Lessons learned from the 2020 Dreamworld case
An outstanding and horrifying example of not carrying out effective risk management was revealed when the 297 pages of the Coroner’s Report into the 4 fatalities that occurred at the Dreamworld Theme Park in Brisbane at the Thunder River Rapids Ride (TRRR) was released on 24 February, 2020. It is a revelatory case study of what must be done to have a safe and healthy workplace.
The Coroner’s Report includes the specific issues he identified and considered during the course of the inquest hearings. The four deceased persons died because of “the combined effect of severe internal and external injuries as a result of multiple compressive impacts” when the raft they were in collided with another raft and became caught in the mechanism of the ride.
The coroner sets out the specifics of numerous instances over a period of many years where key WHS risks were not eliminated or minimised at Dreamworld and their risk management system did not comply with the WHS risk management requirements of the WHS Act or WHS Regulation. A number of those instances are set out at the end of this article for your reference.
Those instances clearly show that the hazards at the Thunder River Rapids Ride were not fully identified and correctly managed. Key risks were not assessed and eliminated or minimised in accordance with the hierarchy of risk control measures in the WHS Regulation.
In referring to his statement of “how rudimentary and deficient the safety management practices” were at Dreamworld, the Coroner wrote “... Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety.” – p270
Quotations from the Coroner’s Report
“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. 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.” – p258.
“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.” – p258
“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.” – p259
“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." – p259
“… 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.” – p260
“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.” – p260
“.. 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." – p266
“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.” – p266
We can determine from the report that Dreamworld's WHS management system failed. As identified and stated, key to those failures was the failure to train staff in risk management principles and actions. But even before that, the instructions and maintenance requirements of the machinery were obviously not well-known enough or respected. Businesses that provide machinery, equipment and plant have duties to ensure that their products are fit for use and that end-users have the correct information to be able to use the equipment properly. There is no mention or suggestion that the provider of the machinery was at fault, therefore onus falls on Dreamworld. It was Dreamworld's duty to ensure that instructional information for the ride was followed and this included its service schedule. The fact that the equipment was 30 years old would surely have been motivation enough to take special care of the machinery and to do regular risk assessments? Ignorance of these basic concerns causes tragedies - like this one.
For more information feel free to contact us at train@courtenell.com.au or phone us on 02 9552 2066
3rd March 2020
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