June 26, 2018

Early lessons emerging from the Inquest into the deaths at Dreamworld

The first two weeks of evidence in the coronial inquest into the deaths of four members of the public (Roozi Araghi, Luke Dorsett, Kate Goodchild and Cindy Low) on the Thunder River Rapids ride at Dreamworld on October 25 2016 are already providing us with insights into how such a tragedy could take place.

At the end of the second week of the inquest, Dreamworld's CEO Craig Davidson has resigned.  This departure follows the April 2017 decision of Deborah Thomas, the then CEO of Dreamworld's parent company, Ardent Leisure, to step down in the wake of the incident.

Ardent Leisure has released a statement at the end of the second week of evidence in the inquest acknowledging the need to learn and committing to: "the implementation of all Coronial Inquest recommendations in consultation with Workplace Health & Safety Queensland and the theme park industry."

Recently appointed Ardent Chairman Dr Gary Weiss has said that the company needs to learn from the evidence:

“Like everyone else, I have been deeply concerned by what has emerged from the inquiry over the past fortnight, and this is why it is important that we listen to the evidence, understand all we can and apply the lessons learned to ensure such accidents never occur at our parks…”

While a recruitment process for Mr Davidson's replacement takes place, Nicole Noye has been appointed as Acting CEO of Theme Parks having previously served as Ardent's Group Chief Experience Officer.  Ardent Leisure has also announced two new executive appointments of Phil Tanner as Director of Safety and former Queensland Police Inspector Mike McKay APM as Director for Culture, Community and External Relations. 

To anyone who has investigated serious incidents and how they occur, the lessons emerging for safety management sound eerily familiar. Appropriate resourcing for critical operational and support functions has been at the heart of many of the lessons suggested by the early evidence.

1. The impact of cost cutting on safety - evidence before the inquest include minutes of an engineering management meeting from March 2016, some seven months prior to the tragedy that outlined monthly expenditure was AUD$125,000 over budget on a year-to-date basis. The document went on to state: “Revenue is up but profit is down, cutbacks are now being enforced.” Whenever cost reduction exercises are adopted, there is a need to consider the safety implications of such exercises and ensure that safety critical functions are adequately supported. In the context of amusement ride operations, preventative maintenance regimes are such fundamental functions. The March 2016 engineering minutes stated that: “Repairs and maintenance spending needs to stop, only CAPEX [capital expenditure]”. 

It will be interesting to see whether the inquest further explores what level of oversight and due diligence was exercised by managers and senior leaders from a safety perspective given those stark statements from the engineering records.

2. Effective training for personnel including emergency drills - Detective Sergeant Nicola Brown of Queensland Police told the inquest that the police investigation identified the ride operator, Courtney Williams had access to an emergency button in the unload area that could halt the conveyor stopping the ride within two seconds but she told police investigators that she was not aware of what the switch did and was told not to worry about the button as “no-one uses it”. 

The day of the incident was the worker's first day acting as the load operator on the ride.  She had received 90 minutes of training in the operation of the ride before her shift started.  On day seven of the inquest, the court heard a different story from the individual who provided the worker with training in the ride, Amy Crisp.  The inquest was shown a video recorded at the site 5 days after the incident with the trainer and police.  The trainer indicates that she pointed out the e-stop button and told the ride operator "If you hit that, it will stop your conveyor and a pump and she understood that."  "She said, 'yeah, yeah I get it'".

Peter Nemeth, a senior ride operator had earlier told the inquest that he was “surprised” to learn the e-stop button could halt the conveyor within 2 seconds and told the court that managing responsibilities was “impossible” with 36 checks required in less than a minute. 

Unfortunately, it is not uncommon following a serious incident to see a disconnect in evidence between workers and trainers. What this highlights is the need to continuously test assumptions and check that your training approach has the desired effect, assessing that there has been effective knowledge transfer that can be used in practice.  This is one of the reasons why scenario-based drills are an important part of effective systems. 

The forensic crash investigators identified pressing that emergency button at any stage during the event right up to the point of impact may possibly have limited the extent of some of the injuries. The inquest has also heard that the emergency button was not clearly labelled. There was a memo issued to staff in the week prior to the incident that stated to only use the button if the main control panel could not be reached. However, the “slow-stop” button on the control panel would only halt the rafts about eight seconds after the button had been pushed.  The control panel for the ride is understood to be more complex than other rides, a matter identified by auditors, and was confusing to some ride operators. Furthermore, early evidence seems to suggest that Dreamworld did not conduct ride-specific emergency drills for staff to support effective emergency response.  

Furthermore, early evidence seems to suggest that Dreamworld did not conduct ride-specific emergency drills for staff to support effective emergency response.  This position seems to have been refuted by Dreamworld spokespersons outside the inquest.  However, to date five ride operators have given evidence that they had not received emergency scenario training.  

