such as the maintenance of amusement devices would be audited annually by the regulator. Accordingly, OIR is of the view that the proposed approach addresses the outcome of SIA’s suggestion.

f) Each of the critical recommendations as listed in [826]:

1. OIR will continue to consult with Engineers Australia and the BPEQ about the development of regulatory proposals in relation to amusement devices. The OIR acknowledges that the different definitions used for the term ‘competent person’ under the WHS Regulation are not always easily distinguished by persons not familiar with the legislation.
2. The OIR acknowledges concern in the industry as to the availability of registered engineers to inspect amusement devices. Consultation will continue with industry stakeholders, Engineers Australia and BPEQ about this matter, and broader factors influencing the decisions of engineers to work in the amusement device field.
3. Every application for design registration is checked by the OIR to ensure that the relevant technical standards have been applied for the particular type of plant and that the design has been verified by a competent person. Independent audits are conducted by the Regulator on the design of high-risk amusement devices to verify the quality of the sign-offs on new and modified designs by external professional engineers. Necessary action will be taken if there is evidence that the engineer who conducted the design verification is not fully competent. This process of checking and auditing applies to modification of an existing design for the purpose of re-registration.
4. OIR supports a rigorous approach to ensure that amusement device operators are competent and maintain their competencies with regular opportunities to practice emergency and evacuation procedures. The draft Regulation changes will insert a provision to require that the person with management or control of an amusement device is to ensure that the device is only operated by a person who is a ‘competent person’. An amendment will also be made to mandate the instruction and training requirements for amusement device Operators, which will be outlined in the safety case to be provided by the Major Amusement Parks. Risk control measures will also be required to be implemented by Major Amusement Parks to minimise the magnitude and severity of an incident to people at the Park.
5. The OIR has been actively participating in international efforts to ‘harmonise’ the requirements of relevant design standards on amusement devices from Europe, America and Australia. Harmonisation will ensure that critical safety requirements are similar across the standards.

 

 

VILLAGE ROAD SHOW SAFETY SYSTEMS

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840. During the course of the coronial investigation, information was sought as to Safety Management System in place at the various Village Road Show Theme Parks throughout Australia. Details as to the training and ride operation of the Wild West Falls Adventure Ride at Warner Brothers Movie World on the Gold Coast was also sought.

841. Executive Safety Manager, Mr. John Donaldson, who has held this position with Village Road Show for the past 17 years, subsequently provided a number of statements detailing the various safety systems and practices in place at Village Road Show.

842. For the maintenance, inspection and testing of amusement devices at Sea World, Movie World and Wet ‘n’ Wild, the following processes are in place: 

• Requirements of the manufacturer are reviewed and added to the maintenance schedule program (Maximo). This program, which has been in use for the past 20 years, contains a database of all maintenance checklists, inspection reports and any documentation received by any inspections undertaken throughout the year.
• Any advice received back from a manufacturer in relation to a ride or process is recorded and actioned through the record of change of management/maintenance process.
• Annually, an audit schedule is tabled with the Corporate Governance Committee, which states that an independent ride engineering audit commences in October. Upon completion of an amusement ride audit, Village Road Show is issued with a certificate from an external engineer to verify a record of the annual inspection, which is utilised for renewal of plant registration. The competent persons engaged by Village Road Show to carry out inspections on the amusement devices are DRA Safety Specialists, Tom Polley and Tim Gibney, all of whom are qualified RPEQ engineers. A yearly rotating schedule is used for the engineers utilised.
• Figtree is a risk management database also utilised by Village Road Show, which records all of the hazards, risks and actions identified for the Theme Parks. Actions are assigned to managers to rectify issues, which are escalated if not completed.

843. Since 2011, Village Roadshow have been utilising external engineers to review their rides and provide independent advice and reports. Mr. Donaldson notes that some of the Engineers have been engaged by Village Road Show for around 20 years to undertake AS3533 audits. These external audits are in addition to internal audits, which are conducted by safety advisors within Village Road Show who are required to undertake checks throughout the year on the various attractions.

844. At inquest, Mr. Donaldson elaborated on the training regime and maintenance scheduling program in place at the various Village Roadshow Theme Parks. For the past 20 years, a system has been in place to house the records in relation to each of the rides, maintenance checklists, inspection reports, and including all regular inspections undertaken on the ride (such as daily, weekly, monthly and yearly). Updates and safety bulletins issued by the manufacturer of rides or Regulator are housed in this database as well.

845. Information was also provided as to the attractions training procedures (‘the Procedures’) in place at Movie World for the Wild West Falls Adventure Ride. Relevantly, the Procedures state the following:

• A structured and methodical approach to Operational training is contained within the Attractions Training Framework.
• The Operational department maintain a close relationship with the Technical Services Department regarding attraction matters and ensure that Manufacturer bulletins and/or procedure manual updates are implemented and adhered to.
• All Attractions are rated annually by the Park Supervisors and Trainers for the purpose of ranking the most appropriate progression of team members. Team members are assigned an Easy or Moderate Attraction at the start of their employment based on their comprehension and aptitude shown at Attractions Essential training, and depending on Attraction availability with Scheduled Closures. Once trained on one or two Attractions, team members will not progress to their next Attraction until assessed as ready by their Supervisory and Trainer team. 
• Individual Attraction training is provided, which includes an overview of the ride by way of a PowerPoint presentation, a specific training plan for the ride to be followed by the trainer, as well as a procedure manual issued to the trainee for the specific Attraction being learnt. It is noted that these manuals are reviewed and updated annually as a minimum, more frequently as procedural and/or manufacturer changes occur. Every training day is to follow a similar pattern, which includes all elements of the Procedure Manual, practical time at each position and an evacuation walk through for each position. If simple changes are to be made, these are communicated in the form of Toolbox Talks delivered by the Ride Supervisor in the morning and signed by all operating team members on the day.
• At the end of each Training Day, a team member must have demonstrated their competency in each required line of the Competency Checklist and completed a Written Test achieving more than 80%.
• Each Attraction has a dedicated daily Supervisor who oversees the Attraction and provides feedback and support to each Attraction Attendant. This feedback and coaching is detailed on the daily Attraction Transfer Sheet, which is recorded in each individual team members Discipline Dossier.
• All team members must also undergo an individual Attraction Training written test every six months and score more than 80%.
• Team members conduct weekly Attraction evacuation drills, scheduled for a particular day at each Attraction and is logged on an Evacuation Record sheet.
• Team members are subject to random Assessment at Attractions using the iAuditor app.
• A mentor program was in place called HERO (Helping, Encouraging and Respecting Others), which identifies key team members who are role models to other employees. HERO team members are rostered on to buddy training on training days.
• Operations Trainers were progressing through key modules of a Cert IV in Training and Assessment.

 

EXPERT EVIDENCE

Engineering Expert Advice

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846. During the course of the coronial investigation, expert engineering advice was sought in relation to the incident and various aspects associated with the TRRR. Separate advices were provided by the following experts:

1. Dr Frank Grigg, Forensic Engineering Consultant;
2. George Rutherford, Technical Director of Projects etc. Pty Ltd; and III.
3. Dr Duncan Gilmore, Gilmore Engineers.

847. At inquest, evidence from the engineering experts was heard by way of a conclave.

848. A summary of the individual expert reports received, as well as the joint expert advice and evidence provided during the inquest, are outlined below.

Report on the Design of the Conveyor System by Dr Frank W. Grigg, Forensic Engineering Consulting Pty Ltd

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849. On 3 November 2016, as part of the OIR investigation into this incident, Dr Frank Grigg was requested to consider the construction of the conveyor and provide expert comment on a number of matters including, whether it was suitable for its application as of 2016, the modifications made and the shutdown process that was in place when the water level dropped. In addition to considering various internal Dreamworld documentation as well as CCTV of the incident, he also attended the scene on two occasions with OIR investigators.

850. In order to assess the suitability of the conveyor design, Dr Grigg noted that it was necessary to determine, as best as possible, the interaction of the conveyor with the rafts during the incident. CCTV footage of the event was utilised, along with survey data and measurements taken by Bennett and Bennett, in order to estimate the raft positions and likely interactions during critical events. It was noted that:

- Immediately after the first contact of the rafts, as Raft 6 was pushed forward by Raft 5, it would be expected, based on the properties of the inflated tubes as well as the observations during subsequent OIR testing, that there would be some compression of the tubes as a result of the forces between them.

- Given the continued movement of the conveyor, the contact geometry and the compression of the tubes during contact at this stage of the incident (first contact), it would be expected that: 

• The lower quadrant of the front of Raft 5’s tube would have pushed against the upper quadrant of the rear of Raft 6’s tube - locally compressing and distorting the tube segment contact.
• The front of Raft 5 plug would have tended to pitch upwards because the compression of its tube at the front would have acted as a ‘jack’ against the surfaces beneath it and because the geometry of the tube contact would have tended to cause the front of the raft to ‘ride up’ on the rear of the leading raft. Notably, a lot of the rafts weight at the time would have been borne by the conveyor. As such, the dominant direction of force transferred from Raft 5 to Raft 6 would have been in the horizontal direction.
• The rear of Raft 6 would have tended to pitch upwards because of the compression of its tube at the rear by Raft 5, which would have acted as a ‘jack’ against the support frames surfaces. 

851. Dr Grigg noted that ‘the amount of upward pitch experienced by each raft plug at the contact end would depend significantly on the inflation pressures of the deformed tube segments and the magnitude of the contact forces between them’. Given Raft 5’s tendency to pitch upwards, it would be expected that the rear edge of Raft 5 would pitch downwards, and as such, become ‘more exposed to contact with the front edges of the full width slats on the conveyor’.This would have been similar for Raft 6, which would have caused it to pitch downwards and be more exposed to contact with the edges of the support frame. 

852. Dr Grigg further noted from the CCTV footage, that at 2:05:04 pm, Raft 6 can be seen to be providing sufficient resistance to the forward motion of Raft 5 to cause it to slip on the moving conveyor slats.The conveyor then ‘engaged’ with the raft substantively, during which time it was thought that a full width slat was likely positioned immediately behind the rear of Raft 5. 

853. Dr Grigg found that the following characteristics of the conveyor and the support frame, contributed to the incident: 

- The distance between the full width slats was excessive, which led to –

• Increased probability of the plug pitching down aft and engaging more substantively with the slats and being driven forward forcefully. An increase in the number of full width slats would have reduced the probability of this occurring and may have made it more likely that the raft would have slipped on the top of the conveyor.
• Provided a significant gap between the conveyor head end and the support frame, which increased the probability of the raft falling into and becoming caught in the gap. Additional full width slats would have reduced the size of the gap between the conveyor head end and support frame, which would have likely reduced the engagement of the raft in the gap.
• Increased the severity at which the raft shook once it had fallen into the gap. If additional full width slats had been in place, this would have changed the size of the gap thus lessening the size of the compressive force imposed on the raft tube and plus, which would have resulted in less severe shaking.

- Upwardly bowed full width slats on the conveyor increased the probability of the conveyor engaging the raft and moving it forward forcefully.

- The distance between the support frame cross members was excessive. Dr Grigg noted that the distance between the first and second cross members was about 1450mm, with the second and third being 1270 mm. The distance between the support frame rails was 1450 mm. Accordingly, there was limited support to a raft plug, increasing the probability of the front edge of a downwardly pitched raft plug engaging with the third cross member. A central longitudinal member could have prevented the bottom of Raft 6’s plug from engaging the cross member of the frame. 

- The distance between the conveyor head end and the support frame was excessive.

854. Dr Grigg found that:

The design of the conveyor, most notably the fitting of a full width slat to every 6th link (every 3rd outer link), gave rise to the risk of positive engagement between the slats and the bottoms of the plugs of the rafts as well as the tubes, so as to produce the force necessary to cause the raft being discharged from the conveyor to tilt upwards when it hit the rear of the raft that was stranded on the support frame as a result of the water level dropping. It also resulted in the violent shaking of raft #5 after it had been titled up and caught between the conveyor and the support frame. 

855. Dr Grigg noted that an automatic shutdown of the conveyor in the event that one of the pumps failed would have prevented the incident from occurring. Furthermore, had a means of detecting a stranded raft in the unload area been installed, which stopped the conveyor, the tragic incident would have been prevented, as had been the experienced in 2001. In relation to the incident in 2001, Dr Grigg concluded that this ‘provided clear operational experience of what could occur in the event that the movement of a raft became blocked after being discharged from the conveyor, even without pump failure and water level dropping’.

Safety Related Control Systems, Summary Report 170326GRa, Expert Report by George Rutherford, 26 March 2017

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856. Mr. George Rutherford, Technical Director from Projects etc Pty. Ltd was requested by OIR to attend Dreamworld immediately following the incident to assist with their investigation. Various site visits were subsequently undertaken, including observation of the re-enactment attempts carried out by QPS.

857. Mr. Rutherford is a qualified engineer and has various workplace health and safety competency training. For 25 years, he has been involved in Safety/ EMC Assessments and Testing for a wide range of Products, Plants (Machinery) and Systems against International and National Regulations and Standards.

858. Despite multiple requests, documentation relating to the TRRR, namely circuit diagrams, critical components lists, risk assessments were not provided to Mr. Rutherford by Dreamworld. He raised significant concern should these ‘basic’ documents not exist as they would ‘likely lead to unsafe maintenance practices by Dreamworld Staff and perhaps inadequately safety design in rides’. It is of note that documents of this nature were unable to be sourced by Ardent Leisure, and as such, have never been produced.

859. Mr. Rutherford reached the following conclusions as a result of assessing the circumstances of the incident: 

• The incident appears to have occurred due to the sudden lowering of the water level at the upper area of the ride. This resulted in the grounding of a raft at the exit side of the Conveyor, which was subsequently struck by the raft carrying Ms. Goodchild, Mr. Dorsett, Ms. Low and Mr. Araghi, as it was forced off the conveyor. 
• The lowering of the water level is likely to have been caused by the south water pump stopping. Such a stoppage may have gone unnoticed and was possibly masked by the noise of the North Pump, which was still operating. Mr. Rutherford noted that he did not observe any difference in noise level when the south pump was started/stopped, nor was there a significant change in water turbulence.
• The lowering of the water level to a ‘dangerous state’, which could cause a raft to ground once the south pump had stopped, would have happened ‘very quickly’, and in Mr. Rutherford’s opinion, far too quickly for a busy Ride Operator to take any appropriate action, ‘even if it was clear to the operator what action they were meant to take’. He is of the view that the lowering of the water level should have been detected automatically.
• The result of the raft collision was worsened by the air gap between the end of the conveyor and the metal structure (support rails) in the unloading/loading areas. The reasons for the large gap needed to be determined, particularly as this may have occurred inadvertently over time with the replacement of corroded parts, as opposed to by a deliberate design.
• The ride operation procedure appeared to be ‘vague’, with the Dreamworld technicians observed by Mr. Rutherford not to have been completely confident as to what components of the ride were stopped by the Emergency stop button at the Main Operator control panel. 
• The modification carried out on the conveyor in early 2016 (installation of SIL 3), was confirmed to have been able to achieve the necessary level of safety. 

860. In Mr. Rutherford’s opinion, the primary cause of the tragic incident was ‘the lack of a suitable safety rated water level detective system interfaced to the upgraded conveyor system – such a safety system could easily have been provided and at a minimal cost’. He further states that the incident occurred as a result of a series of unfortunate events and timings, the absence of which had allowed the ride to operate for many years without incident. He opines that ‘I feel lessons should be learnt from this unfortunate incident particularly the importance of a correct initial risk assessment/regular updating of that risk assessment and the need for correctly assessed/rated safety circuitry’. 

861. Further, whilst unrelated to the incident, Mr Rutherford highlighted the following issues associated with his observations of the TRRR: 

• The interlocked lockout facility on the Main Operator control panel had NO level of safety designed into it and could have ‘foreseeably failed dangerously (and undetected) in a single fault condition and would then not provide any protection against start-up of the ride’.
• The emergency stop located above the Operator panel that stops the water pumps has NO level of safety designed into it, and only stops the north pump. It could foreseeably fail dangerously (and undetected) in a single fault condition and would then not provide any emergency stopping of the pump.
• Upon opening the Operator panel, a ‘rat’s nest of wiring’ was found, with some dangling disconnected wires with uninsulated ends. Mr. Rutherford was of the view that ‘such a poor level of installation could lead to dangerous malfunctions of the ride including unexpected start-ups and even unexpected launching of rafts during loading.’
• From the CCTV footage, it is clear that when the south pump stopped, a massive and fast backflow of water went into the outlet for which there was no guarding. If a patron had fallen into the water at such a time, there was a high likelihood that they would have been drawn into the pump outlet. Such a hazard could have been identified in a risk assessment of the ride, with appropriate countermeasures put in place.

