After four years of questions, inquests and grief, the families of the four people who tragically died at Dreamworld in October 2016 can receive some solace from a report handed down by the Coroners Court of Queensland today.
In his findings Coroner James McDougall determined the 2016 Thunder River Rapids Ride (TRRR) disaster, which caused the deaths of Katie Goodchild, Luke Dorsett, Cindy Low and Roozbeh Araghi, was the result of "systemic failure" by Dreamworld.
So grievous were the company's failings that the theme park's parent company Ardent Leisure (ASX: ALG) has been referred to the Office of Industrial Relations for possible prosecution.
"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," said McDougall.
"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."
"Shoddy" record keeping to blame
Not only did McDougall determine that the ride itself was clearly unsafe, but the record keeping and safety procedures of Dreamworld staff, described by the Coroner as "shoddy", meant a tragedy of this kind was inevitably going to occur.
"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," says McDougall.
"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."
"I find that shoddy record keeping was a significant contributor to this incident."
This lack of oversight was further highlighted by the Coroner, who says prior incidents on the TRRR should have triggered alarm bells for safety officials.
"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," says McDougall.
"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."
"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."
Chillingly, the Coroner points out one specific instance when one of the TRRR rafts flipped in the same way as the raft that sparked the Inquiry. Following that incident, during which no one was hurt as no one was on the raft, the safety official wrote: "I shudder to think if there had been guests on the rafts".
Ardent Leisure could face prosecution
Since the tragedy Dreamworld parent Ardent Leisure has implemented a number of safety measures and procedures, but McDougall effectively said in his report that the park is too little, too late.
"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," says McDougall.
"Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety. That cannot be allowed."
As a result, the Coroner has called on the Queensland government to make changes to the current regulatory framework in the state to ensure a more structured and compliance focused regime is implemented.
McDougall has also referred Ardent Leisure to the Office of Industrial Relations for possible legal prosecution as he reasonably suspects the company 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," says McDougall.
"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."
Following the release of the Coroner's Report, Ardent Leisure issued two statements to the ASX expressing its sympathies to the victims of the tragedy and reaffirming a commitment to implementing stringent safety procedures at its theme parks.
"Safety is the team's number one priority and they are proactively focused on continuous improvements to safety across the Park in the areas of ride safety and reliability, training of ride operators, emergency management procedures, safety management systems and safety governance," says Ardent Leisure.
"The new leadership team is committed to continuing to improve and enhance safety systems and practices. We are also committed to working with WHSQ and other emergency services authorities to ensure we have the most robust safety systems and procedures in place."
In response to the report's release, the Queensland Government has released a statement in support of the findings.
"The majority of recommendations in the findings have already been implemented by the decisive steps we have taken in the past three years to improve safety on amusement rides," says the office of the Minister for Education and Industrial Relations Grace Grace.
"But we are conducting a thorough examination of the recommendations to determine if more needs to be done to ensure the highest levels of safety in theme parks."
"We are committed to providing the highest safety standards, from rides at carnivals and school fairs, to those at our major theme parks."
Read the full report here.
Shares in Ardent Leisure are down 16.31 per cent to $1.18 per share at 4.45pm AEDT.
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