A coroner has condemned Dreamworld over multiple systemic failures leading up to the deaths of four patrons at Dreamworld’s Thunder River Rapids ride in 2016, referring owner Ardent Leisure to Queensland’s Office of Industrial Relations for potential prosecution.
Coroner James McDougall handed down his scathing report into the 2016 tragedy at Dreamworld, which claimed the lives of Cindy Low, Kate Goodchild, Luke Dorsett and Roozi Araghi, in the Brisbane Magistrates Court on Monday morning.
The coroner told the court that while Dreamworld had a reputation as a modern, world-class theme park, its safety and maintenance systems were “rudimentary at best” with “frighteningly unsophisticated systems” and there had been a “systemic failure by Dreamworld in relation to all aspects of safety.”
He said there is no evidence that Dreamworld ever conducted a proper risk assessment of the ride in its 30 years of commission.
The coroner believed shoddy record keeping was a significant contributor and the inquiry had heard staff were both over-stretched and under-prepared for serious incidents. He said it was unclear why an inexpensive and basic device such as a water level monitor was not installed on the ride.
He said there were a number of occasions that should have triggered hazard identification risk assessment and it was clear from expert evidence that at the time of the incident the design and construction of the ride posed a significant risk to the health and safety of patrons.
He said the required assessments were not carried out and that while owners should be risk-averse, this was not the case with this ride.
Safety certificates were issued for the Thunder River Rapids Ride only weeks before the tragedy, although the external engineer had not been provided with paperwork detailing the ride’s safety audits.
The coroner is referring parent company Ardent Leisure for possible prosecution under section 48 of the Act, believing the company may have committed an offence under workplace law. He is also referring the findings to the Board of Professional Engineers Queensland.
The Queensland Government has accepted the coroner’s findings and referred the matter to the independent Work Health and Safety Prosecutor to decide whether action will be taken against Ardent.
Under Queensland law, companies can be fined up to $3 million and individuals fined up to $600,000 or jailed for up to five years.
In 2018, Dreamworld employees including first responders sued Ardent Leisure for psychological trauma.