862. On 7 July 2017, a further supplementary report was provided by Mr. Rutherford in relation to the feasibility of a water level detection system being added to the TRRR safety control system at the same time that the Conveyor Safety Control System was upgraded in 2016.

863. In relation to the above, Mr. Rutherford noted the following:

• Based on circuit diagrams provided by the new system installer company, there remained some spare capacity for additional safety sensors/safety outputs on the ABB Pluto D45 system. These inputs could have been used had a system to detect water level been installed in the load/unload area of the TRRR.
• A detection of the sudden lowering of the water level could have been achieved by a simple arrangement of suitable float switches in a ‘baffled area’ within the load/unload area. Otherwise, more sophisticated water level switches could have been made available on the controller by reconfiguring some of the inputs. 
• In either case, a SIL 3 rating for the water level detection system would have easily been achievable. This would have brought the conveyor to a safe stop as soon as the water level had fallen to a critical level, thereby likely avoiding the collision of the rafts which resulted in the fatalities.

864. Mr. Rutherford estimated that the cost of such a water level detection system being supplied and interfaced with the safety controller already installed, including dual diverse water level sensors, cabling installation, programming and testing/validation, would have been around $2000-$3000, had it been carried out at the same time as the other modifications in February 2016. Mr. Rutherford confirmed his view that the ‘primary cause of the tragic incident was the lack of a suitable safety rated water level detection system interfaced to the upgraded Conveyor system’.

Report by Dr Duncan Gilmore, Managing Director and President of Gilmore Engineers Pty Ltd

Spoiler

865. For the purpose of the coronial investigation, an independent expert engineering review and assessment of the TRRR and incident was sought from Consultant Engineer, Dr Duncan B Gilmore, Director and President of Gilmore Engineers. An expert advice was subsequently provided.

866. Dr Gilmore was briefed with a selection of the relevant documentary, expert and visual exhibits contained within the inquest brief, deemed necessary to provide an expert opinion as to the questions posed. A schedule of this material was settled and provided to all of the parties for comment. No objection or submission to include further material was advised by any of the parties prior to the inquest hearing.

867. A summary of the general comments made as to the ride and incident, as well as advice as to the specific questions posed, are outlined below.

General comments as to the TRRR, past incidents and risk assessments

Spoiler

868. Having considered the design of the ride, Dr Gilmore notes that the ride is clearly dependent on an adequate water level. When this drops, the rafts settle on the steel supporting rails and cannot travel through the watercourse, which includes at the end of the conveyor discharge point. This means that rafts can collide before a raft has cleared the conveyor.

869. Dr Gilmore states that the behaviour of rafts in low water was not understood as there was no engineering controls on the water level; when it fell only administrative controls were in place. There was no critical water level for which the water should not fall below nor an acceptable time for the water level to be below normal. 

870. Dr Gilmore noted that the presence of the unexplained, arbitrary and unnecessary horizontal 430 mm gap between the end of the conveyor and the steel support frames in the unload area allowed the raft that flipped to be jammed within the space. He opines that had this gap not been present, the dynamics of the incident may have been different, and the raft may have risen up vertically but not wedged. This would have been driven by the large slat gap and the presence of a raft in the unload area. It all originates, however, from a low water level and low water flow.

871. Dr Gilmore recognised that this particular incident was a ‘high risk, low probability incident, similar to an aircraft losing engine power or having to ditch in water’. This type of fault had seemingly not been experienced previously, although pump failure was not a new occurrence on the ride.

872. Dr Gilmore notes that the probable cause of the incident suggests that there has been a lack of ‘design mind’ behind the ride, which has been ‘configured to perform an action without an overall design philosophy’. The ride had been extensively modified over the past 30 years, with the original rotating platforms removed, underwater supporting steelwork frames added, conveyor slats removed, as well as many other features.

873. In Dr Gilmore’s opinion, the root cause of the incident was a combination of events, namely an equipment failure (pump), leading to a water level drop, and a subsequent lack of timely recognition by staff of the importance of this event combined with shutdown action. He notes that the incident happened quickly and required the Operators to react quickly to stop the conveyor, amongst the other tasks of loading and unloading guests. The best remedy, in his opinion, would have been the installation of engineering controls to monitor the water level and quickly shut down the conveyor belt should the pump fail.

874. Dr Gilmore further states that the ‘design’ of the ride should have been put through a rigorous risk assessment process initially when commissioned, and each time any modification was made, exploring all of the possible operating scenarios for the ride. The purpose of this would have been to uncover hidden low probability operating scenarios which may pose a risk to patrons.

875. In relation to Mr. Polley’s assessment of the TRRR 27 days prior to the incident, Dr Gilmore notes that this was a ‘cursory inspection’ and not a risk assessment of the design and analysis of the operation of the ride for which a design fault or the like may be identified. It seems it was assumed that the ride was safe and will continue to be operated safely and appropriately.

876. In relation to the JAK audits, Dr Gilmore notes that whilst the level of risk assessment conducted is somewhat unknown, given no design modifications were recommended in any of the years they were engaged, it can be confidently concluded that a full risk assessment of the design and operation was not conducted. Dr Gilmore did note that a number of recommendations made by JAK, particularly in relation to the labelling of buttons, were not carried out by Dreamworld. Dr Gilmore notes that pictures of the ride taken at the time of the incident demonstrates that the buttons at the Main Operator control panel remained unlabelled.

877. In 2013, JAK recommended that an ‘Emergency shutdown’ procedure be posted on the wall of the ride and that a simpler process be considered, such as a singular emergency button. This recommendation was not actioned by Dreamworld, with the risk being deemed as ‘acceptable’.

878. Having considered a wealth of records provided by Ardent Leisure for the purpose of the coronial inquiry as to the history of the TRRR, Dr Gilmore concluded that there was no evidence a thorough risk assessment and questioning/analysis/review/testing of the design of the TRRR was ever conducted. Dr Gilmore stated that:

Based on the ability of the failure of one pump in 2016 to lower water levels to critical and unsafe values at the unloading zone, without being safeguarded by an engineering control, an ability which seemingly has been in place for the 30 year life of the ride, it is my opinion that a risk assessment of the ramifications of the design methodology of the ride was never conducted initially in 1985/1986 during design and construction, and has not been conducted thoroughly since that time.

879. With respect to the previous incidents on the TRRR, in particular that which occurred in 2001, Dr Gilmore noted that:

• No engineering controls were implemented subsequently to prevent such an impact, and administrative action was instructed.
• The incident in 2001, in Dr Gilmore’s opinion, should have been sufficient to instigate installation of engineering controls and an investigation of what caused the rafts to tilt vertically and bunch up at the conveyor exit.
• This experience was first hand at Dreamworld and was available for implementation immediately and further testing as desired. It was a lost opportunity not to have followed through and subsequently modified the design of the TRRR, making it safer for patrons and potentially avoiding the October 2016 incident.

Specific Issues to be considered

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880. Dr Gilmore was requested to consider the following specific issues, the answers of which are outlined below:

I. Whether the initial construction of the TRRR was compliant with the requisite Australian Standards in place at the time (as can best be determined from the material available)? Particular comment is requested in relation to the appropriateness of the design of the conveyor slope.

- The TRRR was most likely generally compliant with Australian Standards in place in 1986.

- There is no information available as to whether a risk assessment was conducted by a designer in 1986.

II. Whether the modifications made to the TRRR were in breach of the requisite Australian Standards particularly those applicable to the construction of the conveyor and the installation of guiding rail? 

- The modifications made to the ride, including the removal of the conveyor slats, removal of the turntable and installation of supporting steelwork in the water, represent major alterations to the physical construction of the ride and should have been configured by a designer or ‘competent person’ with tertiary engineering qualifications and experience (AS-3533.1-2009 and AS-3533.2-2009).

- In addition, such modifications should have been subject of a detailed and exhaustive risk assessment investigation, and should have also been registered with OIR.

III. Whether the TRRR, as it was on 25 October 2016, complied with the requisite Australian Standards in place at the time?

- Australian Standards cannot stipulate guidelines for the construction and maintenance of every type of component which might be required in an amusement ride. The Standards allow for individuality by delegating responsibility to a ‘designer’ or ‘competent person’ with tertiary qualifications in engineering and experience. 

- Current AS-3533.1-2009 and AS3533.2-2009 both require the regular risk assessment of the design and any modifications by a person nominated as the ‘designer’ by the proprietor, or an appointed suitable ‘competent person’. With respect to the TRRR, there was no evidence that a thorough risk assessment and analysis/review/testing of the design of the TRRR was ever conducted or attempted.

- The design and construction of the TRRR did not comply with the requirements of the Australian Standards in place at the time.

IV. What risks did the design and construction of the TRRR, including the various modifications made, pose to patrons? 

- Given the TRRR operated successfully and injury/fatality free for approximately 30 years indicates that for the majority of its lifetime, the design and construction of the ride posed little risk to patrons. However, as built at the time of the tragic incident, it is Dr Gilmore’s opinion that the design and construction of the TRRR in the conveyor/unload zone posed a significant risk to the health and safety of patrons. The risks include:

• Electrical faults of unknown origin existed in the power circuit.
• If one pump failed, the water level on which proper operation of the ride relied dropped dramatically.
• Two-thirds of the conveyor had been removed, which created a gap into which the rafts might lodge between the slats and be pushed forcefully by the conveyor, rather than allow the slats to slip and slide uneventfully beneath the raft.
• If the water dropped in the unload zone, a raft would drop and rest on supporting steelwork in the trough, which prevents a raft from moving forward and away from the exit region of the conveyor
• When a raft is pushed along forcefully by the conveyor and came into contact with a stationary raft on the supporting steelwork in the unload zone, the rear raft was caused to ride up and over the raft ahead, flipping it vertically. Once flipped and tilted the raft was drawn into the gap created between the end of the conveyor and supporting steel work. Dr Gilmore is of the view that the gap should never have been present. Had it been minimal, the raft may have flipped, but the outcome for the occupants may have been different, although a risk of bodily crushing injuries remained. Dr Gilmore noted that ‘being tilted and under threat of being spilled onto a moving slat conveyor is however a catastrophic event and one which should have been guarded against under any circumstances’.
• The seat belts were only ever intended to brace passengers against inadvertently falling into the water, with the seats not designed to be in any way protective for a tipping event.
• The Main Control Panel had no emergency stop button, which could stop the conveyor.

V. What engineering measures could have been implemented to prevent a similar incident from happening?

- The following engineering measures could have been implemented:

• Promptly investigate and control electrical faults occurring in the pump circuit.
• Install a control function to shut down the conveyor if a pump fails or the water level drops to a critical level where rafts do not float in the unload area.
• Install a heightened water intake mouth on the pumps to maintain water level at a satisfactory level if one pump failed.
• Size the pumps so that the water level can be maintained on one pump alone.
• Remove supporting steelwork from the unload/load area trough.
• Install other means of ensuring stable and slow raft movement in the unload/load areas if required.
• Install proximity sensors in the rafts so that if they become overly close in the unload zone, the conveyor is stopped.
• Reinstall all conveyor slats to ensure that the conveyor will slip underneath the rafts and not forcefully engage with their base.
• Install an emergency conveyor stop button at both the main and unload control panels.
• Consider protective seat structures and seats which will protect patrons from injury if the raft is tipped.

VI. Were the previous risk assessments and maintenance of the TRRR undertaken internally by Dreamworld, and those commissioned by external providers namely DRA, JAKS and Mr. Tom Polley, sufficient to identify risks associated with the TRRR?

- Risk assessments were not commissioned from external providers DRA, JAKS or Mr. Tom Polley.

- JAKS conducted a visual inspection of the ride with respect to safety and compliance, rather than a risk assessment. Given no design modifications were recommended in any of the years, Dr Gilmore confidently concludes that a full risk assessment of the design and operation was not conducted. 

- Mr. Polley’s inspection was cursory and not a risk assessment of the design with analysis and demonstration of the operation of the ride.

- Maintenance conducted by Dreamworld can only be inferred from the pre-service inspections. 

- There is no evidence that a thorough risk assessment and questioning/analysis/review/testing of the design of the TRRR has ever been conducted.

VII. Please consider the content of the safety bulletin from OD Hopkins (ODHA 00-1) issued in March 2000 and provide comment on the content and how it may have applied to this tragic event? 

- The relevant items from the Bulletin were (1) the need to immediately activate an emergency stop on a ride if a raft gets jammed or hung up any way; (2) critical to maintain water levels; and (3) aviator type seat belts, with Velcro belts also acceptable.

- All the items recommended, following incidents on raft rides carrying guests turned over during the course of the ride, were nominally enacted by Dreamworld, including an emergency stop button (which was not readily accessible to the Operator in charge), the awareness of staff that the water level needed to be maintained, and Velcro seat belts were in use.

VIII. In light of the tragedy of this incident are there any changes that could be made to the Australian Standards or present regulatory system for amusement rides in Queensland which may prevent a similar incident from happening in the future?

- Current WHS Regulations and Australian Standards as are in place are adequate. 

- Changes are required to the tightening of the checking and enforcement process i.e. full risk assessments and inspections are actually conducted and fully reported, recommended engineering, administrative and protective equipment controls are properly implemented together with documentation of the history and maintenance. This could be performed by having the requirements independently certified annually by an RPEQ in a similar manner to the annual inspections for mechanical and structural adequacy, together with random spot checks of documentation by WHS Queensland.

- Evidence suggests that prior to 2016, the system of ensuring compliance of amusement rides with Australian Standards and WHS Regulations had been unsuccessful at Dreamworld.

IX. In your opinion are there any other issues arising from this tragic event, which need to be considered and addressed in order to ensure a similar incident that can occur in the future? If so what measures need to be undertaken? 

- Dr Gilmore recommended the following measures:

• Initiate a formal document and control systems for each ride. Appoint a ‘designer’ or ‘competent person’ for every ride, registered with WHS Queensland, with tertiary qualifications in engineering and experience.
• An external party (RPEQ) to be used to conduct independent risk assessments.
• Specify that a full risk assessment on the whole ride be conducted at least every 5 years or each time new hardware/electrical modifications or additions/subtractions are performed.
• Spot checks by OIR to ensure proper conduct and thoroughness.
• Regulations should make it clear the onus placed on the RPEQ when conducting an annual inspection or a risk assessment.
• The operation of the ride should be visually observed during a risk assessment.
• Look for probability failures – the excuse that the ride has been trouble free for 30 years is not an acceptable excuse. History shows that low probability coincidences often turn out to be the cause of a major unexpected incident.
• Observe how the machine handles adverse events.
• Consult Theme Park records internally and internationally.
• Look at design records.
• New designs should be documented to reveal the design methodology, what was considered, safety considerations, log and register with WHS Queensland to keep centrally.
• Testing must be carried out and be comprehensive.

 

ENGINEERING EXPERT CONCLAVE

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881. The expert engineering evidence in relation to this incident was heard concurrently during the inquest by way of a conclave. Accordingly, Dr Frank Grigg, Dr Duncan Gilmore and Mr. George Rutherford gave evidence as a panel, and a joint expert advice was tendered.

Joint Engineering Expert Advice

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882. Following the provision of further short answer written responses by each of the experts, and a teleconference with Counsel Assisting, a joint advice opinion was provided by Dr Grigg, Dr Gilmore and Mr. Rutherford. It was acknowledged that given the differing areas of engineering expertise, the opinions expressed by Mr. Rutherford in answer to the questions posed were limited to Risk Assessment Concepts, Safety Related Control Circuit Concepts and Electrical Safety Concepts. Statements made, which were not specifically attributed to Dr Grigg or Dr Gilmore, were intended to be read as opinions shared, given their area of practice and expertise.

883. Relevant excerpts from this advice, as well as the evidence provided during the inquest proceeding, is summarised below.

(1) Whether the initial construction of the Thunder River Rapids Ride was compliant with the requisite Australian Standards in place at the time?

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Standard in place at the time of construction

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884. It was agreed amongst the experts that there was no key applicable Australian Standard (AS) in place at the time the TRRR was commissioned in 1985/1986. The first edition of the AS-3533: Amusement Rides and Devices was published in 1988. Section 1.3.20 relates to Amusement Rides and Devices, including ‘Raft Rides’ like the TRRR. Accordingly, the ride was required to satisfy the District Inspector, OIR that it complied with other safety standards, which it appears to have done based on the material available in relation to the initial design and registration.

885. Mr. Rutherford is of the view that no similar standards (which are now current for the area of Safety Related Control Circuits) existed at the time of the initial construction of the TRRR. However, traditional ‘electro-mechanical’ type interlocking & non-safety controllers (of a lesser level of reliability compared to equivalent systems used today) were already in existence, and may well have been applied. He further notes that with respect to electrical safety requirements, which were in place at the time, such as the National Wiring Rules, would have likely resulted in adequate electrical safety had it been installed to a professional standard. Mr. Rutherford is of the view that the Safety Related Control Systems and Electrical Safety of the TRRR were probably in line with standard practices at the time of initial construction, however, have become noncompliant with current practices over time.

