River of tears

Integrity has no need of rules

Albert Camus ¹

On 25^th October 2016 a tragic incident on the Thunder River Rapids Ride at the Ardent Leisure Dreamworld amusement park near Queensland’s Gold Coast, claimed the lives of four people. A circular raft containing six passengers collided with an empty vessel and flipped upwards and capsized as it approached the disembarking dock. Following the impact, four adult occupants suffered fatal injuries and two adolescents miraculously survived the horrific ordeal. Emergency services including paramedics rushed to the scene and the entire theme park was eventually evacuated and closed. Families, close friends and witnesses were left distraught and several noble Red Cross volunteers provided assistance and counselling. The ride and its immediate environs were declared a crime scene pending further investigations via the police and other regulatory authorities and an extensive coronial inquest followed. During the aftermath disturbing allegations emerged regarding operation and maintenance of equipment, which forced the organisation to defend its safety performance and corporate reputation. No major non-conformance issues were identified during a recent mandatory safety inspection and at the time of the incident the theme park was allegedly compliant with statutory registration and certification requirements. Dreamworld reiterated that the safety of guests, staff and wildlife was a core value of its business and…..Rides and slides are checked daily by its experienced team before the theme park opens. This was reinforced via a statement from the theme park’s independent auditor who claimed its annual audits demonstrated a continuous improvement in the management of safety. ^2–18

However, evidence from heavily redacted documents obtained by the Australian Workers’ Union under freedom of information and media reports during the subsequent coronial inquest suggest otherwise. The Thunder River Rapids Ride began operating in the 1980s and was modified extensively throughout its lifecycle. It was considered by many of its attendants as one of the more challenging and complex rides to manage at the theme park and a catalogue of electrical, mechanical faults and operator errors emerged over recent years. ^19–22

During a trial run without passengers back in 2001 several empty rafts collided near the unloading bay. A junior assistant operating the ride that day provided vague recollections of capsized vessels and described the event as pretty frightening. An internal investigation alleged the senior attendant became distracted, reacted impulsively and operator error was established as the root cause, which was more than likely the consequence. ^23–26

In early October 2004, a person fell into the water near the unloading dock and recovered without suffering serious injuries. The following year in August 2005 three vessels were involved in a significant collision when the Thunder River Rapids ride operator became distracted. More recently in 2014, a pump was inadvertently shut down and ride water levels quickly subsided. A raft laden with several passengers became stranded and was struck by another occupied vessel. Following an internal investigation or brutal witch hunt, an operator was dismissed although no significant asset damage or serious injuries were sustained during the incident. ^27–30

The operating console was unnecessarily complicated and cluttered with a bewildering network of light emitting diodes, which were supplemented with green and red indicator buttons. There was no electrical schematic to assist electricians with tracking faults or troubleshooting. At the end of each day operators used a conventional routine or sequence to ensure the ride was correctly shutdown. Beneath the console electrical components and circuitry were described as a rat’s nest and concerns were repeatedly raised with senior management and site supervisors regarding substandard wiring. ^31–33

On a busy day, maintenance crews could attend up to 20 malfunctioning rides, which were classified as code six events to allay public fears and prevent unnecessary panic. The rapids ride was renowned for its unpredictability and regular breakdowns, which were usually attributed to its two temperamental pumps that sustained the ride’s water levels. Pump inspections, faults and resetting were usually assigned to an electrical mechanic or licensed electrician in the maintenance team. ^34–37

Several hours before the tragic events unfolded, a water pump recorded an earthing fault and had already tripped twice earlier in the day. The theme park’s engineering supervisor confirmed the ride should have been shut down following the second failure. However, the defective pump was merely reset and it failed for a third time with devastating consequences. Ride operators, attendants and many other assistants were regularly indoctrinated about pump failures via a verbal axiom. This allowed water pumps to malfunction three times before the ride was shut down by the operator, which was incongruous with prescribed requirements in its operating manual. ^38–42

The Thunder River Rapids Ride was equipped with two emergency stop devices. One button located near the console slowed the ride gradually until it stopped and another device near the unloading dock immobilised its mechanism almost instantaneously. Evidence from a senior operator and junior attendant who were on duty that day confirmed they were unaware of the variable emergency stop response times. The button near the unloading jetty was never pressed as the tragic events unfolded and its activation may have limited the devastating consequences. Supplementary engineering controls including additional water level sensors and reliable limit switches could have provided extra layers of protection to reduce the risk. Several operators had not received emergency response training or participated in simulated evacuation drills. ^43–50

 In November 2012 a registered in-service inspector with the Australian Institute for the Certification of Inspection Personnel ascertained many pressure vessels on the theme park rides were noncompliant and classified as unfit for service. This involved numerous compressors and air receivers, which required statutory registration and regular inspections. Its engineering department was unable to provide evidence of a quality management system covering the routine inspection and service of critical components. The issue was eventually referred to the regulatory authority and a ruling confirmed registration of the entire amusement ride sufficed and duplication of individual critical components was considered superfluous. This creates a significant anomaly with the validity of its annual audits and the national audit tool specification criteria. Dreamworld allegedly demonstrated continual improvement in the management of safety although a major non-conformance was evident covering a breach of legislative requirements for the inspection and testing of pressure vessels. ^51–65

Despite the corporate sincerity and its outpouring of confected grief the Ardent board charter depicts organisational values with an obstinate deification of the mercenary Friedman doctrine. Its primary role is…..To promote the long term health and pro$perity of the group and to build $u$tainable value for it$ inve$tor$, which is inconsistent with the object of safety legislation. This was reflected via deplorable crisis management protocols and woeful behaviour from a didactic chairman and the embattled celebrity chief executive officer in a nefarious attempt to protect reputations and secure performance bonuses. ^66–72

Dreamworld planned to reopen the theme park before the blood had been washed from the surrounding concrete. It was only postponed because the site was classified as a crime scene under a warrant from the Queensland Police Service. An early opening may have compromised the forensic investigation and the company was forced to issue an embarrassing apology during the media maelstrom. It decided to wait until after the funerals and completion of the complex investigation. ^73–76

Ardent Leisure held its annual general meeting in Sydney several days after the tragedy and its socially autistic chairman stepped down amidst the crisis. The chief executive officer donated a recent cash bonus of almost $170,000 to the Red Cross for the support of bereaving dependents. However, the board approved a $843,000 performance incentive scheme, which included substantial cash payments over several years to quench a ravenous maw. Claims that police and Dreamworld had contacted all of the families were disputed by close relatives during a press conference following the meeting. ^77–80

The ignominy escalated as the organisation attempted to block the release of sensitive documents under freedom of information. The site remained closed for almost seven weeks and the Queensland Police Service in its report to the coroner recommended no criminal charges be brought against Dreamworld theme park employees. A coronial inquest commenced at Southport courthouse in June 2018 and Deborah Thomas, the former chief executive officer with Ardent Leisure, received almost $3000 per day to attend the inquest. Soon after the hearing opened, the Dreamworld chief executive officer resigned and has since been rewarded via a lucrative sinecure with the Gold Coast Tourism Corporation at Destination Gold Coast. The carousel of culpability with its predictable retrospective judgement of convenience continues spinning like a roulette wheel amidst a corporate kleptocracy, which is proudly endorsed by a conspiratorial elective dictatorship. Meanwhile, the grieving dependents are left chasing smoke to rebuild their shattered lives and the haunting refrain from Eric Patrick Clapton lingers…Oh, how long must this go on? Drowning in a river, drowning in a river of tears. ^81–88

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