Thunder River Rapids Incident Coronial Inquest Findings

[DaptoFunlandGuy]

“Primary safety controls were administrative controls reliant on ride operators to maintain safe spacing”

 

“Dreamworld never engaged a person capable of mitigating these risks”

 

[Jdude95]

Suggested updates were never taken on board. Things such as positioning sensors or conveyor speed regulators. Primary source of ensuring raft spacing was undertaken by load and unload staff. This was not sufficient to ensure rafts did not collide or flip. Should have been addressed due to rafts colliding and flipping in 2 previous incidents in 2014 and 2001. 

The risk of rafts colliding was known to Dreamworld. Investigators were unable to replicate the outcome of the 2016 but are confident that it was still a very high risk. 

It became apparently during the inquest that best practice was not followed on the ride. These standards are the minimum requirement.

[webslave]

 

[DaptoFunlandGuy]

“While there is always an inherent risk of safety, it is expected that all action will be taken by the owner”

”dreamworld never co ducted a risk assessment for TRRR In it’s 30 years of operation”

”dreamworld places much reliance on Bob Tan’s expertise”

”Bob was not a qualified engineer, which should have been known by the park.”

“his involvement with many projects at Dreamworld was dangerous.“

 

There can be no suggestion the ride operators did not conduct themselves in accordance with their training 

Staff cannot be the sole means of identifying risks.

dreamworlds safety department was not set up effectively.

risk management at the park was “immature”

[webslave]

 

[DaptoFunlandGuy]

Resounding message From park management: “as such risks and hazards had not been identified, they were unaware and unable to take action”

[Jdude95]

There is no evidence that Dreamworld ever undertook an engineering risk assessment in the 30 years of the rides operation. A great deal of reliance was placed on Bob Tans expertise. He was not a qualified professional in Queensland and Dreamworld should have been aware of that. Bob Tan being in charge of engineering and maintenance was a clear danger. 

It is surprising that Bob Tan never recognised the risks posed by TRR. Dreamworld placed heavy reliance on Ride Operators to identify risks. Whilst this information can be valuable. It shouldn’t be the sole source of feedback regarding potential risks. There was no risk reporting in place. There were no safety audits undertaken in regards to the human component of the rides. Departments didn’t talk to eachother and share information across departments. 

DW Management maintained that they were never aware of such issues as they were never raised.

[DaptoFunlandGuy]

Total failure by everybody at Dreamworld to identify the hazards on TRRR.

Safety systems rudimentary at best.

departments operated in silos

record keeping was ad-hoc.

safety systems were frighteningly unsophisticated.

”it was simply a matter of time”

Maintenance and inspection was “reactionary”

“Widespread lack of record keeping and document management”

 

It is significant that the GM of engineering had no knowledge of the previous raft crashes

“Shoddy recordkeeping” was a significant contributor to this accident.

Edited February 24, 2020 by AlexB

[Jdude95]

The systems in place at Dreamworld were frighteningly unsophisticated. Records in regards to the ride were sparse. This poor record keeping continued through its 30 years or commission. The records that did exist, lacked information. Maintenance records and training were severely lacking. Incident exposed the widespread lack of record keeping over the past 30 years. It is significant that the GM of engineering had no prior knowledge of any incidents that occurred. Shoddy record keeping was a significant reason for this incident.

[DaptoFunlandGuy]

The coroner is now reading the technical circumstances of the accident.

failure of the south pump, drop in water level, conveyor belt not stopped.

Dreamworld was aware the pump failure was an issue to ride operation, but no audible alarm to indicate the pump failure.

 

The gap between the rails and the conveyor created a significant “nip point” large enough to grab raft 5.

TRRR was “severely lacking in automation”

 

A basic automated detection system for the water level would have been inexpensive and may have prevented the accident.

 

a one button shutdown was recommended, and was unfortunately not undertaken.

it is unclear why this action was never taken.

[Jdude95]

Failure of south pump which caused a drop in water level. Conveyor continued to operate. Ride should not be operated with one pump as per process. There were no alarms or warnings to suggest the water level has changed. There was no automated safety system in place with no audible or visual alert in regards to the water level. It is unknown why the gap between the end of the conveyor and the rails in the troughs was so large. A raft valleyed on the support rails through the station. The spacing of the slats allowed the doomed raft to get pinched and dragged into the conveyor mechanism. 

Proper record keeping and maintenance would have identified such issues and rectified them. 

It is unknown why a simple water level sensor was never implemented. It would have been inexpensive and prevented the incident from occurring. The emergency stop buttons were inadequate. Maintenance suggested in early 2016 that a simple one button shut down process should be implemented but it was never put in place. This is contrary to Australian Standards.