AS-3533 - 1988

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886. Upon release of AS-3533-1988, the view shared by the experts was that best practice would have been to ensure the TRRR complied with the Standards, although no action was mandated.

887. At inquest, Dr Grigg further explained that ‘best practice’ in this instance would have been to take all precautions suggested in the Standard, even if they weren’t mandatory, with a common sense consideration of the risks present for the ride and rectification by way of engineering solutions where possible. Dr Gilmore further noted that ‘best practice’ would be to take the most updated advice given in relation to safety, per the Standards.

888. With respect to the requirements of AS-3533-1988, the following were noted in relation to the TRRR: 

1. It appears on the documentation available that the TRRR would have complied with the AS-3533-1988 design requirements for Rafts (s. 4.4.10) and Flumes (s. 4.4.10.2) when the ride was first opened. However, Dr Gilmore noted s.4.4.10(b), which stipulated that the depth of the water in the flume shall be the minimum necessary to maintain floatation of the raft when fully loaded, does not appear to have been adhered to. The water course on the TRRR was substantially deeper than that necessary for floatation and increased the risk of drowning. Dr Grigg notes, however, that the water depth near the head end of the conveyor may have been greater than that in other parts of the ride due to the horizontal discharge of the original pump.
2. It is unknown whether the TRRR would have complied with AS section 7: Maintenance and Inspection, particularly those pertaining to Logbook (s. 7.5), Section 9: Information provided by the manufacturer, and Section 10: Marking. At inquest, the experts agreed that it was unclear as to compliance in this regard due to the lack of documentation available, kept or retained in relation to the TRRR.
3. Given the loading and unloading components of the ride design when first commissioned involved a turntable, which was removed at some time before 1998, it cannot be determined whether the original installation would have provided unrestricted views of all embarkation and disembarkation stations, as was required by Section 3.13: Controls Stations.
4. Having considered the control arrangements found in place after the tragic incident, it appears that the Operator at the Main Control Panel may not have had safe control of all functions in an emergency, per s.3.13(c), which includes the absence of an emergency stop button for the conveyor. Additionally the “Conveyor Stop” and “Emergency Stop” (which only Stopped the North Pump) and likely all other “safety functions” (e.g. Raft Release etc) were not designed/implemented as “safety related features” but were of low reliability and subject to failure in the case of a single fault occurring.
5. No edition of the AS-3533 applicable to Design and Construction (1988 or subsequent) deals directly with the design, construction of, or modifications to a conveyor.

2) Whether the modifications made to the TRRR were in breach of the requisite Australian Standards, particularly those applicable to the construction of the conveyor and the installation of the guiding rail?

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889. The experts found that the known mechanical modifications to the TRRR, which are relevant to the incident, were as follows:

1. Conveyor slats: Whilst it seems that every second slat of the conveyor was removed in 1989/90, it is unclear when the removal of every third slat took place. ii.
2. Removal of the Turntable: It appears that the turntable passenger loading and unloading device was removed in the early 1990’s, with the support rails in the unload area being installed at the same time. iii.
3. Addition of raft support rails in the unload area: Whilst the specific date of the installation of the support rails downstream from the conveyor is unknown, it seems that these may have been put in place at the time of the removal of the turntable. It was noted, however, that the rails in place at the time of the incident were younger than expected, and therefore may have been replaced and/or moved since the original installation.

890. It appears probable that the majority of the modifications were made to the TRRR when AS-3533-1988 was in place. Accordingly, reference to modifications was made in Appendix H: Statutory Approval, Section H4 – Modification and Alterations, which states that modifications, which may cause increased stresses or ‘otherwise affect safety’, are deemed to make the unit a new model and new approval may be required.

891. In 1997, AS-3533-1988 was expanded to include Hazard Identification, risk assessment and risk control measures (s.2.2). Accordingly, if the modifications to the TRRR were made before the introduction of the 1997 Standard, there was no strict requirement for a reassessment of the safety of the TRRR, unless further modifications made were considered to constitute a redesign, pursuant to the application of AS-3533.1-1997.

892. The experts were of the view that in modifying the original design of the conveyor (removal of the slats) and the installation of the support railing at the unload area, a “designer” should have consulted with a documented risk assessment of the hazards envisaged to be introduced or altered undertaken. These alterations would have amounted to a new design, and should have been re-registered with the Regulator. Notification of these modifications should have been made to the Regulator.

893. AS-3533.2-1997 described the requirements for the operation, maintenance and inspection of fixed amusement rides and should have been considered in relation to the TRRR. Specifically,

i. Section 5 – Maintenance, Replacement, Repair and Inspection – specifically, s.5.1, which includes:

….

Following major maintenance and repair, and at random intervals on other occasions, a hazard identification and risk assessment procedure should be completed to ensure new hazards are not present, and residual risks identified by the designer or manufacturer are not increased.

NOTE: A typical hazard identification and risk assessment procedure is given in Appendix F.

ii. Appendix F – Hazard Identification, Risk Assessment and Risk Control Process – This Appendix explicitly details Mechanical Hazards for consideration as part of the hazard identification and risk assessment process, which includes those involving crushing, shearing and entanglement. AS-3533.2-2009 provides almost identical guidance as that provided in Section 5.1 of 1997 Standard, with more substantial guidance provided for in Appendix F, and reference directly to AS 4360-1995 – Risk Management.

894. It was agreed by the experts that AS 3522.2-1997, s.5.1 should have triggered a mechanical hazard identification and risk assessment of the TRRR on a number of occasions during the operating period after the 1997 edition of the Standard was in place.1660 If a hazard identification and risk assessment procedure, as per the recommendation of Section 5.1, had been completed following the implementation of any of the relevant modifications, it is most probable that some safety issues associated with at least the removal of the full width conveyor slats and the installation of the support rails, would have been identified.1661

895. At inquest, it was agreed that s.5.1 essentially reflected what was ‘best practice’ for amusement device owners at the time in relation to the process to be undertaken should any modifications be made to the ride.1662

896. Given the TRRR 1991 Operator Procedure Manual identified the events ‘loss of power to one or both pumps’ and ‘person in the water’ as ‘emergency situations’, consideration should have been given to mechanical hazards associated with these situations in any hazard identification and risk assessment, regardless of the requirements of the Australian Standards or Regulations.1663 Such an assessment would have considered the underwater risks to a “person in the water”, of which some of the obvious include:

A. The excessive gap between the full width conveyor slats posed a significant risk of injury to any person who fell onto the conveyor whilst it was in operation;

B. The area between the head of the conveyor and the support rails posed a significant mechanical hazard;

C. The clearance between a moving raft and the support rails was a shear/pinch point; and

D. The support rails could have been considered an entrapment hazard.

ii. If the event of ‘loss of power to one or both pumps’ had been risk assessed, it should have indicated that when the water level dropped:

A. The ride would have been operating outside of its design envelope and there was at best a significant risk of property damage or at worst a significant risk of injury to patrons.

897. Given the unclear history for the various changes (both electrical and mechanical) that have occurred over the years since the initial installation of the TRRR, it appears that most of the ride has been modified in an undocumented way with little or no consideration being given to the effect of safety via a detailed and formal risk assessment process. As such, hazards were never identified by a designer with a risk assessment being undertaken.

898. In relation to the importance of risk assessments for amusement rides, during the inquest, Dr Grigg noted that:

…the important thing about doing a risk assessment is to try and think about the possibilities of what could happen under virtually all circumstances, and to take appropriate action to minimise those risks. In some cases, it mightn’t be possible to completely eliminate a risk.

But you’ve got to be aware of what the risk is and you may need – if you can’t come up with an engineering solution, it may be that you’ve got to rely on some sort of administrative control by putting – having people telling patrons what they’ve got to do and what they’ve got to look out for, or something…

But nevertheless you’ve got to identify that the risks exist.

899. All of the experts concurred that the previous incidents on the TRRR, particularly in 2001 and 2014, should have alerted Dreamworld to the hazards present on the ride. These incidents should have prompted a thorough risk and hazard assessment of the ride, including the design, looking beyond the circumstances of the incident. In accordance with the hierarchy of controls, elimination of the risk, plant and engineering controls should have been considered as solutions to identified hazards before administrative controls.

3) Whether the TRRR, as it was on 25 October 2016, complied with the requisite Australian Standards in place at the time?

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900. AS-3533.2-1997 and subsequent editions describe the recommendation in section 5.1 for hazard identification and risk assessment (including mechanical hazards) to be performed at reasonable intervals, and the requirement of the involvement of ‘competent persons’ in these tasks. It also describes other maintenance, replacement, repair and inspection activities. The documentation available in relation to the TRRR clearly shows that whilst a number of audits and ‘risk assessments’ were performed on aspects of the ride, the identification and assessment of mechanical hazards was rarely considered and when it was, it was not considered to the extent recommended by AS-3533.2.

901. It is clear that the maintenance documentation, including logbook records (s.5.5 AS-3533.2) did not comply with the Standard, and because of this, relevant information regarding modifications and alterations were not communicated to or assessed by competent persons.

902. There were no directly relevant safety designs applicable to the conveyor at the time of the incident of concern. Mr. Rutherford further noted that although the AS 1755 (now superseded by AS/NZS 4024 Parts 36XX), which covers conveyors, states that conveyors specifically designed to carry people are not covered by these Standards, any Risk Assessment carried out under the AS/NZS 4024 (Safety of Machinery) should have identified the pinch/draw-in/shear hazards at the end of the conveyor.

903. Mr. Rutherford notes that other than the modifications made to the Conveyor Control System by PFI, other parts of the TRRR Safety Related Control System, including existing controls for the ‘Prevention of Start-Up’, ‘Water Pump Emergency Stop’, ‘Conveyor start/stop’ and possibly other “safety features” (e.g. Raft Release etc) at the Main Operator Panel were not in compliance with the Standards for Safety Related Control Circuits at the time of the incident. Additionally, the state of the electrical wiring within the Main Operator control panel and apparent lack of documented electrical circuit diagrams and critical components list could have impacted on the safety of the ride during any maintenance and modifications being performed.

4) What risks did the design and construction of the TRRR, including the various modifications made, pose to patrons?

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904. It was recognised by the experts that the TRRR had operated successfully and injury/fatality free for almost 30 years. As such, for a majority of its lifetime it seems that the general design and construction of the ride may have posed little risk to patrons. However, at the time of the fatal incident, the design and construction of the conveyor and unload area posed a significant risk to the health and safety of patrons.

Specific hazards associated with the design and operation of the TRRR:

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905. As it was at the time of the incident on 25 October 2016, the experts agreed that the design and construction of the TRRR in the conveyor/unload zone posed a significant risk to the health and safety of patrons.

906. The following specific hazards associated with the design and operation of the ride were identified:

1. The wide spacing of the slats of the conveyor would have created a much greater risk of injury to a person who had fallen into the water in the vicinity of the conveyor or had otherwise interacted with the conveyor whilst it was operating. This spacing of slats also gave rise to the risk that the plug of a raft would engage on a slat causing the raft to be pushed forward positively, rather than simply slipping and sliding uneventfully beneath the raft, in the event of the forward movement of the raft being obstructed.
2. The gap between the slats at the head end of the conveyor and the steel support frame was much larger than necessary. This gave rise to the flotation collar of raft number 5 being able to fit into the gap when the raft tilted; and this resulted in the occupants of the rear seats of the raft being struck by the slats of the conveyor. Had the gap been minimal, the raft may have flipped and the occupants jostled, but the outcome may have been somewhat different. Being tilted and under threat of being spilled onto the moving slat conveyor is a catastrophic event and one which should have been guarded against under any circumstances. Falling towards the slat conveyor which is powering onwards can only lead to body crushing injuries.
3. The head end of the conveyor being unguarded would have created a high risk of injury to a person who had fallen into the water in the vicinity of the conveyor or otherwise interacted with the conveyor whilst it was operating.
4. The installation of the steel support frame and rails would have created a much greater risk of injury to a person who had fallen into the water by creating pinch/shear points with the raft movements and also increasing the probability of entanglement and drowning. However, it is recognised that the frame probably assisted in stabilising the rafts at the load and unload stations as well as being of assistance when inspecting the undersides of the rafts.
5. Electrical faults of unknown origin existed in the pump power circuit. These occurred randomly.
6. If one pump failed, the water level on which proper operation of the ride relied dropped dramatically and quickly at both the unloading and loading stations.
7. If the water level dropped in the unload zone, a raft in that zone would drop and rest on steel support frame, which had been installed in the trough. This undoubtedly allowed patrons to disembark safely if the water level was low, but it stopped the raft moving forwards and away from the exit region of the conveyor, creating a blockage.
8. From the information provided, it is unable to be determined whether the removal of the turntable at the unload area of the TRRR increased the risk of exposing patrons to mechanical hazards. Information available suggests that the operation of the turntable may have reduced the Operator workload, and lessened the risk of rafts jamming or colliding in the unload area. However, without more detailed information as to the construction of the turntable, the comparative level of risk cannot be adequately determined.
9. It appears that the seat belts were only ever intended to brace passengers against inadvertently falling into the water as the raft travelled around the waterway on rough waves. The seats were not designed to be in anyway protective for a tipping event i.e. they were not steel reinforced so that they might protect their occupants and cause the conveyor to stall rather than crush both the seats and patrons.
10. The Main Control Panel had no emergency stop button, which would stop the conveyor immediately.
11. Mr. Rutherford notes that parts of the TRRR Safety Related Control System, including existing controls for ‘Prevention of Start-Up’, ‘Water Pump Emergency Stop’, ‘Conveyor start/stop’ at the Main Operator Panel were not in compliance with the Standards for ‘Safety Related Control Circuits’ at the time of the incident. They were not designed to have any particular level of safety reliability and could have malfunctioned in the case of a single foreseeable fault condition. The “Conveyor Stop” function at the Main Control Panel was not designed as a “safety stop”. It is designated as a Category 2 Stop under AS/IEC 60204-1, which could fail to stop the conveyor in a single fault condition.

907. It was noted by Dr Gilmore during the inquest that none of the other comparable international rides had a similarly configured conveyor to the TRRR. Rather, the slats were closer together preventing a person from falling through into the water or mechanism. Dr Grigg notes that it is unknown why the gap in this area is so big, and he suspects that it was done without anyone considering the implications.

908. Dr Grigg and Dr Gilmore both agreed during the inquest that any competent person conducting a risk and hazard assessment of the ride would have easily identified a risk associated with the slat spacing, as well as the other aspects of the formation of the ride as outlined above. All of the experts strongly rejected any suggestion that their conclusions in this regard as to the obvious nature of the hazards on the ride were influenced by ‘hindsight biased’ or knowledge of the tragic incident.

909. Mr. Rutherford highlighted during the inquest that the changes and modifications made to the TRRR over its 30 years in commission not being documented was a ‘major issue’.

5) The cause of the incident on the TRRR

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910. In general terms, the experts were of the view that the incident occurred as a result of an equipment failure (south pump), leading to a water level drop, following which the conveyor was not stopped.1679 911. The experts agreed that the following sequence of events transpired on 25 October 2016:

1. Drop in the water level due to failure of the southern pump.
2. Continued operation of the conveyor.
3. Contact between the Raft (#5) and the lead raft (#6).
4. Forceful engagement of the Raft (#5) by the conveyor.
5. The lead raft (#6) snagged on support frame.
6. Raft (#5) entered gap between conveyor and support frame.

912. It was the view of the experts that if any of the above events had been avoided, the incident would not have occurred. It is considered that a change of any one of the engineering measures identified in Question 6 would probably have prevented the disastrous outcome. Significantly, whilst the water level drop was a primary cause of this incident, there were multiple other hazards evident on the ride, as outlined previously (conveyor slat removals, nip point etc.), which could have caused other catastrophic incidents to occur at any time. 

913. Dr Grigg also noted that Raft #6 was heavily loaded towards the front and very lightly loaded at the rear. Raft #5 was heavily loaded at the rear. These distributions may have contributed to the interactions that the lead raft (#6) had with the support frame, and Raft #5 had with the conveyor. Differences in raft passenger weight distribution may in part have explained why a similar incident did not occur in 2014, when rafts came into contact at the same location.

914. The experts also noted that a number of human factors associated with the failure of the procedures to enable a rapid response to an emergency situation also appeared to have contributed to the tragic outcome, including:

1. Delay in action because of the procedural requirements of Operators, including the multitasking required of the No. 1 Operator and the requirement of the No. 2 Operator to alert the No. 1 Operator.
2. Inadequate alarms to alert the No. 1 Operator.
3. Multi-step shutdown procedure, which caused a delay in isolating critical machinery (conveyor).
4. The memorandum, dated 18 October 2016, requiring the Unload Platform E-Stop only to be pressed if the Main Control Panel cannot be reached.
5. Insufficient training of the Operators, especially in actions required in an emergency situation.
6. Inadequate recognition or downgrading of what constitutes an emergency. In the June 2016 edition of the Operators Procedure Manual, the only identified emergency event was person in water and/or raft capsized.

