One fault that caused Dreamworld disaster
When one of two pumps operating the Thunder River Rapids ride at Dreamworld failed, causing the water level to drop dramatically, tragedy ensued.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi all suffered fatal injuries when they were thrown from their raft in the unloading area and either trapped or ejected into the water beneath a mechanised conveyor in October 2016.
Coroner James McDougall today delivered his long-awaited findings, totalling almost 300 pages, after overseeing an inquest into the deaths and the "unique and catastrophic incident".
He told a packed Brisbane Magistrates Court there was a "total" and "systemic failure by Dreamworld to ensure all aspects of safety".
He referred the Gold Coast theme park's owner and operator, Ardent Leisure, to the Office of Industrial Relations to consider whether there is sufficient evidence to proceed to prosecution.
"It is reasonably suspected that Ardent Leisure may have committed an offence under workplace law," Mr McDougall said.
The "moderate thrill ride" was statistically the most popular and had been operating for almost 30 years at the time of the incident.
But what was it that made the coroner consider the four deaths as "simply a matter of time"?
THE WATER PUMPS
The ride was designed to simulate white water rafting for six people within each circular raft.
Under the conveyor belt, in a separate confined enclosure, were two water pumps considered "north and south" due to their positioning.
There were separate buttons to stop and start the pumps on the main control panel.
The inquest heard there was no emergency stop for the south pump, or one that stopped both pumps simultaneously.
There was also no formal water marker in the trough where rafts were loaded and unloaded.
"Rather, operators were required to measure the water level by reference to a scum mark on the wall of the trough, which was made from years of the ride operating," the coroner said.
Mr McDougall said it was clear the failure of the south pump was to blame for the disaster.
"It remains unknown and impossible to understand why the conveyor kept going if the water level dropped on the ride," he said today.
An independent expert engineering review and assessment of the ride was conducted by Dr Duncan B Gilmore from Gilmore Engineers.
"Having considered the design of the ride, Dr Gilmore notes that the ride is clearly dependent on an adequate water level," the coroner's findings state.
"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."
The coroner's first of many recommendations was for changes to be made to Queensland's regulatory framework with respect to the inspection of "major amusement park devices", "given the circumstances of this tragic incident".
He suggested a major inspection or full risk assessment must be done by a competent person at stipulated intervals, as suggested by the manufacturer or at a mandated duration.
Senior Constable Steven Cornish, of the Forensic Crash Unit, found the "primary cause of the event was due to the failing of the south pump, which in turn led to a sudden drop in water level".
"It was proven during testing that a raft was unable to complete the circuit when only one pump was in operation," the findings say of his evidence.
"Water level monitoring for the ride was undertaken through visual observations by the operator, using existing structures of discolouration of the trough walls.
"There was no automated safety system to monitor the water level and provide any audible or visual alert should the level fall below a safe operating level."
'FRIGHTENINGLY UNSOPHISTICATED' SAFETY PROCEDURES
The coroner said Dreamworld presented itself as a modern, world-class theme park but it had "frighteningly unsophisticated systems" and its safety procedures were rudimentary at best.
Expert testimony made it "clear" the design and construction of the ride and its unload area "posed a significant risk to the health and safety of patrons", Mr McDougall said.
These hazards included the configuration of the ride with its wide spacing of conveyor slats, the "nip point" at the head of the conveyor, the steel support railing, the effect of a pump failure on the water level and the lack of an emergency stop button on 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," the coroner said.
He said Ardent Leisure provided "sparse and haphazard records" to the inquest indicating "various risk assessments" were conducted on different aspects of its rides.
But there was no evidence Dreamworld conducted a thorough engineering risk assessment of the ride in its almost three decades of operation.
"Whilst the scope of these risk assessments varied somewhat, it is clear from the material provided that a documented engineering risk assessment of the ride, adequately considering the hazards posed by different components or the ride as a whole, was never conducted," he said.
"This is particularly troubling having regard to the previous incidents already documented."
Mr McDougall found "shoddy record keeping was a significant contributing factor" to the tragedy and "contributed to the masking of the real risk" of the Thunder River Rapids ride.
'I MISS HER HUGS AND CAKES'
On Monday, the loved ones of the four victims, who didn't address the court during the inquest, were given an opportunity to tell the coroner of the shattering impact of their deaths.
• "She had mastered the art of unconditional love." - Mathew Low said of his wife Cindy.
• "Dreamworld was a catastrophe waiting to happen because of their barefaced disregard for safety and maintenance." - Mr Low said in a statement after Monday's findings.
• "Mum was a wonderful person with a very big heart … I miss her hugs and the cakes she used to make." - Isla Low, nine, said of her mother.
• 'I arrived to a nightmare, my mother was hysterical. Dreamworld cares about saving face and the bottom dollar." - Ms Low's brother, Michael Cooke, said about the day he found out his sister had died.
• "I know my daughter wouldn't want her to carry the burden." Ms Low's mother, Donna Cooke, said of the note she gave to the young ride operator.
• "My huge regret is that the day she needed me most, I wasn't there." - Kim Dorsett said of her daughter, Kate Goodchild.
• "The easier part was burying them, the harrowing part is living without them." - Ms Dorsett on the loss of her daughter, son and his partner.
• "Such tragedies do not happen by accident, they do not happen out of nowhere. We hope they did not die in vain." - Shayne Goodchild, father of Kate and Luke.
LAWYERS AND THEME PARK OWNERS RESPOND
Roger Singh of Shine Lawyers, which represented multiple witnesses and first responders at the inquest, said he was "flabbergasted by the litany of failures on behalf of Dreamworld".
"(I) can only imagine how difficult it will be for the families of the deceased to swallow these damning findings," he said in a statement released on Monday afternoon.
"We now know this ride posed an unacceptable risk to the health and safety of hundreds of thousands of visitors to Dreamworld for decades.
"The theme park had many opportunities to prevent this tragedy from occurring but there is no evidence to suggest a proper risk assessment was ever conducted.
"The bottom line is the four people who perished could still be here today if it wasn't for Dreamworld's reckless disregard for health and safety."
He welcomed the news of the referral of Ardent Leisure to the OIR by the coroner.
The company could face fines of up to $3 million, with individual executives facing up to $600,000 and five years' jail.
Following the tragedy Queensland introduced new safety regulations for amusement rides, including mandatory major inspections of rides by qualified engineers every 10 years and improved training for ride operators.
The state government also tightened workplace health and safety prosecution laws and introduced the charge of industrial manslaughter.
Ardent Leisure Theme Parks chief executive John Osborne responded to the findings on Monday afternoon.
"First and foremost, we express our deepest sympathies to the families and friends of Roozbeh (Roozi) Araghi, Luke Dorsett, Kate Goodchild and Cindy Low," he told reporters in Brisbane.
"Our thoughts are also with the first responders, emergency services personnel, investigators, counsellors and Dreamworld team members affected by this tragedy.
"We would like to acknowledge the attendance and involvement of the families, witnesses and all other participants in the inquest process, as well as the Coroner and his team."
Mr Osborne said the theme park has "enhanced emergency management procedures" and all ride operators are assessed on a regular basis "in order to verify their competency".
He said there has been "considerable change" at Dreamworld over recent years and safety is their "number one priority", with the aim of exceeding workplace health and safety requirements and becoming the industry leader.
Company chairman Gary Weiss said a number of people had been compensated through private agreed settlements.
He said Ardent Leisure acknowledged the "loss and suffering" experienced by many as a result of the tragedy, which he's committed to ensuring "never happens again".
Dreamworld will construct a memorial garden to honour and pay respect to the four victims.