[DaptoFunlandGuy]

It was only 20 seconds from when the water began to drop until raft 6 became stranded

Approximately 50 seconds after when raft 5 collided.

It is not clear when the operator initiated the shutdown from CCTV, or if in fact he did.

Testing found no issue with the controls.

 

CCTV shows conveyor began a slow stop 11 seconds after the collision.

It is clear that the 38 signals and checks to be undertaken by the ride operators were excessive.

[Jdude95]

Guests in unloading and loading rafts gave evidence that was contradictory to other statements provided. There is no way to tell if and when and how many times the lead operator his the e-stop button on his control panel. The conveyor takes 11 seconds to perform a slow stop which is seen happening after the rafts have already collided. 

The unload operator didn’t press the e-stop button near her as the lead operator was still in control of his panel and she was not told that the e-stop near here stopped the conveyor. 

There are 38 checks undertaken by the ride operators which is excessive. There was no training in regards to what checks and tasks took priority. 

Unload operator was told in a memo to not press unlabelled e-stop at unload platform unless lead operator was incapacitated.

[DaptoFunlandGuy]

Operating manuals were drafted by ops department without input from maintenance or safety departments.

5 breakdowns of TRRR in the prior 7 days due to the failure of the south pump.

Ride was reset without investigation.

no specific training provided to staff on how to manage a ride with multiple failures.

 

 

“Regardless of training provided, it would never have been sufficient to overcome the design and engineering faults...”

 

[Jdude95]

Ride controls were complex, confusing and lacked clear labelling. The safety of the ride was all undertaken at a staff level, no automated safety systems. 

The south pump tripped multiple times earlier that day. Pump was reset and brought back into operation as it wasn’t investigated further. There was confusion as to how the breakdown policy should apply. Confusion in regards to how many breakdowns would need to occur before a problem is investigated and escalated. Maintenance staff weren’t trained that there were any risks or failures with the ride. There was a significant breakdown in the procedure prior to the incident. Coroner can’t understand why actions weren’t taken earlier in the day as the faults were known and apparent. Training times was dependant on complexity of the ride but seemed inadequate. All training was word of mouth that would be passed from operator to operator. There was a lack of proper training for new ride operators. There was nothing that specified what an emergency was in terms of when to use emergency stop buttons. There were no emergency drills undertaken at the park either. Had this had been done, it might have reduced the stress and improved the response.

[DaptoFunlandGuy]

The coroner rejects the suggestion of “hindsight bias” due to the numerous prior incidents.

dreamworlds experts are rejected by the coroner as experts on hindsight bias.

“Mr Tan had numerous responsibilities and was moved to multiple different positions within the park, but no one was ever charged with conducting risk assessments in the park”

”such hazards would have been obvious to someone suitably qualified”

That no one was injured “was more good luck than good management”

Burden on ride operators was significant and unfair.

[webslave]

ABC News is mixing narratives:

[DaptoFunlandGuy]

Regular ongoing and adequate auditing to be undertaken by the regulator is essential in the industry.

Significant changes at Dreamworld since the incident including inspections, emergency drills, training and safety management systems. 

village roadshow SMS cited also.

it is without question more direct oversight and auditing of the industry is necessary.

The coroner has now turned to the findings:

He has named the deceased to formally identify them.

At 2:05, the deceased collided with an empty raft at the unload, causing their raft to lift and be pulled into the conveyor.

cause of death was sever internal and external injuries as a result of multiple compressive impacts.

Recommendations:

 change regulatory framework for inspection and licensing.
require amusement owners use effective safety management system 

owner must comply with updated Aus standards.

annual risk assessments must be completed by competent persons.

operators must be assessed as competent

regulator must conduct audits on a regular basis by suitably qualified and trained inspectors.

major parks in QLD required to implement effective procedures and processes to ensure safe operation aligned with the new regulations and inspection requirements.

new code of practice to establish a minimum standard must be developed.

Directions:

the coroner has directed the matter to be referred to the office of industrial relations for consideration of whether there is a case for prosecution of Ardent for breaches of WH&S Act.

Dreamworld engineer has also been referred to the engineering authority.

The inquest is closed.

[Jdude95]

Findings have been handed down. 

[DaptoFunlandGuy]

The findings are being uploaded to the coroners court website NOW

[Jdude95]

We are adjourned for the day 

[joz]

Holy shit.

 

Nothing surprising in here but still.

[Brad2912]

Thanks guys!

[Cryptic Hatter]

Thank you to the both of  you for keeping  us up to date

[New display name]

........................./´¯/)
......................,/¯..//
...................../..../ /
............./´¯/'...'/´¯¯`·¸
........../'/.../..../......./¨¯\
........('(...´(..´......,~/'...')
.........\.................\/..../
..........''...\.......... _.·´
............\..............(
..............\.............\

Ardent Leisure!