915. Dr Gilmore noted that, in his opinion, the root cause of the incident was that a combination of events occurred for which the outcome was uncertain and unknown. Staff (operational and technical design and maintenance), as well as auditors and annual inspectors had never been alerted or aware that this combination of events could pose a threat. The ride design should have been put through a rigorous Risk Assessment process initially when commissioned, and each time any modification was made, exploring all possible operating scenarios for the ride.

916. Dr Gilmore further stated that the TRRR was internally manufactured, as opposed to being purchased from an international manufacturer, the onus for identifying necessary periodical safety upgrades, thoroughly analysing and documenting the implications of any modifications to equipment, and conducting risk management audits would rest totally with the owners of the TRRR.

6) What engineering measures could have been implemented to prevent a similar incident from happening?

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917. The experts were of the view that a number of engineering measures could have been implemented to prevent a similar incident from occurring. Namely: 

• Installation of a control function to shut down the conveyor if a pump fails or the water level drops to a critical level where rafts do not float in the unload area. Mr. Rutherford noted that had there been an appropriately safety rated, designed and installed automated detection system for the water level as of the date of the incident, which was suitably interfaced to the Conveyor Safety Control System, the tragedy may have been avoided. Such water level sensing systems are now common place on modern rides and can be easily retrofitted in cases that their existence will enhance safety on older rides. Other means of stopping the conveyor movement in the event of a drop in water level, such as interfacing to the Pump Operation circuits, could also have achieved a similar safe result.
• Size the two pumps so that the water level can be maintained on one pump alone. Dr Grigg noted, however, that the two pumps installed are very powerful, and it is considered likely that for power supply reasons it was necessary to use two pumps so that their starting did not occur simultaneously and thereby create a very substantial peak load on the power supply. It is not apparent that one pump would be more reliable than two.
• The E-stop for the conveyor at the unload station should have been clearly labelled, and its function should have been duplicated at the Operator’s control station so that in an emergency the conveyor could be stopped as quickly as possible.
• A central longitudinal member in the steel support frame may have moderated the degree of obstruction of the forward movement of raft number 6, thereby reducing the risk of the lead raft snagging and the rafts tipping up. Alternatively, removal of the supporting steelwork from the unload/load area trough could be considered. However, it was noted that the removal of this steelwork may have resulted in undesirable instability of the rafts during unloading and loading.
• Dr Gilmore suggests the installation of other means of ensuring stable and slow raft movement in the unload/load areas if required, to prevent rafts from becoming stationary in the unload area. Dr Grigg questions the cost effectiveness of such an arrangement.
• The spacing of the slats on the conveyor should have been much closer or an alternative conveyor design used.
• The gap between the slats at the head end of the conveyor and the steel support frame should have been only sufficient for reliable operation, and probably no more than about 100mm.
• Consider protective seat structures and seats, which will guard patrons from injury if the raft is tipped. The seat belts must be quick release, however, as the danger of drowning persists. AS3533.1 – 2009 section 2.8.10.4.1, specifically prescribes quick release fittings only with no metallic buckles. Dr Grigg was of the view that properly installed aircraft style lap seatbelt with a positive latching mechanism should have been used instead of the Velcro belt.
• Install proximity sensors in the rafts so that if they become overly close in the unload zone, the conveyor is stopped. Dr Grigg, however, questions whether this would achieve the desired outcome.
• Promptly investigate and correct electrical faults occurring in the pump control circuit.

7) Were the previous risk assessments and maintenance of the TRRR undertaken internally by Dreamworld, and those commissioned by external providers namely DRA, JAKS and Mr. Tom Polley, sufficient to identify risks associated with the TRRR?

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918. The experts unanimously agreed that the response to this question was no. The risk assessments, maintenance and inspections of the TRRR described in the brief were insufficient and did not meet the recommendation of AS-3533.2- 1997 (and later editions) or AS/NZS 4024. This was because Hazard Identification and Risk Assessment Procedures (s. 5.1 and Appendix F) were lacking. It is not clear who was nominated as the qualified ride ‘designer’ or ‘competent person’ with responsibility for the design overview and initiation of all ongoing modifications.

919. AS-3533.2-1997 separately describes the requirement for Annual inspections (s. 5.4.2) and the recommendation for Hazard Identification and Risk Assessment Procedures (s. 5.1 and Appendix F). There was no indication in the records produced by Ardent Leisure of an ‘Annual Inspection’ as defined by the Standard having been performed prior to 2016. 

920. The experts agreed that Mr. Polley’s inspection in 2016, would have met the general requirements for an ‘annual inspection’ as described in AS-3533.2- 2009. However, his inspection was cursory in nature and not a risk assessment of the design with analysis and demonstration of the operation of the ride, which was not required by the Standard.

921. On the material provided, which is scant, poorly recorded and entirely inadequate, there does not appear to have been any risk assessments of the operating procedures and the physical functioning of the TRRR and its controls other than by JAK. However, the scope, level of risk assessment and audit tools used by JAK are largely unknown, with no reference made to AS-3533. It does appear that the audits consisted of visual inspections of the rides with respect to safety and compliance. However, given that no design modifications were recommended in any year (such as comments on water depth, pump reliability, steel frames in the troughs, conveyor design, conveyor slat design/replacement, seat belt reliability), it can be confidently stated that a full risk assessment of the design and operation was not conducted by JAK. It was noted that JAK appear to have been the only external assessors to have considered the functioning of the controls, however, some of their recommendations were not acted upon.

922. The focus of Mr. Polley and DRA appear to have been on the maintenance and structural condition of the ride, and related management documentation, as dealt with in AS-3533 Parts 2 and 3, rather than on the design aspects as to the rides fitness for purpose and safety as a system when operating.

923. Mr. Rutherford noted that a ‘visual’ inspection of the external areas only (e.g. Main Operator control panel area) may indicate that an adequate set of safety features are in place as the ‘Prevention of Start-Up’ interlock switch was an approved switch intended for safety applications, and the Emergency Stop was the required RED/YELLOW colour. However, this will not reveal that the internal components used and interfaced to, as well as the configuration, provide an actual safety level. This can only be determined by a person with adequate knowledge of Safety Related Control Circuits, along with reference to up to date Circuit Diagrams and detailed CCL (Critical Component List), neither of which appear to be in existence for the TRRR at the time of the incident, other than in the case of the PFI 2016 modification.

8) In light of the tragedy of this incident, are there any changes that could be made to the Australian standards or present regulatory system for Amusement Rides in Queensland, which may prevent a similar incident from happening in the future?

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924. The suggested changes to the current regulatory system in Queensland to ensure a similar incident doesn’t happen again, as recommended by the experts, are outlined below. I accept that those recommendations should be adopted.

925. It was recommended that Annual Risk assessments of amusement devices should be required to include detailed examination of the operation of the ride during all modes of operation and possible emergency conditions. The assessment should include all possible control system functions and variations and it is likely that it would require assessment by both competent mechanical and electrical engineers. At inquest, the importance of this detailed consideration of the device was said to be necessary given the complexity of the machine. 

926. Furthermore, the section in the Australian Standards applicable to waterborne rides (including raft rides) needs to be reassessed to include some of the types of safety requirements associated with roller coasters, including more thorough considerations for lifts/elevators, collisions and passenger loading/unloading.

927. The requirement for hazard identification and risk assessment in AS-3533.2 section 5.1 should also be made mandatory. Any modification or alteration to the ride should require hazard identification and risk assessment to ensure that changes made do not affect safe operation and use. 

928. Better direction to other relevant Australian Standards (e.g. the AS 4024 series) should also be provided. A requirement that hazard identification and risk assessment include consideration of failures that may affect safety.

929. Dr Gilmore is of the view that whilst the relevant Australian Standards and Regulations in place in Queensland are adequate, a tightening of the checking and enforcement process should take place, such as a requirement that full risk assessments and inspections are actually conducted and fully reported. It is also recommended that engineering, administrative and protective equipment controls are properly implemented, together with documentation of the history and maintenance. This could be performed by having the requirements independently certified annually by an RPEQ (or several RPEQ’s), in a similar manner to the annual inspections for mechanical and structural adequacy, together with random spot checks of documentation by OIR. Mr. Rutherford noted that any such RPEQ involved must be able to demonstrate adequate knowledge and experience in the areas that they are reviewing. For example, an Electrical RPEQ does not necessarily have adequate knowledge in the area of Safety Related Control Circuits, as this is a specialist area.

930. At inquest, Dr Gilmore noted that whilst the Australian Standards have stipulated hazard identification requirements since 1997, this was not being carried out in relation to the TRRR, and unfortunately there were no regulatory checks to ensure it was being done.

931. Dr Grigg is of the view that seat belts with positive latching buckles, as found on aircraft lap seatbelts, should be required. Their mounting points should be located in the same position relative to the seat as that used in cars and aircraft.

932. Mr. Rutherford is of the view that there are adequate details and requirements in the current applicable Australian Standards with respect to Safety Related Control Systems and Electrical Safety, if these standards are followed correctly. However, he cites a lack of enforcement by the Regulators as an issue to be addressed. The enforcement by the Regulators in Australia varies on a State by State basis. In Mr. Rutherford’s experience, OIR is currently the most proactive Regulator in Australia in relation to Machinery Safety compliance, and has a culture of trying to educate not only the Amusement Ride Industry, but Industry in general, as well as other State Regulators. One weakness in this approach is the lack of detailed knowledge on Safety Related Control Circuits held by the majority of OIR Inspectors. Mr. Rutherford is of the view that this must be addressed, in conjunction with mandatory requirements for up to date circuit and component documentation for all Plant safety features (not only Amusement Rides). There must also be support provided by OIR for Inspectors to issue Prohibition notices and the like on significant Plant.

(9) In your opinion, are there any other safety issues arising from this tragic event, which need to be considered and addressed in order to ensure a similar incident does not occur in the future? If so, what measures need to be undertaken?

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933. The experts all agreed that having considered the circumstances of this tragic incident, the recognised absence of adequate documentation and engineering controls destroys the assumption that the annual ride inspection was a sufficient oversight mechanism (according to Regulations) for the public safety of the ride. The initiation of a formal document and control system for each ride should take place, which includes the appointment of a designer or competent person for every ride, registered with OIR, with tertiary qualifications in engineering and relevant experience.

934. Dr Gilmore recommended the use of an external party to be engaged to conduct independent risk assessments. The independent party must be a Registered Professional Engineer of Queensland (RPEQ). Dr Grigg questions the need for an independent RPEQ for annual assessments if the competent person is qualified.

935. It was further proposed that the Regulations should make clear the onus placed on a competent person (who may be an RPEQ) when conducting an annual inspection or a risk assessment, in order to provide support for time spent in conducting such a task thoroughly. These assessments should include the following:

1. The operation of the ride must be visually observed, with the ‘what if’s’ asked and trial events conducted i.e. not a cursory inspection or tour.
2. Low probability failures need to be actively considered. Suggestions that the ride has been trouble free for 30 years is not an acceptable excuse. History demonstrates that low probability coincidences often turn out to be the cause of a major unexpected incident. Examples abound in aircraft, train, motor vehicle, motor cycle and helicopter crashes, crane and elevating work platform collapses, and fires.
3. Observe how the machine handles adverse events. Run trial days where pumps are shut down, water levels decreased (or increased), rafts bottle neck, impact each other, to highlight weaknesses and expose hidden features of the design.
4. Consult Theme Park records internally and internationally. v.
5. Consider whether the machine was fool-proof, and if not what engineering controls could be possibly utilised. vi.
6. Look at design records.

936. During cross examination at the inquest, when asked about predicting low probability events, as this incident was characterised, Dr Grigg stated,

Dr Grigg: I can agree that low probability events can be difficult to predict, but I don’t think for a minute that anyone doing a risk assessment on that ride would not observe things which could be regarded as anything other than hazards.

Mr. Hodgkinson: Well, I will come back to that, but do I understand your evidence to be that the proposition you agree with, in relation to this ride, you draw some additional matters about the objectives foreseeability of the hazards?

Dr Grigg: No, I think – it’s a low probability event simply because it has operated for 30 years without anything happening. I think that’s my interpretation of what Dr Gilmore is referring to, and it’s a bit like, you know, somebody crossing the road: they’ve done it many times, but there’s the risk that they’re going to get knocked down by a car. It might be a low probability event, but you know that you – it’s a hazard and you’ve got to do something about it if you’re the individual crossing the road. And in this case, the patrons weren’t in a position to do that, but the people running the ride should have appreciated that there was a risk there.

937. When he asked about the inability of investigators to re-enact the tragic incident, Dr Gilmore stated: 

The outcome of the – the unfortunate deaths of people might have been difficult to – to predict, but the – the coming together of rafts was not difficult to predict, and in fact, Dreamworld themselves had three – three prior incidents, in ’04, ’05 and ’14, in which rafts came together and bumped, and they themselves shut down the conveyor because they required the – they thought that the situation had become undesirable and dangerous – and I think that’s as far as you need go. If you identify a situation where two rafts come together, that’s – that is a situation where you shut the conveyor down, and whatever happens after that – that – that may be more – more difficult to predict, but the – it can go any way from there, but – and, in – in this incidence, it went one particular way.

938. Dr Gilmore further stated:

…I don’t think it’s actually relevant that the police were unable to exactly replicate the – the exact incident because the crux of - of the incident was that two rafts came together. After that, what actually happened – we know what happened – but it could’ve gone any one of many different ways.

…

The fact that the – it turned upside down and people fell into the conveyor, into the water, that’s one way but another might’ve been people fell off the raft into the water. Who knows – might’ve happened then.

..

It might’ve ended up happening but it may have ended up another way.

939. It was also suggested that a requirement be introduced stipulating that a full risk assessment (according to Australian Standards) on the whole ride be conducted during commissioning, after major modifications and every 5 years. The annual inspection is an ideal time to report any new modifications or installations/equipment changes in the past year. The RPEQ, who performs the mechanical/structural inspection, or another independent competent person (preferably also an RPEQ), should be requested to include a review of written documentation and the ride, illustrating any recent modifications within the past year, including photographs, and present a recommendation as to whether a fresh risk assessment should be conducted immediately. The Proprietor must keep ongoing detailed written documentation of equipment maintenance and any modifications, which can be made available for spot checks by OIR. It would be expected that the RPEQ would be assisted by the designated competent person during these assessments.

940. With respect to annual inspections, given the report need not be submitted for a compliance check, it is recommended that spot checks by OIR be carried out to ensure proper conduct and thoroughness. Annual inspections should also include photos to identify if modifications have been made and if they have been advised to WHS Queensland as required.

941. In relation to ‘new designs’, the experts suggested that these should be documented to reveal the design methodology, what was considered, safety considerations, with the log and register with OIR to be kept centrally. Further, testing of a ride must be carried out, and be comprehensive. It is difficult to nominate dynamic aspects which might be required for example to identify a problem hidden for 30 years. This has to be overcome by inquisitiveness and enthusiasm, which needs to be well documented.

942. Mr. Rutherford is of the view that OIR Inspectors (and any organisation or individual involved in this area) need to be more aware and knowledgeable on applicable Safety Related Control Systems and Electrical Safety. He also notes that it is important that documented Electrical Circuitry, Critical Component Lists etc. are updated as modifications occur. These are essential to the safe on-going maintenance of Plant.

 

Expert’s Response to the Proposed Draft Regulations

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943. Having heard the evidence of Mr. Bick in relation to the new safety case regime proposed in Queensland, the experts were asked to comment on the sufficiency of the amendments and new scheme.

944. In response, the following comments of note were made by the experts:

1. Dr Gilmore and Dr Grigg agreed that the new Regulations needed to include a requirement that the owner of an amusement device comply with the updated Australian Standards.
2. Dr Gilmore endorsed the development of a Code of Practice for amusement devices as has been suggested by OIR.
3. Dr Gilmore endorsed the introduction of a safety system of management and the enforcement of such a requirement by the Regulator through active auditing and spot checks.
4. Mr. Rutherford noted that it was important that the new Regulations require the consideration of hidden components of an amusement device to ensure a detailed review is conducted.

Mr. Chan’s Response to the Expert Evidence

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945. Mr. Chan agreed with the suggestion made by Dr Gilmore as to the extension of the annual inspection requirements for the competent person engaged so as to include a risk assessment, as detailed above at [925]. Whilst he acknowledged that the current requirement for annual inspections does not expressly include a risk assessment, the obligation of the Engineer conducting the inspection to consider the hazards present would be beneficial. We would interpolate ‘essential’.

