DreamWorld Nightmare: The Coroner’s Report

Background

On the 25 October 2016, four people tragically died in an accident on the Thunder River Rapids Ride (TRRR) at the Dreamworld Theme Park (Dreamworld). Dreamworld is owned and operated by Ardent Leisure Ltd. The Queensland Coroner’s Court undertook an inquest to review the circumstances and cause of the fatalities, with the final report handed down in February 2020. Much of the inquest explored the workplace health and safety measures (including staff training and safety features on rides); problems with the standards and complying with same as well as oversight from the state regulator.

At the end of the report, the coroner, James McDougall, remarked upon “how rudimentary and deficient the safety management practices in place at Dreamworld were prior to this tragedy. Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety. That cannot be allowed” (emphasis added).[1] The coroner unfavourably contrasted the behaviour of the Board of Ardent Leisure with the safety systems and governance at rival company, Village Roadshow.[2]

Despite these damning comments, subsequent media discussion criticised the coroner for not examining the relevant corporate governance issues in greater depth.[3] These questions are especially pressing given that the parent company, Ardent Leisure, “became a textbook example of how not to deal with a crisis”, with the preponderance of negative media attention focused on the then CEO of Ardent Leisure, Deborah Thomas, but not the executive of Dreamworld or the other members of the Ardent Leisure Board.[4]

Issues on the Day

The TRRR broke down twice before the accident, at 11:50 am and 1:09 pm. There had been water level issues, as the water pump had stopped on two occasions. In the preceding week, the TRRR had broken down five times. All the breakdowns were attributed to the ‘South pump dropped out earth Fault’. On the day, there were two ride operators: Mr Nemeth, an experienced ride operator and safety representative, and Ms Williams, who had just started TRRR operator induction training that morning (approximately 15-20 minutes,), and it seems was not shown the emergency shutdown procedure during that time.

The four patrons travelled the entire TRRR course in the Raft 5 without incident and were picked up by the conveyor belt at the end of the ride. The raft in front of them, Raft 6, became stranded on the steel support rails situated at the end of the conveyor near the unloading area. Ms Williams and Mr Nemeth noticed that the water level was going down dramatically, and Ms Williams claims that whilst she had her back to the conveyor attempting to communicate with Mr Nemeth about the situation, she saw that his ‘facial expressions just completely dropped’. She turned around and saw that a raft was travelling down the conveyor, and would collide with the raft stranded on the metal support rails.

Between 2:04:50pm and 2:05:35pm, Raft 5 continued to travel on the conveyor where it collided with Raft 6 before being lifted and pulled vertically into the conveyor mechanism.[5] The two children escaped to safety, but the four adults were either trapped in the raft or ejected into the water beneath the conveyor.

While it might seem as though the accident came down to only a few seconds, the tragedy was the cumulative result of decades of issues with risk assessments, staff training, communication and documentation practices, and safety audits.

I think we do need to highlight what happened on the day – the loss of water from the South pump and restarts and the training of the person who had to stop the ride – that is important for context… it was mere few seconds which made all the difference.

Previous Incidents

During the TRRR start-up procedures on 18 January 2001, some empty rafts collided in the unload area of the ride, and one of them flipped over. An investigation was conducted, but the Coroner’s Report noted that it did not include a thorough risk or engineering hazard assessment, and the recommendation from the investigation to conduct further training for emergency situations was not implemented.[6]

Another incident occurred on 7 October 2004, where a guest lost her balance and fell into the water while disembarking from the ride when the raft was stationary. Dreamworld’s internal investigations resulted in corrective actions to the ride and the staff training regime.