3. Heed your near miss events as early warning signs and act accordingly - In opening remarks for the inquest, Counsel Assisting, Ken Fleming QC, had stated that the incident itself was a “significant mechanical breakdown” involving a failure of the south pump that caused a massive drop in water with one boat becoming caught on the rails as the water dropped. Senior Ride Operator Sarah Cotter told the inquest that she attended the two electrical faults that occurred on the Thunder River Rapids ride on the day of the incident. The earlier “earth faults” occurred at 11.50am and 1.09pm on 25 October and had caused the water levels in the ride to drop. Ms Cotter gave evidence on Monday that she asked the technician attending: “What are we going to do about this [pump] problem? This is ridiculous” and was told by the engineer technician attending that the alarm needs to happen three times before the ride was shut down. Matthew Robertson, ride technician, indicated to the inquest that was his understanding of the policy prior to the incident. Ms Cotter gave evidence she was unaware of a breakdown policy that stated a ride had to be shut down and authority sought from an engineering supervisor if there were two exact malfunctions within a 24-hour period. . An engineering supervisor, Peter Gardner confirmed that was the correct procedure but agreed under questioning that he had not told his team the correct procedure.  It was put to Mr Gardner by Counsel Assisting, Ken Fleming QC that "That ride should not have been in service after it broke down the second time, should it?"  Mr Gardner replied, "No." Electrician Jacob Wilson gave evidence that he had reset a water pump following pump failures that occurred on the ride earlier in the week of the incident (on October 19 and 22) but that neither he nor his colleagues attempted to "diagnose the cause" of the fault. Mr Robertson told the inquest that technicians could be called to twenty ride shutdowns a day due to faults. He had not been given any framework for assessments as to whether rides faults could be dangerous and stated that he was required to use his “own judgement” in that regard. This evidence is also of relevance to the training and communications lessons emerging. There is little utility to policies and procedures if they are not known to the workers that need to implement them.

4. Appropriate resourcing of the safety function - Mr Thompson told the inquest: 

there was only one of me...it made it hard for me to do proactive work when I was putting out forest fires”.

In Mr Thompson’s view, a team of six was required to effectively support health and safety management at the amusement park. Indeed, Dreamworld employed a dedicated team of six safety professionals following the fatalities. 

I hear eerily similar statements from safety professionals working across many industries all the time. Take this moment to ask yourselves whether you have put the business case to management for effective resourcing for safety and have briefed them specifically on what functions are not being performed because of your resourcing levels.

5. Keeping systems under review and following through on implementing audit recommendations - the inquest has heard that the WHS policy at Dreamworld had not been updated for six years. Further, Recommendation 13 of a 2013 JAK safety audit of the Thunder River Rapids ride was that “a single emergency shutdown procedure be considered” as there was no single emergency stop button that could immediately stop the ride, with separate buttons to stop the conveyor and the water pumps.

The inquest has also heard that Dreamworld sought and was granted two extensions on its registration by the regulator, Workplace Health and Safety Queensland, for the Thunder River Rapids ride which was due to expire in January 2016 some 9 months prior to the incident. According to news reports, the reason given was apparent difficulty in finding a competent person to conduct the inspections of the amusement park’s ‘big nine thrill rides’ after Dreamworld “discovered its own engineers were not qualified". Dreamworld lawyers outside the court indicated the check was completed prior to the fatalities. It seems from the evidence that this registration issue was viewed as a“technical noncompliance” rather than a critical aspect of the systems legislatively mandated to ensure public safety.

This is an interesting detail as regulation 241 of the Work Health and Safety Regulation 2011 (Qld) requires rides to undergo a detailed inspection by a competent person at least once every 12 months (in addition to any re-registration). Indeed, WHSQ's form for applications for registration of plant requires a declaration that the amusement ride has been inspected and assessed as safe to operate by a competent person in accordance with regulations 240 and 241 of the WHS Regulation. Such a detailed inspection (if conducted properly and according to the requirements of the WHS Regulation) would have picked up any failures or issues associated with a lack of maintenance or failures in the more regular inspection processes). It remains to be seen if the inquest further explores this issue in detail and in particular:

  • what level of analysis is undertaken by the regulator in reviewing and approving such requests for extensions from duty holders

  • to what extent critical risks and requests for extensions on usual regulatory processes are triggers for additional regulatory oversight (such as inspections by the regulator), and

  • the availability and use of competent persons for detailed inspections of amusement rides at Dreamworld and across the industry at the relevant time as well as for the industry on an ongoing basis.

The regulatory environment and applicable standards for amusement ride operations will come under greater scrutiny in the two weeks set down for later in the year.

No doubt these lessons and more will be further explored as the evidence continues.  At the end of the first two weeks of evidence, it is understood that the inquest hearing is approximately 18 witnesses behind schedule (approximately halfway through its planned evidence for the first two weeks).  It may be longer than anticipated before we see the Coroner's findings. As Counsel Assisting Ken Fleming QC told reporters at the close of the second week:

"Nobody can pre-empt anything.  We cannot, at this point, reach any conclusions because that can only be done at the end of all of the evidence and all of the assessing of that evidence is done."

The inquest is due to resume on October 8 2018.  A further two weeks of hearing is set down for November 12 to November 23 2018.