946. With respect to the suggestion that a full risk assessment on the whole ride be undertaken after all major modifications and every five years, Mr. Chan stated that the proposed amendments to the Regulations included a requirement with respect to major inspections of amusement devices, at timeframes suggested by the manufacturer or a component, or 10 years. He questioned the validity of stipulating a general 5 year arbitrary timeframe, when this may not accord with the requirements of the manufacturer in relation to a particular component of the device (i.e. a shorter or longer period may be necessary).

947. Whilst Mr. Chan did not agree with a blanket requirement that amusement device owners should follow ‘best practice’ by updating a ride when any change was made to the applicable Australian Standard, he did agree that this would be appropriate for changes made to the Standards applicable to the maintenance and inspection of a device. I would agree that it becomes mandatory.

 

FURTHER EXPERT ADVICE

Human Factors Report on Fatal Incident, Professor Penelope Sanderson

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948. During the course of the OIR investigation into the causes of this fatal incident, a Human Factors Report was sourced from Professor Penelope Sanderson, a Professor of Cognitive Engineering and Human Factors, School of Psychology, University of Queensland.

949. Professor Sanderson was requested to consider nine specific questions concerning the cognitive and other factors impacting Ride Operators in various situations with respect to the specific operation of the TRRR. The expert advice provided is outlined below.

(1) Given the ride’s layout, controls and displays, what perceptual motor and cognitive skills should Operators have developed to carry out the ride’s required tasks across a range of normal conditions?
 

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950. In relation to a two person operation of the TRRR, Professor Sanderson notes that there are 22 signals to process and tasks to perform if Ride Express guests and children are present, and 17 signals if this is not the case. In addition, there are also around 21 background or periodic checks of the ride operation and engineering status for the Load Operator to carry out. Accordingly, there are a total of between 38 to 43 signals and checks that must be done.

951. Based on calculations and analysis conducted by Professor Sanderson of the TRRR cycle times, the following factors of a two person operation were noted: 

(a) The 17-22 signals to notice and tasks to perform have to be completed in around 35 seconds during holiday periods and in around 43 seconds during non-holiday periods

(b) For every one second of operation, therefore, an Operator should process approximately one signal or perform one task.

(c) In addition, for every one second of operation, an Operator should complete approximately one background or periodic check.

(d) This very high ratio of signals/tasks/checks to elapsed time would be difficult to achieve fully, and difficult to sustain fully.

(e) Given the operational constraints of the ride, including timing and buffering capacity, Operators are forced to prioritise activities that get rafts loaded and dispatched. Accordingly, they would need to develop ways to manage periodic and background checks either through incorporating them into ‘rituals’ where possible, performing them parallel to other activities, performing them only when there is unoccupied time during load activities or performing them less frequently then on every dispatch cycle.

(f) There was no explicit training for Operators on how to prioritize or manage what could become an overload of activities.

952. Professor Sanderson noted that given the Load Operator’s primary task is to settle guests into rafts and have them dispatched, which already requires 17-22 steps, it is unlikely that all the 21 background and periodic checks could be done for each cycle. However, a failure to perform any one of those checks might be a factor which could contribute to an incident.

953. Professor Sanderson states that the design of the Main Control Panel at the TRRR does not translate the buffering capacity of the ride or the potential time for the Operator to process signals, complete tasks and perform periodic and background checks. That is, the design of the panel does not make the Load Operator ‘smart’ about how best to use the time available in the system. In addition, there are no cognitive aids provided in the form of readily visible checklists of periodic and background checks, which need to be performed.

 

(2) Given the ride’s layout, controls and displays, what perceptual motor and cognitive skills should operators have developed to carry out the ride’s required tasks in different kinds of emergency situations?

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954. Professor Sanderson noted that in the TRRR manual, there was ‘quite complex mapping of anticipated emergencies and operational problems’ to the actions that the Operator is expected to carry out. There are differences in the expected response depending on the type of emergency or operational issue, which includes whether the ride needed to be shut down or whether dispatch should be suspended, as well as whether a supervisor needed to be advised or not. Professor Sanderson noted that there was potential for Operators to be made ‘smarter’ in their response to anticipated emergencies by better information design and display, as well as better training and training evaluation processes, such as emergency drills or simulations. 

955. In relation to classifiable emergencies, which are defined as a feasible emergency situation that the Operators and/or engineers recognise, Operators will need to be able to recognise the potential consequences of the emergency and apply to appropriate procedure.In order for this to occur, a general familiarity with the ride structure, functioning and risks will be necessary.

(3) Could operators be impaired from executing corrective action in an emergency situation?

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956. Professor Sanderson notes that any operator of a system can be impaired from executing appropriate corrective action in an emergency situation, which can arise from a variety of sources, including stress. Stressful situations can narrow a person’s attentional focus, and may prevent them from processing information, which seems peripherally less important. Several studies have shown that people under stress may be able to carry out highly familiar and wellpracticed routines, however, will struggle carrying out novel or rarely used processes. 

957. Professor Sanderson noted that from Mr. Nemeth’s account, the approach of Raft 5 towards Raft 6, stranded on the support rails, was stressful and may have narrowed his attentional focus so he did not fully process the information Ms. Williams was asking him from the unload area. Furthermore, the stressful events coupled with the poor user interface design of the Main Control Panel, may have meant that Mr. Nemeth did not activate the conveyor stop button effectively. 

958. In evidence during the inquest, Professor Sanderson stated that the stress associated with responding to the emergency situation, which presented on the day of the tragic incident, in addition to the regular Operator duties to be carried out, would have made it difficult to work out exactly what to do in the situation, particularly as there wasn’t a procedure for exactly that situation. 

(4) Could Operators’ normal tasks/duties impact on their ability to observe and respond effectively to emergency situations in a timely manner?

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959. Professor Sanderson notes that normal tasks and duties may delay or preclude Operators from either noticing or being able to respond effectively to operational problems or emergency situations, with the reverse also being the case. 

960. Having considered the activity sequence specified in the Operator Procedure manual in the event of an operational problem requiring a shutdown, which has up to 11 steps, Professor Sanderson found that this may make it difficult for Operators to observe and respond to emergency situations, which occur in addition to operational problems, such as retrieving rafts, focusing on operating the Main Control Panel or observing guest behaviour. 

961. In relation to operating problems, which require a shutdown, as noted in the Operator Procedure Manual, Professor Sanderson noted the following:

• Loss of power to one or both pumps: This causes a drop in water level over a short period, which may be noticed relatively quickly by an Operator if they are loading a raft or manning the Main Operator control panel and noticed the pump amps drop. However, if the Operator was communicating with guests, these signals may be missed, thereby delaying the Operator’s ability to observe and respond quickly to this operational problem. •
• Loss of power to the conveyor or chain break: Normal activities could delay an Operator noticing that the conveyor wasn’t operational, thereby delaying the response.
• Raft stall at the bottom of the conveyor: Unless the Operator was viewing the CCTV at the Main Control Panel, other operational tasks would delay their ability to observe this issue and respond accordingly. •
• Raft Jam: How quickly an Operator responds to such a situation largely depends on where this happens around the watercourse and what the normal duties and tasks the Operator is engaged in at the time. •
• Raft slips on conveyor: Whilst it was recognised that this failure was lessened by the recent installation of the sensors and jacks at the beginning of the conveyor, CCTV would be the only means such an event would be noticed, and it would depend on what other tasks the Operators were engaged in as to how quickly this issue was identified. 

962. Professor Sanderson noted that with the TRRR, ‘any situation where there is a risk of serious injury to Guests or Staff’ depending on its nature, may not be identified if the Operator is ‘facing away from visible evidence of it, if attempted communication between operators does not succeed, or if ambient noise makes it impossible to hear any evidence of it’. 

963. In addition to emergencies, Professor Sanderson was of the view that normal tasks and duties of Operators would affect their ability to observe and respond effectively to operating problems, which may not require a shutdown of the ride. 

964. Two types of emergencies were identified in the Operator Procedure Manual for the TRRR, namely; serious injury to a guest or staff member (3.6.1) and person in water and/or raft capsized (3.6.2). Per the requirements of the manual, an Operator needs to respond to an operational problem by interlacing three sets of activities, namely: 

a. Normal duties/tasks relating to guest management and answering guest questions, and performing background checks and periodic checks on system status.

b. Procedure associated with handling the operational problem.

c. Procedure associated with handling the emergency.

965. Professor Sanderson noted that when two or more activity sequences are interlaced, the likelihood of any one of them may be resumed or completed at an incorrect point is increased. Given the number of events to attend to in such a situation, the time required to complete each may be greater than that available to complete them in a safe manner. 

 

(5) What factors might prevent or limit effective communication between Operators at the un-load and load stations?

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966. Professor Sanderson noted that the following factors limited or prevented effective communication between Operators at the load and unload stations of the TRRR:

• Sight lines – there was 12 m between the two stations, with some structures creating obstacles between the two. There was no radio or telephone communication between the two points. Visual communication was the main potential means of communicating, which was difficult when the responsibilities of each Operator require them to have their back to one another. •
• Noise: It was noted that ambient noise created by the functioning of the ride could jeopardise the Operator’s ability to successfully attract the attention of the other through vocal communication. Various noise was evident from the operation of the ride and includes the sound of the dispatch alarm, the conveyor, the rapids, guest conversations and other nearby attractions (for example, the Buzzsaw).
• Reflections on the glass of the Load station workstation

967. Given the above ambient sounds present at the TRRR whilst it was in operation, it would have made it difficult for the unload and Load Operators to attract each other’s attention and to sustain a conversation, which would make it more challenging to respond to an emergency. 

(6)(a) Did the training provided to Operators enable them (on the day) to respond effectively to emergency situations in a safe and timely manner?

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968. Professor Sanderson recognised that it was impossible to write procedures and to train staff in all emergency situations. However, training is not a ‘reliable way to compensate for poor design in the way the engineering constraints and possibilities for operation action have been conveyed to the operator through the user interface’. 

969. Having considered the circumstances of the incident on 25 October 2016, and the response by both Mr. Nemeth and Ms. Williams in the context of the Operator Procedural Manual and associated supplementary memorandums, Professor Sanderson noted that:

• The manual does not specify the timeframe by which a shutdown needs to be performed in the event of a pump failure; and 
• It is unclear what kind of training would be adequate to ensure reliably rapid and highly accurate responding to the unanticipated emergency as transpired during the tragic incident.

(6)(b) Would periodic and scenario-based emergency drills improve Operators’ ability to respond to actual emergency situations?

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970. Professor Sanderson noted that emergency drills provide an opportunity to develop procedural knowledge, rather than a purely operative level of declarative knowledge through simply reading procedures or hearing them described. Drills can help Operators reduce the impact of stressors on their performance and provide experience at solving the problems presented under less stress than in an actual emergency, which provides procedural knowledge. However, for an Operator to obtain the ability to respond to different kinds of actual emergencies, drills need to cover a range of emergencies, including anticipated emergencies, classifiable emergencies and multiple-event emergencies.

971. Professor Sanderson notes that an important component in any kind of drill is the after-action replay and the after-action debriefing. 

(7) Are user interface principles applicable to the design of each control board? Could the design and layout of the control boards contribute to errors?

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972. Professor Sanderson notes that user interface principles are applicable to the design and layout of any device or system with which people interact. This is especially so when the system is physically large or involves a hazard, in which case ‘the user interface must bring relevant information to the operator, display it in a way that the operator will understand, and provide appropriate controls whose functioning the operator will understand’. 

973. Professor Sanderson found that from viewing the video walkthroughs, Operators had different mental models of some system functioning and procedures, as well as different ways of enacting procedures. Examples include:

• Order of performing the emergency sequence.
• Whether the E-Stop at the unload station stopped the conveyor or the conveyor and the North pump.
• How long the operator should hold down the conveyor stop button on the Main Control Panel for it to activate.

974. Professor Sanderson also noted that the Operator Procedures for the ride use text only, with no schematics, pictures or diagrams. The procedures therefore are possibly not as effective as they could be for all learning styles. 

(8) Could individual, situational and environmental factors contribute to the way Operators implemented procedures?

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975. Professor Sanderson found that individual, situational and environmental factors could contribute to the way Operator’s implemented procedures both in general and around the time of the incident. In general, situational and environment factors have a more systematic influence on how Operators implement procedures.

976. It was noted that in relation to the TRRR, there was some differences, which emerge as to the Operator Procedure manual descriptions of procedures and how Operators implemented those procedures. 

977. In relation to the tragic incident, it is unclear whether and when the technical part of the shutdown sequence of the ride was initiated at the Load station, and if initiated, when it was completed. If the procedure was not completed in the 54 second interval between Raft 1 being grounded and Raft 2 colliding with it, factors needed to be considered as to why this may occur with an experienced Operator. It is possible that the sequence was interrupted by other tasks necessary to perform, or there was sequence confusion. 

(9) Did the operators’ normal duties/tasks (and degree of training) have any impact on their ability to observe and respond to the emergency situation?

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978. Professor Sanderson was of the view that when the Operator’s execution of normal Code 6 duties at the Load station is combined with the communications difficulties and the unanticipated nature of the emergency, there is a strong case that the combination of factors would have reduced the Operator’s ability to observe and respond to the emergency.

Expert Report by Principal Naval Architect, Mr. Mark Devereaux

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979. At the request of OIR, Principal Naval Architect, Maritime Safety Queensland, Mr. Mark Devereaux considered the floatation and stability characteristics of the rafts used on the TRRR.

980. Mr. Devereaux, having considered the CCTV footage, relevant photographs, the physical rafts and other relevant brief material, as well as the design aspects of the ride, he concluded that the floatation or buoyancy aspects of the design or construction of the rafts were not significant contributing factors in the tragic incident. Assuming the rafts are regularly drained of any trapped water and the tube channels are kept inflated, he found that the rafts had adequate stability for operation in the TRRR. Mr. Devereaux notes that if the raft tubes are kept properly inflated, they have adequate stability for their intended purpose, ‘as it is, the volume of the inflated tubes that provides the significant majority of the buoyancy and stability of the rafts’.

981. Having considered the tragic incident, Mr. Devereaux further noted that there was a critical rate at which water needed to be pumped into the TRRR, to maintain adequate height of the water above the steel supporting rails to allow rafts to remain buoyant and not become stranded.

Dreamworld Ride Velcro Seatbelt Test, APV Engineering & Testing Service, Mr. Jose de Freitas

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982. During the course of the OIR investigation, APV Engineering and Testing Services were requested to conduct static testing as to the performance and reliability of the Velcro Seatbelts in used on the TRRR at the time of the fatal incident. A report outlining the findings of this testing was prepared by Test Engineer, Mr. Jose de Freitas.

983. The testing conducted found that the performance of the Velcro Seatbelts can vary significantly, depending on various factors, which are often not apparent and can be difficult to control. The belt strap overlap, condition and the applied pressure during the belt strap engagement were found to be the three major factors that affected the performance.

984. It was recommended that, for the purpose of the Dreamworld ride application considered (TRRR), an industrial seatbelt in accordance with SAE J386, along with an automatic lock retractor ought to have been used.

 

ANALYSIS OF THE CORONIAL ISSUES

The Findings required by s.45 of the Coroners Act 2003

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985. In accordance with s.45 of the Coroners Act 2003 (‘the Act’), a Coroner who is investigating a suspected death must, if possible, make certain findings.

986. On the basis of the evidence presented at the inquest, I make the following findings pursuant to s.45:

a. The identities of the deceased persons are Kate Louise Goodchild, Luke Johnathan Dorsett, Cindy Toni Low and Roozbeh Araghi.

b. At around 2:05 pm on 25 October 2016, the deceased, whilst traveling on Raft 5 of the Thunder River Rapids Ride at Dreamworld Theme Park, collided with a raft stranded on the steel support railings at the unload area shortly after exiting the conveyor. This collision caused Raft 5 to be lifted and pulled vertically into the mechanism of the conveyor. Two other occupants of Raft 5 managed to escape, however, the deceased were caught in the mechanism of the ride, and were either ejected into the water beneath the conveyor or trapped in the raft.

c. The date of the death of all of the deceased persons was 25 October 2016.

d. The place of death for all of the deceased was the Dreamworld Theme Park, 1 Dreamworld Parkway, Coomera on the Gold Coast.

e. The cause of death for all of the deceased was as a result of the combined effect of severe internal and external injuries as a result of multiple compressive impacts.

987. Comments as to the specific issues identified and considered during the course of the inquest hearing are outlined below. I find as follows:

Examination of the Thunder River Rapids Ride at the Dreamworld Theme Park, including but not limited to, the construction, maintenance, safety measures, staffing, history and modifications.