After an instance on 28 August 2005, when the proper circulation of the rafts was impeded by a raft that had taken on water, another investigation was conducted, which noted that the TRRR operators “must perform numerous tasks simultaneously – many of which are cognitively draining”.[7]

On 6 November 2014, the TRRR operator on duty heard the backup compressor shut down without the sounding of a low air alarm. When the alarm sounded 10 minutes later, the water level had dropped. The operator admitted that he had mistakenly turned off one of the pumps and breached many elements of the ride procedure, including restarting the pump, despite his extensive experience with the TRRR. The low water level resulted in a raft “left sitting at the bottom of the conveyor [which] was at serious risk of flipping due to the increased pressure from the re-started pump”.[8] The employee was terminated.

A few days later, the General Manager of Special Projects, Mr Bob Tan, emailed the Dreamworld leadership team highlighting relevant incidents resulting from breaches or deviations in procedures. He referred to the 2001 TRRR Incident, attached photographs of the flipped-over rafts, and commented “This occurred on the rapid ride several years ago, and fortunately there was no injury except for property damage. I shudder when I think if there had been guests on the rafts…”.[9]

Communication Issues

There were serious documentation issues at Dreamworld, especially relating to the TRRR. The ride was constructed in 1985-1986, but information about the original construction and subsequent modifications are minimal.[10] Thus, it was not clear whether risk or hazard assessments were undertaken prior to the modifications.

Mr Angus Hutchings was the Group Safety Manager for Ardent Leisure since 2010 (having been the Safety Manager at Dreamworld from 2004 to 2010) and was also responsible for ensuring that Senior Committee members and Directors were kept abreast of safety-related issues at Dreamworld. He had responsibilities across multiple businesses, including Dreamworld, such as assisting safety managers and coordinating audits.

Hutchings testified that he had sought to introduce an all-of-business risk register to overcome segmentation of knowledge between the departments, but that “he received some ‘pushback’ for this idea”.[11] He noted that there were misunderstandings amongst Dreamworld staff about which responsibilities belonged to other departments.

After the position was vacant for quite some time (for reasons that are not specified in the report), Mr Christopher Deaves was hired as the General Manager of the Engineering and Technical Department in April 2012 and reported to Mr Bob Tan (General Manager of Engineering and Special Projects from 1987 to January 2016).

When Deaves started at Dreamworld, he “found that the records and document control, including for the rides, safety systems, maintenance and training of staff, were significantly lacking, with the limited information available difficult to navigate for the purpose of retrieval, cataloguing and distribution”.[12]

As recognised by Hutchings in his suggestion for an all-of-business risk register, Deaves noted that “most of the platforms to manage the safety of all asset management were failing because the information always wasn’t available and it wasn’t available to everybody who needed it”.

Auditing

Mr Tan claimed that in relation to decisions as to the conduct of ‘safety audits’ of amusement ride, directives were given by the Board to the CEO, who in turn allocated such matters to the Safety Manager and Mr Tan to implement. Records in relation to these audits were maintained by the Safety Department.[13] The Coroner’s Report noted with significant concern that “there was no one employed at Dreamworld who was dedicated or qualified to undertake full risk assessments of the rides, including the TRRR, from an engineering and hazard perspective”.[14]

In 2004, the independent auditor, JAK Leisure Company recommended that evacuation procedures be re-evaluated on rides where more ‘specific evacuation procedures’ are called for, including the TRRR. The Dreamworld Board response to this recommendation was that “specific ride evacuation procedures are in place for these rides…”.[15] The February 2014 Audit by DRA only saw ‘marginal improvement’ and the report suggested that the recommendation be placed into a Risk Register and allocated to management for implementation.[16] The 2015 Audit noted the emergency systems and documentation were out-of-date.