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988. It is clear from the expert evidence that at the time of the incident, the design and construction of the TRRR at the conveyor and unload area posed a significant risk to the health and safety of patrons. The hazards associated with configuration of the ride identified by the experts and investigators were significant, and included the wide spacing of the slats of the conveyor, the nip point at the head of the conveyor and the steel support railing, the effect of a pump failure on the water level and the absence of the emergency stop button for the conveyor at the Main Control Panel. Each of these obvious hazards posed a risk to the safety of patrons on the ride, and would have been easily identifiable to a competent person had one ever been commissioned to conduct a risk and hazard assessment of the ride.

989. The experts engaged for the purpose of this coronial inquest and by OIR to investigate the cause and circumstances of the tragic incident reached their opinions independently and were all in basic agreement as to the combination of causes. They were highly qualified to do so, based on the evidence presented, and were not influenced by so-called “hindsight bias” in reaching their conclusions. There was ample evidence of the potential for disaster of this nature occurring, based on the evidence before them, and had notice been taken of and lessons learned from, the preceding incidents that were all of a very similar nature, and of which there was ample photographic evidence and reports prepared. It is indeed very fortunate, to quote Mr. Tan, that no lives were lost in those earlier incidents.

990. Whilst it appears from the records provided that the initial design of the TRRR was approved by the Chief Inspector of Machinery in 1987, there were multiple significant modifications made to the ride prior to the incident in 2016. The records available with respect to these modifications are scant and ad hoc, and establish that for the duration of the rides commission, it was modified essentially without a ‘designer’. It does not appear that anyone external or internal to Dreamworld, including Mr. Tan, were ever formally charged with conducting a holistic engineering risk and hazard assessment of the ride, despite the major modifications and changes made during its tenure. The modifications made to the ride, despite being significant, were also never reported to the Regulator. It can be accepted, as was the evidence of the experts that these alterations would have amounted to a new design and should have been registered by Dreamworld with the Regulator. A failure to record modifications, a lack of ‘designer’ input and a lack of reporting to the Regulator have contributed to the masking of the real risk of the TRRR.

991. From the limited documentary information available, it appears that the modifications made to the TRRR were somewhat random, seemingly in response to specific acute issues, without any consideration given as to the other risks or hazards that may be created as a result of the change. There was no proper engineering oversight of the ride, changes made or consideration of past incidents for which engineering solutions should have been implemented. Accordingly, it can be accepted, as was found by the experts, that whilst there were various occasions for which s.5.1 of the AS3522.2-1997 should have been triggered, and a mechanical hazard identification and risk assessment of the ride undertaken, this was never done. Unfortunately, there were clearly a number of missed opportunities during which Dreamworld could and should have identified the safety issues associated with the ride.

992. The maintenance tasks undertaken on the ride, whilst done so regularly and diligently by the staff charged with such a responsibility, seem to have been based upon historical checklists, which were rarely reviewed, despite the age of the device or changes to the applicable Australian Standards, particularly 3533 Part 2 and 3.

993. The external auditing undertaken by JAK was not done so by way of reference to the Australian Standard, and, as was acknowledged and known by Dreamworld, focused on superficial aspects of the ride, rather than the engineering, design and safety aspects. This shortcoming is blatantly obvious from the reports provided by JAK, and was also raised by Mr. Randall once DRA were engaged by Dreamworld in 2013. I am satisfied that Dreamworld knew of this significant limitation with respect to the safety auditing being conducted on its devices, however, failed to take any steps to rectify it.

994. Previous incidents on the TRRR, particularly in 2001 and 2014, should have alerted Dreamworld to the hazards present on the ride, particularly the collision of rafts on the watercourse. These incidents should have prompted a thorough risk and hazard assessment of the ride, including the design, looking beyond the circumstances of the particular incident. In accordance with the hierarchy of controls, plant and engineering measures should have been considered as solutions to identified hazards. Whilst administrative controls are the lowest in the hierarchy, they nonetheless may be sufficient to manage some risks. However, for such a decision to be made, risks actually have to be identified and properly qualified consideration given as to the best solution to manage that risk. The risks and hazards posed by the TRRR, which have been highlighted by this incident and the experts, were never identified by Dreamworld as such assessments were never undertaken. A heavy and unreasonable reliance on administrative controls to ensure the safety of patrons on the TRRR was clearly not a reasoned decision following a proper risk assessment. Rather, it was simply a continuation of processes and procedures that had always been followed, during which there had not been a previous serious incident. This reliance by Dreamworld on the operation history of the ride as to whether a risk or hazard was present is clearly unsound and dangerous. The various high and low probability hazards and risks associated with the ride, which have been highlighted by the experts, were present and should have been identified by a suitably qualified risk assessor.

995. Rafts coming together on the TRRR was a well-known risk, highlighted by the incident in 2001 and again in 2004. During the investigation into the 2004 incident, it was acknowledged that various corrective actions could be undertaken to ‘adequately control the risk of raft collision’, however, a number of these suggestions, including a conveyor speed controller or raft positioners, were not implemented by Dreamworld. The Report into this incident acknowledged that at the time, the primary means of avoiding raft collision at the unload area was through administrative controls by Ride Operators. Whilst some engineering and automation modifications were made to the ride post this incident, it is clear that this primary reliance continued. Clearly, the combination of these controls at the TRRR was not sufficient to ensure that rafts were not able to come into contact with one another near the unload area. The knowledge that rafts could flip if they came together on the watercourse, particularly at the end of the conveyor near the unload area, was recognised throughout the history of the ride, including most recently in 2014. This risk and the peril posed to patrons of rafts colliding and possibly flipping was further highlighted by Mr. Tan in his email to the Leadership Team, where he outlined the events in 2001, stating, ‘I shudder when I think if there had been guests on the rafts…’ Indeed this was recognised during Ms. Crisp’s training of Ms. Williams where she claims she made a point of highlighting that two rafts could not be dispatched together or else there was a risk of capsize. Clearly, the risks associated with rafts colliding was known to Dreamworld.

996. Whilst the exact scenario that occurred in this instance may not have been able to be replicated during testing by Investigators, this is of limited relevance, and does not render the identification of the risk present unpredictable without the benefit of hindsight. The hazards and risks, which caused the rafts to collide at various points on the ride, and in particular at the end of the conveyor, were present and known, and should have been identified by someone qualified to conduct a risk and hazard assessment. Unfortunately, Dreamworld never engaged such a person and as such these risks were never mitigated.

997. It was agreed by the experts, and became obvious during the inquest hearing, that best practice for the TRRR was not followed by Dreamworld, particularly in relation to compliance with introduced Australian Standards designed to ensure the safety of devices. Whether these requirements are mandatory or not is largely irrelevant. Those Standards are the minimum practice that is required. It is the responsibility of those that own and operate high risk plant to ensure that the most up to date safety standards, risks and requirements known to the industry are considered and instituted if possible, to ensure the safety of staff and patrons. This was certainly not the case in relation to the conduct of Dreamworld as to the management, modification and maintenance of the TRRR. Dr Gilmore stated during the expert conclave that should ‘best practice’ not be followed with respect to safety standards, an owner would do so at their own peril. Unfortunately, this failure by Dreamworld to adequately ensure the safety of the ride and manage the obvious hazards and risks present was done so at the peril of Ms. Goodchild, Mr. Dorsett, Ms. Low and Mr. Araghi.

998. Given the nature of fixed amusement devices, it is reasonable for the community to expect that the owner and operator would ensure that there is no risk to the safety of patrons. Owners should be risk averse, which includes considering and identifying low probability failures for their devices, so that these risks can be mitigated altogether. Whilst it is accepted that there is always an inherent risk to safety given the nature of an amusement ride, it is expected, and is indeed reasonable to do so, that all action has been taken by the owner to eliminate the risks posed. That was not the case with respect to the TRRR. There is no evidence that Dreamworld ever conducted a proper engineering risk assessment of the ride in its 30 years of commission. The risks and hazards, which have now been highlighted by the experts, were never identified and considered by Dreamworld because such an assessment was never undertaken.

999. Dreamworld placed a great deal of reliance on Mr. Tan’s engineering ‘expertise’ to ensure the safety of the amusement devices at the Park. Mr. Tan was not an RPEQ, which should have been known by Dreamworld, and was involved in a number of Special Projects within the Park. Sole reliance on him to undertake such an assessment on all of the devices at Dreamworld during his tenure was dangerous, given the level of responsibility associated with such an undertaking and his other responsibilities, including oversight of the E&T Department. Mr. Tan was, until Mr. Cruz was employed shortly before the incident, the only qualified engineer engaged by the Theme Park. It is obvious from the response provided by Ardent Leisure to OIR when asked about compliance with s.241 of the Regulations, that Mr. Tan’s experience was a central tenant of the safety program in place at Dreamworld. For Australia’s largest Theme Park that approach was irresponsibly and dangerously inadequate, particularly given the lack of succession planning in place following Mr. Tan’s departure in January 2016.

1000. It is surprising, however, that Mr. Tan did not ever recognise the risk and hazards present on the TRRR from a design perspective, despite being consulted on various modifications made throughout its commission. Given his formal qualifications, experience and knowledge of the device, this seems like a missed opportunity, although it is accepted that Mr. Tan’s role did not extend to considering the design of the ride.

1001. In addition to Mr. Tan, it seems that Dreamworld placed significant reliance on E&T staff and Ride Operators to identify risks and issues associated with rides. Whilst there can be no suggestion that these staff did not perform the roles they were given with dedication and in accordance with their training, it is unfathomable that this serious and important task fell to staff, who did not have the requisite qualifications or skillset to identify such hazards. Whilst the information and feedback from staff, who work with and on rides, is always valuable, it cannot and should not be the solitary means by which such hazards and risks are identified.

1002. Irresponsibly, and consequently tragically, the Safety Department at Dreamworld was not structured to operate effectively, with the safety systems in place at the time of the incident correctly described as ‘immature’. Document management was poor, with no formal risk register in place, members of the Department did not conduct any holistic risk assessments of rides with the general view being that the E&T Department were responsible for such matters. There were no safety audits conducted as to the human components of the ride systems at Dreamworld. Furthermore, members of the Safety Department were not involved in the drafting of Operating Procedures for the amusement rides, a responsibility left solely with the Operations Department. It seems clear that there was a significant segmentation of knowledge between the Departments, which was further exacerbated by a poor record and document management system, making information difficult to obtain and access. It is important to note that evidence suggests that members of the E&T Department were only involved in developing and implementing controls for a potential hazard once it had been brought to the Department’s attention.

1003. The resounding message of the General Managers responsible for the Departments at Dreamworld was that, as such risks and hazards had never been identified to them, they were unaware and therefore unable to take any action. Given no steps were ever taken to properly identify these risks by qualified people, it is unsurprising that such issues were not raised with management. This general ignorance of proper safety and adequate assessments was a recurring theme throughout Dreamworld in many of the Departments and reflects a systemic failure to ensure the safety of patrons and staff by the use of a proper safety management system, with the necessary engineering oversight of high risk plant.

1004. From the accounts provided during the course of the investigation and inquest hearing, it is evident that only a scant amount of knowledge was held by those in management positions at Dreamworld, including Mr. Deaves, as the General Manager of Engineering, as to the design, modifications and past notable incidents on the TRRR.

1005. It can be concluded beyond doubt that in the 30 years prior to this tragedy, Dreamworld failed to undertake, either internally or via an external auditor, a holistic examination of the TRRR by a suitably qualified engineer, so as to ensure its safe operation through the identification of the high and low probability risks and hazards present.

1006. During the inquest, Maintenance Planner, Mr. Naumann agreed that there had been a ‘total failure’ by everybody at Dreamworld to identify the safety issues in respect of the TRRR, which he acknowledged was completely unsafe at the time the tragic incident occurred. This failure is supported by the evidence obtained and presented during the course of the coronial inquiry. Dreamworld has a reputation as a modern and world-class Theme Park. However, the safety, maintenance and operating systems in use to ensure guests safety were rudimentary at best, with Departments operating in silos, an absence of risk management and informal and ad hoc record keeping. The manner in which the documentation was provided during the course of the coronial inquiry and inquest further demonstrates the frighteningly unsophisticated ‘systems’ in place at Dreamworld intended to ensure the safety of patrons and staff. It is surprising, given the state of the safety management systems in place at Dreamworld that a tragedy of this nature had not occurred before now. It was simply a matter of time. That time came on 25 October 2016.

Records

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1007. Records as to the design and manufacture of the TRRR are sparse. There is limited context as to the creation of the ride, how certain components were designed and commissioned, and the intended ongoing management and maintenance. It is unfortunate that this poor recording keeping continued throughout the 30 years of its commission, with respect to all aspects of the ride. Whilst voluminous records and documents were produced by Ardent Leisure following this tragic incident, and throughout the coronial investigation and inquest, they were arbitrary in nature and lacked context and explanation. This has made the task of piecing together the history of the ride, the modifications made, and the repairs and maintenance conducted, incredibly difficult for all parties. It becomes a more critical issue as a ride ages, because the demands for maintenance, and even replacement, will increase.

1008. What is clear from the records produced, and the difficulties Ardent Leisure had locating the requested information, is that the record keeping, document management and interdepartmental communication at Dreamworld was dire. It appears that the maintenance, inspection and repair action taken in relation to a ride was reactionary to issues arbitrarily or accidentally identified, rather than a proactive systematic approach following an independent, thorough assessment of a ride.

1009. The records and document control in place at Dreamworld, including for the rides, safety systems, maintenance and training of staff, was clearly significantly lacking, with only limited information available. Whilst Mr. Cruz was in the process of undertaking ‘data mining compliance’ with respect to the amusement devices at the time of the incident, this was clearly a difficult process that exposed the widespread lack of record keeping and document management that had been in place at Dreamworld for the past 30 years.

1010. It was recognised by Mr. Deaves that there were no records kept, which were easily accessible or centrally located, whereby staff responsible for the safety of the rides, both from an operations and engineering perspective, could examine and consider previous issues associated with a device. This absence of effective and complete record keeping essentially precluded any staff from being in a position to be able to appropriately and adequately assess and manage the risks, which may be present, particularly for rides like the TRRR. It is significant that the General Manager of Engineering had no knowledge of past incidents involving rafts coming together on the TRRR. It is clear that this lack of knowledge essentially precluded him, and anyone else, from assessing or determining risks associated with the TRRR from an engineering perspective, which contributed to the environment in which such a tragic incident could transpire. I find that shoddy record keeping was a significant contributor to this incident.

The circumstances and cause of the fatal incident on the Thunder River Rapids Ride at the Dreamworld Theme Park, which occurred on 25 October 2016.

Technical Circumstances

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1011. The technical cause and sequence of the tragic incident has been expertly considered and addressed in detail in the evidence as provided by the expert engineers, Senior Constable Cornish and the OIR Inspectors. I am satisfied that the incident occurred as previously outlined.

1012. It is clear that the primary cause of this tragic incident was the failure of the south pump, leading to a sudden drop in water level, following which the conveyor was not stopped. Dreamworld were aware that when one pump failed on the TRRR, the ride was no longer able to operate, with the water level dropping dramatically stranding the rafts on the steel support railings around the trough. Regardless, there was no formal means by which to monitor the water level of the ride, or audible alarm to advise one of the pumps had ceased to operate. Rather, a light on the Main Control Panel or ampere reading was all that notified an Operator of the pump failure, aside from the recognition that the water appeared to have fallen below a historical scum mark in the trough. Despite the significance of the water level to the safe operation of the ride, there was no automated safety system in place to monitor the water level or provide any audible or visual alert should it fall below a safe level.

1013. It was a second, major contributing factor of the incident that the conveyor continued to operate in the event of a pump failure. It remains unknown, and impossible to understand why, the two major components of the ride were controlled independently of each other. It is also unknown as to why there was such an arbitrary gap between the end of the conveyor and the steel support railings, which created a nip point of sufficient size for Raft 5 to be pulled into during the incident. When contact occurred between Raft 5 and the raft stranded on the steel support railing, it became forcibly engaged by the conveyor, due to the slat removal, entering that gap as it continued to impact the other raft, which was snagged on the steel support railing. It was the view of the experts, and which I accept, that had any one of the contributory factors been absent, the incident, as it transpired, would not have occurred. That being the case, given the multiple other hazards evident on the ride as was highlighted by the experts, this would not have precluded another catastrophic incident from occurring in another way.

1014. While the TRRR had operated fatality free for around 30 years, at the time of the fatal incident, it is clear that the design and construction of the conveyor/unload area posed a significant unidentified risk to the health and safety of patrons. A properly documented history with appropriate risk assessments, in all likelihood, would have identified and eliminated the serious risks.

Lack of Automation

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1015. During the inquest, Senior Constable Cornish described the TRRR as ‘severely’ lacking in any type of automation, which was readily available. This was clearly accurate, and a sentiment shared by the engineering experts. It is unknown as to why basic engineering controls, such as a water level monitor or an interlock shutdown function for the conveyor in the event of a pump failure, was not installed on the ride. It is clear from Mr. Rutherford’s evidence that a basic automated detection system for the water level would have been inexpensive and may have prevented the incident from occurring.

1016. The lack of a single emergency stop on the ride, which was capable of initiating a complete shutdown of all of the mechanisms, was also inadequate. Whilst JAK had recommended that a simpler automatic process be considered, and the Operations Department had sought input from the E&T Department as to a one button shutdown, it is unfortunate that no further action or follow up was undertaken. It is not clear as to why such a recommendation was not actioned and the risk deemed by Dreamworld to be ‘acceptable’. It seems this lack of an emergency stop button for the conveyor at the Main Control Panel was contrary to the Australian Standards.

Operators Account of the Incident

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1017. It is apparent that at the time of the tragic incident, Mr. Nemeth held the role of the No.1 Operator and was stationed at the Main Control Panel. He had primary responsibility for the operation of the TRRR. Ms. Williams, as the No. 2 Operator, was stationed at the unload area. There were no other Dreamworld employees in the area at the time.

1018. From the CCTV footage, and Mr. Nemeth’s statement, it appears that it only took around 20 seconds from when the water level started to drop following failure of the south pump, before Raft 6 became stalled in the unload area on the steel support rails. The water dropped dramatically causing the ride to be unable to operate. A further 55 seconds passed, during which time Raft 5 travelled the conveyor and impacted with Raft 6. Statements from the occupants of Raft 6, as well as those, which were being loaded at the time of the incident by Mr. Nemeth, provide contradictory accounts of the sequence of events during the critical seconds before the tragic impact.

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.

1020. During this time, Ms. Williams recalls, and can be seen on the CCTV footage, to remain at the unload station. She did not press the E-Stop button at that platform for a number of reasons, including the fact that the No. 1 Operator was not incapacitated, and as such retained overall control of the ride, including the shutdown procedure. She was also unaware that it stopped the conveyor.

1021. Given the traumatic events that were unfolding, and the multiple tasks being performed by both Ride Operators, it is understandable that there are discrepancies in the recollections provided by Mr. Nemeth and Ms. Williams as to the exact sequence of events prior to the tragic incident. As Ms. Williams had only been trained that morning, her recollection and knowledge of the Operating Procedures for the ride are understandably limited, and based on what she could remember from her 1 ½ hours training with Ms. Crisp.

1022. The stress associated with operating the TRRR, let alone responding to an emergency situation, was highlighted by Professor Sanderson. It is clear that the 38 signals and checks to be undertaken by the Ride Operators was excessive, particularly given the failure to carry out any one could potentially be a factor, which would contribute to a serious incident. There was no training provided to Ride Operators or Ride Instructors as to how tasks should be prioritised, with further hindrance provided by the poor user interface design of the Main Control Panel. The stress associated with responding to an emergency situation, which presented on the day of the tragic incident, in addition to the regular Ride Operator duties to be carried out, would have made it difficult to determine what should be done and in what order.

1023. Whilst it has been suggested by other staff, including some Supervisors, that Ms. Williams should have pressed the E-Stop button at the Unload platform in the circumstances that transpired on that tragic day, this simply does not accord with the training she was provided that morning, the clear requirements of the Operating Procedure Manual for the No. 2 Operator, nor the plain reading of the Memorandum issued on 18 October 2016. Mr. Nemeth was not incapacitated nor did he direct her to activate the E-stop. Rather he was standing at the Main Control Panel, and as the No. 1 Operator, had primary responsibility for the operation of the ride, which included the shutdown in a Code 6 situation. In these circumstances, the fact that Ms. Williams did not press the E-Stop button, which was unlabelled, is unsurprising. In addition, I have already referred to the negative wording of the memorandum produced regarding the pressing of the stop button. Had this been a positive direction to the No. 2 Operator to press the stop button in the circumstances, the tragedy may have been averted.

1024. It is clear that the safe operation of the TRRR primarily relied upon administrative controls, which required the Ride Operators to have an understanding and ability to observe and respond to situations, including emergencies, as and when they arise, including monitoring the water level, load and unload guests onto and off rafts and to monitor guests movements. This lack of engineering controls on a ride of this nature is unjustifiable.

Operator Responsibilities

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1025. The responsibilities and substantial tasks placed on the Ride Operators at the TRRR, particularly the No.1 Operator who had primary responsibility for the operation of the ride and a supervisory role over the No. 2 and 3 Operators, were clearly unreasonable and excessive. The TRRR was commonly recognised as one of the more complex rides to operate at Dreamworld, largely due to the manual elements, monitoring requirements and lack of automated controls. The Main Control Panel was complex, confusing and lacked the required labelling.

1026. Operating Procedures for the rides at Dreamworld were drafted by members of the Operations Department, with minimal input from E&T Department staff or Safety Department. They were supplemented by Memorandums, which were drafted by unknown authors. Those prepared for the TRRR, particularly with respect to the use of the E-Stop at the Unload area, were ambiguous and poorly worded, with relevant terms often left undefined. The expectation that a Ride Operator would be able to become familiar with a detailed Operating Procedure and the supplementary material, which sometimes conflicted, is wrong and poor practice.

Response to the South Pump ‘Earth Fault'

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1027. In the seven days prior to the fatal incident, there were five breakdowns of the TRRR, which were attributed to a failure of the south pump due to an ‘Earth fault’. On each occasion, the drive was reset without any diagnosis of the cause or further investigation being conducted. Whilst Mr. Ritchie concluded that such a fault was no more than an inconvenient and intermittent issue, it seems clear that steps should have been taken to investigate the cause of the fault before the ride was allowed to continue to operate. The fact that the fault caused the pump to fail, rendering the ride inoperable, should have been sufficient to shut down the ride until a deeper investigation had been conducted. Mr. Ritchie’s logic as to the risk posed to guests or Ride Operator’s safety by the fault is unsound, as was the decision to allow the ride to continue to operate pending the inspection by Applied Electro.

1028. From the various accounts provided by members of the E&T Department, there was clearly confusion as to how the Breakdown Policy was to be applied, and whether a fault needed to occur two or three times before the matter was escalated to a Supervisor. This clearly played a part in the fatal incident, given it was the third breakdown of the ride that day. Furthermore, in relation to ascertaining what may constitute ‘immediate danger’ for a particular ride, including the TRRR, there was no specific training provided to staff nor any guidance outlined in the procedure. During the inquest, evidence was given that E&T staff were not provided with training as to any particular risks or dangers, which might be present for a ride, or any particular component of a ride.

1029. Upon any reading of the requirements of the Breakdown Procedure, it seems evident that the practice of resetting the drive for the South Pump following an ‘Earth Fault’, given the nature of the component and the recurring breakdowns over the previous seven days, two of which occurred in close proximity of the same day, was in contravention of the Procedure. It does not appear that the Procedure was adhered to 25 October 2016 at the TRRR. Mr. Ritchie in his evidence agreed that there had been a significant breakdown of the procedure leading up to the incident.

1030. The various elements and components of this tragic incident, clearly demonstrate a systemic failure by Dreamworld, in relation to all aspects of safety, to ensure that the amusement rides open to the public were safe, well maintained and designed to minimise the risk they posed to patrons and the staff. It is unimaginable for the life of the TRRR that a failure of a pump and the consequential drop in water level created immediately a known potential risk to patrons. Why safety action was not taken earlier that day I find very difficult to understand.

Examination of the sufficiency of the training provided to staff in operating the Thunder River Rapids Ride.

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1031. The manner in which new Ride Operators were trained, that is by unqualified Senior Ride Instructors, had been in place at Dreamworld for many years prior to the tragic incident. The time taken to train a Ride Operator seemed to be dependent on the level of complexity and responsibility associated with the ride, and at most, extended to a day on-site training with follow up the next morning. During this time, Ride Operators were expected to become sufficiently familiar with a ride specific Operating Procedure Manual, which for the TRRR, spanned some 18 pages. This level of training, as was highlighted by Professor Sanderson, was clearly inadequate, and led to extensive and necessary ‘on the job’ learnt behaviour as to how to operate the ride effectively.

1032. Whilst there is no suggestion that the Instructors charged with training new Ride Operators did so without the necessary due diligence, they were limited by the training they had been provided and the expectations placed on them with respect to the in-house training. Whilst the training Ms. Williams undertook on the morning of the tragic incident was clearly insufficient for the extensive tasks and functions she was required to perform, this was not due to any particular failing by Ms. Crisp. Rather, it was evidence of an inherent lack of proper training and process in place at Dreamworld to ensure the training provided to new Ride Operators and Instructors was suitable for the roles and responsibilities to be undertaken.

1033. Those responsible for managing the ride, whilst following the process and procedure in place, were largely not qualified to perform the work for which they were charged. Furthermore, the processes and procedures in place at Dreamworld seem to have been created by unknown persons, who it is safe to assume, lacked the necessary expertise. It seems that the practice at Dreamworld was simply to accept what had always been done in terms of policy and procedure, and despite change to safety standards and practices happening over time, only limited and largely reactionary consideration was ever given to making changes, which includes to the training provided to staff.

1034. The Operating Procedures in place in relation to the TRRR, which were supplemented by further memorandums, were extensive and confusing. An example of this was the use of the E-stop at the unload area, for which it was expressly stipulated that it was not be utilised unless in an emergency. There was no indication as to what constituted an ‘emergency’, nor were staff adequately trained or provided with sufficient authority and situational awareness to use the button when necessary. Furthermore, there were no emergency drills undertaken at the Theme Park, despite recurring recommendations from internal and external audits that this be undertaken. Had this been done, it may have reduced the stressors associated with responding to such traumatic events, and made such a response more effective.

1035. Regardless of the training provided at Dreamworld, it would never have been sufficient to overcome the poor design of the TRRR, the lack of automation and engineering controls. The responsibilities on the Ride Operators to respond to various different situations and emergencies, as well as general operational duties, was clearly excessive and unsound.

Consideration of the regulatory environment and applicable standards by which Amusement Park rides operate in Queensland and Australia, and whether changes need to be made to ensure a similar incident does not happen in the future.

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1036. While I accept the OIR submissions that they did undertake onsite auditing and that they were very pro-active with the industry generally concerning safety, the onsite auditing by the Regulator of amusement devices at Theme Parks in Queensland prior to this tragedy obviously did not pick up the dangerous state of the TRRR as described by the independent engineering experts and the OIR inspectors who came to the site after the tragedy. It is also evident from the basis of the extensions granted to Dreamworld for compliance with the annual renewal registration in 2016, that there was an unjustified trust held by the Regulator as to the sufficiency of the safety and maintenance systems in place to ensure the safe operation of the high-risk plant. Clearly, given the nature of this tragedy, and the surrounding circumstances, including the lack of record management, the absence of any meaningful hazard assessments or effective engineering oversight of these devices, this was simply not the case. During the inquest, Mr. Chan acknowledged that the Regulatory framework in place at the time of the incident in relation to amusement devices effectively expected Theme Parks to have developed and implemented safety management systems, including maintenance, operation, training and emergency control, with the qualified engineering and other staff to action it. This was not the case at Dreamworld, and should have been recognised by the Regulator had proper oversight of the industry been in place.

1037. In response to this finding, some of the parties raise the issue of “hindsight bias”. I have previously rejected this argument. It ignores the Australian Standard prohibiting the creation of pinch points. It ignores the history of four previous incidents, extremely similar in nature. It ignores the well-known danger presented by the numerous and regular pump failures. This danger was well known to the Operators, with prescribed responses set out in the Operator’s manuals.

1038. The experts cited by Ardent Leisure in support of the hindsight bias contention do not qualify as experts and are not independent. Indeed no independent expert engineering or other suitably qualified independent witnesses were called except by the Coroner. Those cited by Ardent were not sufficiently trained nor were any of them engaged to consider the design of the TRRR holistically. Modifications were made without much thought to the design of the ride, or other hazards such changes may create. Further, Mr. Tan, as the only engineer, had a number of responsibilities within the Park, and was moved to different positions at different times throughout his tenure with Dreamworld. These hazards were obvious, and were not identified as no-one was ever charged with conducting an appropriate hazard and risk assessment of the ride. The engagement of Mr. Cruz to commence a desktop review of the rides, further supports this lack of consideration and risk assessment of the rides.

1039. In terms of hindsight bias as to the hazards present in the ride, it is clear the while the maintenance and operational staff, as well as OIR inspectors who attended site over the years, may not have identified such hazards, this was not because they were not ‘obvious’. The experts made it clear that such hazards would have been obvious to someone suitably qualified, who was charged with conducting a holistic risk and hazard assessment of the TRRR. It was not the responsibility, nor should it have been, for any of these individuals to conduct such a hazard and risk assessment of the ride. This should have been a separate process to the daily maintenance and operation of the ride. Clearly, this was not the role of external auditors JAK, as was recognised by Dreamworld. Had a proper risk and hazard assessment been done, it is likely that such obvious hazards would have been identified. This was established and reiterated by the experts called by the Coroner.

1040. Submissions are made that there was a 30-year history of incident free operation of the TRRR. This submission ignores the four previous similar incidents. It is quite true no one was injured. This is more good luck than good management. One only has to recall Mr. Tan’s email and the report concerning the 2001 incident, which said, in part, ‘the push of the conveyor caused a compaction effect, resulting in the rafts being caught at the unload area and one raft flipping’. Mr. Tan’s email several years later in 2014, concerning another similar incident, contained a salutary warning: - ‘This occurred on the rapid ride several years ago, and fortunately there was no injury except for property damage. I shudder to think if there had been guests on the rafts’.

1041. It is concerning that despite the multiple compliance activities, including site visits, undertaken by the Regulator at Dreamworld between 2002 and 2016, the deficiencies identified as to the maintenance, inspection, risk assessments, record keeping and engineering oversight of these devices, was not detected. Furthermore, the risks and hazards associated with the TRRR, including the nip point, were not identified by any of the Inspectors, who at times had cause to inspect the ride. Whilst limitations as to the intended purpose of these inspections and attendance at the Theme Park is acknowledged, this failing raises concern as to the sufficiency of the qualifications and training provided to Inspectors responsible for auditing amusement devices.

1042. For older devices, like the TRRR, there is a significant concern as to the poor mechanical integrity of the device, with a lack of modern safety controls and automation, placing a significant and unfair burden on Ride Operators to compensate for these lack of basic safety measures. While newly manufactured and constructed amusement devices are generally engineered to higher standards with greater safety measures and safeguards built in, there is a need to ensure that such devices meet international technical standards, as well as those stipulated in Australia. It is essential that any difference in these standards are recognised and steps taken to ensure any shortfalls with a device manufactured internationally is managed.

1043. Although annual inspections of amusement devices is mandated by the Regulation, it is not a ‘major inspection’ of the device, and the enforcement and check of such an inspection has been seriously lacking in Queensland for some time. As was recognised in the BPR, a ‘major inspection’ should be carried out by a competent person who had formal engineering qualifications and experience, and needed to include an examination of all critical components of the amusement device, as well as the effective and safe operation. Such a person needed to be qualified to make recommendations about the severity of faults observed and the intervals at which inspections and repairs needed to be undertaken for the particular device. This was simply not the case at Dreamworld. Whilst each of the members of the E&T Department were technically qualified and experienced to perform their roles, this did not extend to effectively and properly inspecting, maintaining and risk assessing the amusement devices they were attending. Whilst the evidence of each of these staff members shows that they performed their roles to the best of their abilities, it is clear that there was a broader systemic problem with the lack of qualified oversight of the procedures and practices in place by management.

1044. The extensive auditing by OIR carried out following the tragic incident with respect to the prescribed annual inspections, whilst proper, served to demonstrate the absence of adequate prior compliance activity undertaken by the Regulator. This commitment to in-depth auditing of amusement devices will need to continue under any proposed changes to the regulatory framework. It is essential that for the regulation of amusement device in Queensland to be effective and for owners to remain compliant, regular, ongoing and adequate auditing of all aspects of the safety systems in place at the Theme Park will need to be undertaken by the Regulator.

1045. Concern has been raised by the experts and SIA as to the lack of competent professional engineers with the necessary experience to effectively inspect amusement devices. OIR has stated that consultation will continue with industry stakeholders, Engineers Australia and BPEQ, as to ensure this issue is further progressed. Such steps will be necessary to ensure the effective compliance of the proposed safety case regime once it comes into effect.

1046. The move to self-regulation is fraught with danger. Self-interest and the drive to contain costs leads to the issues, which arose with the internally unqualified engineer, and the type of investigation undertaken by Mr. Polley. The Regulation lacked diligence in these matters.

1047. I accept the OIR, through their BPR and Industry Review, have taken steps to correct the short-comings revealed in the evidence as set out above, however, it has been necessary to draw attention to those matters by way of explanation for the cause of the tragedy. It is to emphasize there were multiple causes all of which must be recognised and addressed to prevent such a tragedy occurring again. I accept there has been a considerable effort put in by the OIR to address these issues.