Mr Mark Thompson was the Safety Manager at Dreamworld since March 2016 and was responsible for ensuring that Senior Committee members and Directors were kept abreast of safety-related issues at Dreamworld. His responsibilities also included delivering training and investigating safety breaches. He did not, however, conduct regular safety audits or inspections at Dreamworld, as these were undertaken by external auditors. Significantly, he “was not aware of the recommendations made by any external auditors commissioned by Dreamworld to conduct assessments in relation to the safety of the rides and attractions, and did not have a copy of the reports commissioned”.[17] Thompson also noted that the Safety Team was often short-staffed and had a great deal of responsibility, making it difficult to complete “the reactive work required, let alone any proactive safety management”.[18]

Key Findings

The main lessons for directors:

  • It is important to use Risk Registers and technology to a high standard – Dreamworld had communication issues due to reliance on paper-based records, a lack of a central location for documents, departmental segmentation, and poor record-keeping;
  • Knowledge-sharing with the executive – management should be aware of previous incidents (i.e. by using a Risk Register and Action Log), design and modifications to equipment, and be able to access information to consider them.
  • Staff training and workload – where workers are likely to experience fatigue due to requirements for high attention and vigilance while completing repetitive tasks through long shifts, the executive and management should be alive to the need for increasing staff numbers and rotating during shifts.

Prosecution

On 21 July 2020, the Dreamworld parent company, Ardent Leisure, was charged with three counts of failing to comply with health and safety legislation and exposing individuals to a risk of serious injury or death.

The Work Health and Safety Prosecutor, Aaron Guilfoyle (who commenced in the role on 18 March 2019), laid charges under s 32 of the Work Health and Safety Act 2011 (Qld),[19] which states that:

32  Failure to comply with health and safety duty—Category 2

A person commits a Category 2 offence if:

(a)  the person has a health and safety duty; and

(b)  the person fails to comply with that duty; and

(c)  the failure exposes an individual to a risk of death or serious injury or illness.

Penalty:

(a)  In the case of an offence committed by an individual (other than as a person conducting a business or undertaking or as an officer of a person conducting a business or undertaking)—$150,000.

(b)  In the case of an offence committed by an individual as a person conducting a business or undertaking or as an officer of a person conducting a business or undertaking—$300,000.

(c)  In the case of an offence committed by a body corporate—$1,500,000.

The charges allege that the company failed to comply with its primary safety duty under s 19(2) of the Work Health and Safety Act 2011 (Qld), which states that:

19  Primary duty of care

(2)  A person conducting a business or undertaking must ensure, so far as is reasonably practicable, that the health and safety of other persons are not put at risk from work carried out as part of the conduct of the business or undertaking.

It is alleged Ardent Leisure failed to ensure, so far as was reasonably practicable:

  • the provision and maintenance of safe plant and structures;
  • provision and maintenance of safe systems of work; and
  • the provision of information, training, instruction or supervision that was necessary to protect all persons from risks to their health and safety arising from work carried out as part of the conduct of the business or undertaking.

The maximum penalty is a fine of $4.5M, with each charge carrying a maximum penalty of a $1.5M fine. Mr Guilfoyle confirmed he does not propose to lay any further charges in the matter. The charges against Ardent Leisure will be mentioned in the Southport Magistrates Court on Wednesday 29 July 2020.

[1] Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 270.

[2] Charlie Peel and Craig Johnstone, ‘Dreamworld Risks: Board Failed to Act’ (26 February 2020) The Australian 13; Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 148, 215, 270.

[3] Tony Boyd, ‘Dreamworld’s Accountability Absent’ (25 February 2020) The Australian Financial Review 40.

[4] Mark Ludlow, ‘Sleepwalking to Disaster’ (26 February 2020) The Australian Financial Review 36.

[5] Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 105-108

[6] Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 63.

[7] Ibid, 68.

[8] Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 70.

[9] Ibid, 71.

[10] Ibid, 25.

[11] Ibid, 75.

[12] Coroner’s Court of Queensland, Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low and Roozbeh Araghi (24 February 2020) 78.

[13] Ibid, 84.

[14] Ibid, 85.

[15] Ibid, 134.

[16] Ibid, 153.

[17] Ibid, 74.

[18] Ibid, 74.

[19] Office of the Work Health and Safety Prosecutor, ‘Charges laid in Dreamworld referral’ (Media Release, 21 July 2020) <https://www.owhsp.qld.gov.au/news-and-media/charges-laid-dreamworld-referral>.

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