1048. The OIR draws my attention to the difficulties arising when requiring all amusement devices to comply with Australian Standards. This difficulty is brought about by the fact that most amusement devices are designed and manufactured overseas, predominantly based on European standards. Of course, this was not the case with the TRRR. While I accept the obvious difficulties this may present, it could and should be overcome by initial and regular inspections when the devices are installed and operating in Australia. This will ensure that such rides comply with obvious standards, such as the Australian Standard to prevent nip points, like the extreme danger to passengers presented by the TRRR should the raft be tipped up or passengers fall out into the conveyor mechanism as was the case under consideration.

Mr. Polley’s Conduct

Spoiler

1049. With respect to the inspections undertaken by Mr. Polley, and the subsequent annual plant renewal certification provided for the TRRR and other amusement devices at Dreamworld, it is concerning that this was done without the provision of any documentation pertaining to the ride. That this limited the scope of Mr. Polley’s engagement by Dreamworld is clear, and his failure to ensure that he was furnished with documentation relevant to his assessment, which is cited in the certificate issued, falls below the industry standards expected of an RPEQ, particularly those charged with inspecting amusement devices.

Changes Made at Dreamworld Following the Incident

Spoiler

1050. Since the tragic incident, significant changes have been made at Dreamworld, including the audit and inspection of the amusement devices by qualified Engineering firms, consideration of WHS practices, reviews of operating procedures, changes to the training regime with emergency drills being introduced, as well as the introduction of a safety management system to control safety risks. Whilst these steps are certainly positive, they serve to highlight, particularly given the established safety management systems in place at Village Roadshow, how rudimentary and deficient the safety management practices in place at Dreamworld were prior to this tragedy. Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety. That cannot be allowed.

What further actions and safety measures could be introduced to prevent a similar future incident from occurring?

Spoiler

1051. Considering the circumstances of this tragic incident, it is clear that the recognised absence of adequate documentation and engineering controls challenged and contradicts any assumption that the annual ride inspections carried out by Dreamworld were a sufficient oversight mechanism (according to the Regulations) for the public safety of the ride.

1052. The transition to a safety case and licensing regime in Queensland, as detailed in the new Regulations, if enforced and audited regularly by the Regulator, will certainly be a more rigorous and hands-on regulatory approach to the Major Amusement Park industry. The requirement for a safety management system certainly appears to be a far more comprehensive and integrated approach to ensuring the effective management and control of risks with respect to amusement devices. It is undoubtedly a significant move away from the current self-regulatory nature of the industry. Given the circumstances of this tragic incident, it is without question that more direct oversight and regular auditing of the maintenance and inspection of amusement devices within the Theme Park industry is necessary. It was acknowledged by OIR that there needed to be a more holistic sign off with respect to amusement devices in Queensland, which will likely require the engagement by the RPEQ of other specialists. It is essential that there is regulatory oversight of this process to ensure compliance and that safety is being systematically managed by the Amusement Park. The proposed changes to the required competencies, training and instruction of those charged with operating amusement devices, as outlined in the draft Regulation, are necessary to ensure the safe operation of such a device.

1053. As was proposed by SIA, for this regime to be effective, spot checks of the annual and major inspections carried out by the competent person, particularly of highrisk rides, will need to be undertaken regularly by OIR. This will ensure consistency and sufficiency of the sign-off. It will be incumbent on the Regulator to ensure, through auditing and enforcement, that the approach taken by the RPEQ engaged by the owner of the high-risk plant to undertake such an inspection, thoroughly considers the history, maintenance, safety and performance of the ride prior to certification. Those responsible for auditing the Theme Parks will need to have the requisite skills and knowledge to be able to effectively assess the suitability and sufficiency of the maintenance, inspection and safety programs in place. If there is no appropriate history, then the device should not be allowed to operate.

1054. From the draft Regulations provided, which are now in effect, it appears that the proposed safety case and license regime will require detailed information on how amusement devices will be maintained, inspected and tested to be submitted to OIR. Matters, such as the maintenance of amusement devices, would then be audited annually by the Regulator. It is this auditing oversight that will be necessary to ensure compliance by owners with the new regulatory framework. Until this event, there was an abject failure of obligation in this part of the Regulation.

1055. I note that Counsel for Ardent Leisure Limited raise objection to the scope of the inquest and any finding I make regarding the system of training in place at Dreamworld contributing to the incidents as inappropriate, wrong, and beyond the scope of the inquest. They also raise the same criticism of any finding relating to the lack of record keeping. This submission is interesting given the material willingly supplied by Ardent Leisure as to other rides within the Theme Park, supplemented by the extensive oral evidence volunteered by Ardent employees under extensive cross examination by all Counsel, including those appearing for Ardent Leisure. I reject this submission in so far as it is relevant as this evidence is clearly “connected to” and “relates to” the matters under consideration in this inquest. See Doomadgee v Clements [2006] 2 Qd R 352 per Muir J paras 30-33.

RECOMMENDATIONS IN ACCORDANCE WITH s.46

Spoiler

1056. Section 46 of the Act provides that a Coroner may comment on anything connected with a death that relates to:

a. public health and safety,

b. the administration of justice, or

c. Ways to prevent deaths from happening in similar circumstances in the future.

1057. Given the concerns raised in this matter and the evidence provided during this inquest, I make the following recommendations:

I. OIR

Spoiler

 

(a) Changes be made to the current regulatory framework in Queensland with respect to the inspection and licensing of Major Amusement Park devices to ensure that a more structured and compliance focused regime is implemented. Given the circumstances of this tragic incident, it is crucial that consideration is given to the following, when changes to the Regulation are considered:

- The requirement that owners of amusement devices utilise a safety management system to effectively manage and control  risks with respect to amusement devices.

- An owner of an amusement device must comply with the applicable updated Australian Standards.

- Annual risk assessments should be conducted by competent person/s and involve the detailed consideration of the device, including all possible control system functions and variations, as well as a detailed examination of the operation of the ride during all modes of operation and possible emergency conditions.

- The competency of those charged with operating an amusement device.

-The requirement of a major inspection or full risk assessment of the device by a competent person (RPEQ) at stipulated intervals, as suggested by the manufacturer or at a mandated duration (5 – 10 years). 

- Regulations should make it clear of the onus placed on the RPEQ when conducting an annual inspection or a major risk assessment, which should include:

1. The operation of the ride should be visually observed during a risk assessment.
2. Low probability failures need to be actively considered.
3. Observe how the machine handles adverse events. Run trial days where pumps are shut down, water levels decreased (or increased), rafts bottle neck, impact each other, to highlight weaknesses and expose hidden features of the design.
4. Consult Theme Park records internally and internationally.
5. Consider whether the machine was fool-proof, and if not what engineering controls could be possibly utilised. vi. Look at design records

- Regular auditing and oversight of such devices, as well as the associated inspections and required safety systems in place at the Major Amusement Park, must be conducted by the Regulator.

Whilst the safety case regime introduced by the recent amendments to the Regulations would appear to ensure this necessary regulatory oversight by way of a more mandated approach to the maintenance and inspection of amusement devices, it is essential that this be monitored and maintained by way of regular and effective auditing. Such auditing should be undertaken by suitably qualified and trained OIR Inspectors. Major Amusement Parks in Queensland need to be required to implement effective control measures with respect to the devices in operation, and the Regulator must actively ensure this takes place.

Strict adherence to the timeframes proposed by the safety case and licensing regime in the draft Regulation should be maintained in order to ensure the expedited introduction of a more intense regulatory framework for Major Amusement Parks in Queensland and, most importantly, patron’s safety.

(b) That OIR continue to develop a Code of Practice for the amusement device industry in Queensland, which will establish a minimum standard for the operation of amusement devices, in consultation with the requisite industry stakeholders, including the Amusement Device Working Group.

(c) That efforts to harmonise the requirements of the relevant design standards, particularly the critical safety requirements on amusement devices in Australia, Europe and America continue in consultation with relevant industry stakeholders.

(d) Steps be taken to rectify the lack of detailed knowledge of Safety Related Control Circuits held by the majority of OIR Inspectors.

 

II. Other agencies

Spoiler

(a) The Board of Engineers, in consultation with OIR and other industry groups, to continue efforts to address the shortfall in suitably qualified and experienced RPEQ’s with respect to the inspection of amusement devices.

(b) That a reassessment of the Australian Standards applicable to waterborne rides (including raft rides) be undertaken to include some of the types of safety requirements associated with roller coasters, including more thorough considerations for lifts/elevators, collisions and passenger loading/unloading.

(c) Consideration as to whether the requirement for hazard identification and risk assessment in AS-3533.2 section 5.1 should be made mandatory. Furthermore, whether any modification or alteration to the ride should require hazard identification and risk assessment to ensure that changes made do not affect safe operation and use.

DISCRETION TO REFER IN ACCORDANCE WITH s.48 (4)

Spoiler

1058. Section 48 of the Act gives the Coroner discretion to refer information obtained whilst investigating a death, to give the information to the appropriate prosecuting authority, if the Coroner ‘reasonably suspects a person has committed an offence’.

1059. A referral can also be made pursuant to s.48 as to a person’s professional conduct to the relevant professional disciplinary body if the Coroner reasonably believes the information might cause that body to inquire or take steps in relation to the conduct.

Referral of Ardent Leisure Limited to the OIR

Spoiler

1060. It is reasonably suspected that Ardent Leisure may have committed an offence under workplace law. Whilst various breaches of the WHS Act have previously been considered by OIR with respect to this incident, the details of which have been included in the inquest brief, given the significant further documentary material provided during the course of the coronial inquiry, and produced at inquest. I refer my Findings and the evidence gathered in the course of the Inquest to OIR for further consideration as to these matters. Whether there is sufficient evidence to proceed to prosecution is a matter for OIR.

Mr. Polley

Spoiler

1061. It is arguable that Mr. Polley’s conduct in issuing the subsequent annual plant renewal certification for the TRRR and other amusement devices at Dreamworld, without any documentation pertaining to the ride being supplied by the Park and his failure to properly inspect the ride, was a failure, which falls below the industry standards expected of an RPEQ, particularly those charged with inspecting amusement devices. For this reason, I refer his conduct to the Board of Professional Engineers of Queensland.

I close the inquest

James McDougall

Coroner

Southern Region

Edited February 26, 2020 by Jamberoo Fan

[Cryptic Hatter]

9 hours ago, Skeeta said:

This needs to be highlighted.  

DW put money ahead of guest no two ways about it.  We all thought DW was looking like a shithole and DW was not spending money on the upkeep of the park, but we never thought it went to the level of DW not spending money on keeping the rides safe.  Well it turned out Ardent was making a killing in profits and killing people at the same time. 

Cost cutting on safety is something you think would happen if a company was in trouble and not to turning a pretty penny.

 

 

No DW did what they were told to do by the big money hungry bosses at Ardent Leisure!
Ardent Leisure's bosses back then didn't care nor want to spend money.
also no one had intent to kill people they just did not use their brains to realize that what they were doing for so many years by denying  DW to spend money would end in such disaster.

[joz]

As much as that's true, everything from the inquest points more to disorganization and incompetence. I think a culture of trying to not spend money which probably came from the top exacerbated the situation, but with a competent engineer employing good practices you don't get the results you get. Ultimately the people in charge didn't have a clue what they were doing.

 

Ardent are by no means innocent, but nor are those who administered the park.

[Richard]

Dreamworld’s senior management team is appointed by and reports to Ardent. They negotiate and accept remuneration and bonuses tied to the performance of Dreamworld and in many cases share-based incentives that put their motives directly in line with that of the parent company. 

There were no evil corporate overlords forcing decisions upon a hapless Dreamworld team. Just systemic and cultural failings at every possible level of the organisation.

You can perhaps argue that Dreamworld as a brand (or some other intangible concept) was a victim of its owners’ shortcomings but to suggest that Dreamworld as an organisation is a victim takes away a lot of blame that falls to them for many, many short-sighted, naïve and demonstrably reckless decisions in the years both before and since Ardent took ownership. 

[DaptoFunlandGuy]

12 hours ago, joz said:

with a competent engineer employing good practices you don't get the results you get.

I think this is potentially the victim of the cost saving issues in itself. There has been many points made about if a competent person was employed to manage the risks this wouldn't have happened, but a competent person would have charged more for their expertise, qualifications and time than say - a foreign engineer without Australian qualifications did.

[webslave]

I too would reject the notion that all of this came down to cost-cutting.  Instead, the report paints a clear picture of a heavily siloed organization that had very little safety culture, very weak processes, very weak documentation, little oversight from regulators, and a lack of sophisticated enough talent to even realise any of it.  There's little evidence in the report that anyone knew of an imminent and likely risk and decided that cutting costs was more important than mitigating it, such was the lack of sophistication in its employ.  That's why I think that criminal charges may be a difficult bar to clear.

[New display name]

@webslave it doesn't take much talent to realise rafts known to flip can flip again.  DW had the opportunity to fix it and they didn’t.  

[webslave]

I'd agree @Skeeta, it wouldn't take much talent to figure that out.  But they didn't.  I think they were all too eager to believe it was the fault of the operator(s) or a "freak accident".

One of the things that will have watered down the effectiveness of the talent they did have was the silos the organization allowed them to work in.  It's poor culture.

[New display name]

31 minutes ago, webslave said:

I'd agree @Skeeta, it wouldn't take much talent to figure that out.  But they didn't.  I think they were all too eager to believe it was the fault of the operator(s) or a "freak accident".

One of the things that will have watered down the effectiveness of the talent they did have was the silos the organization allowed them to work in.  It's poor culture.

But it doesn't matter what you think or the courts.   I have already made my mind up, like the thousands of other people.  People think DW put money first so it doesn't matter if it's true or not.

[webslave]

2 minutes ago, Skeeta said:

But it doesn't matter what you think or the courts.   I have already made my mind up, like the thousands of other people.  People think DW put money first so it doesn't matter if it's true or not.

For sure.  I'm glad for the most part as an enthusiast community we can have discussions that can go a little deeper than that.

[DaptoFunlandGuy]

47 minutes ago, webslave said:

I think they were all too eager to believe it was the fault of the operator(s) or a "freak accident".

But that's easy to play back to cost motivation too.

its far cheaper to add yet another procedures on top of an already complicated process for the operator to follow than it is to implement proper failsafe safety controls.

[webslave]

1 minute ago, AlexB said:

But that's easy to play back to cost motivation too.

its far cheaper to add yet another procedures on top of an already complicated process for the operator to follow than it is to implement proper failsafe safety controls.

Yes, that's one thing you can tie it back to, but certainly not the only thing.  Organizational arrogance is often a strong contender as a motivator here, for example.

[Levithian]

Maybe some of you may think a little differently if you remember that the engineering manager was previously a supervisor at movieworld, so standing there saying you didnt know you needed to do risk assessments, had no formal process for modifying or documenting repairs or didnt know it was part of your job just doesnt fly. Id be willing to bet money there is paperwork burried within the archives at vrtp that has his name on a bunch of processes doing exactly those things. It's lucky the coroner didnt hand down a reccomendation OIR seek to prosecute individual people because he might have been in a lot of trouble if they went digging for evidence.

Edit: by saying that i mean it potentially shows someone was negligent in their duties and can be legally held accountable.

Edited February 27, 2020 by Levithian

[Spotty]

Which manager was previously a Supervisor at Movie World?

I know in the past few years quite a few very senior staff have left VRTP and moved over to Dreamworld (Greg Yong and several other high up people). 

[T-bone]

Chris Deaves @Spotty. Often said to be the guy who killed some of villages most popular and iconic rides/ attractions.

[rappa]

On 28/02/2020 at 4:28 AM, Levithian said:

Maybe some of you may think a little differently if you remember that the engineering manager was previously a supervisor at movieworld, so standing there saying you didnt know you needed to do risk assessments, had no formal process for modifying or documenting repairs or didnt know it was part of your job just doesnt fly. Id be willing to bet money there is paperwork burried within the archives at vrtp that has his name on a bunch of processes doing exactly those things. It's lucky the coroner didnt hand down a reccomendation OIR seek to prosecute individual people because he might have been in a lot of trouble if they went digging for evidence.

Edit: by saying that i mean it potentially shows someone was negligent in their duties and can be legally held accountable.

I’m glad someone said it. 

[Troy81]

Do we have any idea if/when the fines will be handed down?

[rappa]

This latest stuff is truely terrifying and also just shameful.

 

The fact that the most basic fundamentals of control system design and risk assessment weren't even present is just unbelievable. ANYONE with ANY knowledge of how rides should be could walk up to that thing and know it wasn't right.

At least we know the price Dreamworld placed on a life is about 3grand

Edited May 4, 2020 by djrappa