River of tears

Integrity has no need of rules

Albert Camus 1

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On 25th 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. 218

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. 1922

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. 2326

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. 2730

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. 3133

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. 3437

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. 3842

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. 4350

 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. 5165

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. 6672

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. 7376

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. 7780

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. 8188

Bibliography

1. Albert Camus Quotes [Internet]. BrainyQuote. 2017 [cited 24 June 2017]. Available from: https://www.brainyquote.com/quotes/quotes/a/albertcamu121575.html

2. Clapton E. Eric Clapton – River of Tears HD [Internet]. YouTube. [cited 12 October 2018]. Available from: https://www.youtube.com/watch?v=Jzjb3bdMDYU

  1. Paterson M. Dreamworld Media Statement – Incident Update 26/10/2016 [Internet]. Dreamworld. 2016 [cited 11 October 2018]. Available from: http://journalists.medianet.com.au/DisplayAttachment.aspx?j=868328&s=2&k=9508320

4. Thunder River Rapids Ride [Internet]. Wikipedia. [cited 11 October 2018]. Available from: https://en.wikipedia.org/wiki/Thunder_River_Rapids_Ride

5. Ardent Leisure – Home [Internet]. Ardent Leisure. [cited 11 October 2018]. Available from: https://www.ardentleisure.com/

  1. Dreamworld – Park Info [Internet]. Dreamworld. [cited 11 October 2018]. Available from: https://www.dreamworld.com.au/park-info
  2. Dreamworld: What we know so far about the Thunder Rapids tragedy [Internet]. ABC News. 2016 [cited 11 October 2018]. Available from: http://www.abc.net.au/news/2016-10-28/what-we-know-so-far-about-the-dreamworld-tragedy/7974358
  3. Dreamworld rapids ride: ‘Miracle’ that children survived Queensland’s worst theme park tragedy [Internet]. ABC News. 2016 [cited 11 October 2018]. Available from: http://www.abc.net.au/news/2016-10-26/girls-survived-dreamworld-rapids-ride-accident-which-killed-four/7965068
  4. Why a Qld ambulance officer described Dreamworld victims as having suffered ‘injuries incompatible with life’ [Internet]. News.com.au. 2016 [cited 11 October 2018]. Available from: https://www.news.com.au/national/ambulance-officer-slammed-for-saying-four-dreamworld-dead-suffered-injuries-incompatible-with-life/news-story/8d090b77b4f942237839b488b6567637
  5. Red Cross ‘angels’ offer comfort to anyone affected by Dreamworld tragedy [Internet]. Kidspot – parenting. 2016 [cited 11 October 2018]. Available from: https://www.kidspot.com.au/parenting/real-life/in-the-news/red-cross-angels-offer-comfort-to-anyone-affected-by-dreamworld-tragedy/news-story/a581a845d0f78664b7346b7ffd57f645
  6. Fernando G. Funds flow as deadly Dreamworld ride investigation ‘grows in complexity’ [Internet]. News.com.au. 2016 [cited 11 October 2018]. Available from: https://www.news.com.au/national/victoria/funds-flow-as-deadly-dreamworld-ride-investigation-grows-in-complexity/news-story/c49f4d37cd7b66539486fa16e314ba72
  7. Legal cloud delays public release of Dreamworld deaths report [Internet]. Brisbane Times. 2017 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/dreamworld-death-report-release-delayed-20170930-p4yw75.html

13. Coronial inquest into Dreamworld deaths to start [Internet]. SBS News. [cited 11 October 2018]. Available from: https://www.sbs.com.au/news/coronial-inquest-into-dreamworld-deaths-to-start

  1. Moore T. Dreamworld accident: AWU takes Dreamworld ride staffing concerns to detectives [Internet]. Brisbane Times. 2016 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/dreamworld-accident-awu-takes-dreamworld-ride-staffing-concerns-to-detectives-20161028-gsdhvq.html

18. Safety Auditing Amusement Industry [Internet]. DRA Safety Specialists. [cited 11 October 2018]. Available from: http://www.drasafety.com.au/safety-auditing-for-amusement-industry

19. Craw V. Dreamworld sought to withhold information from Australian Workers’ Union relating to safety and incidents [Internet]. News.com.au – Queensland. 2016 [cited 11 October 2018]. Available from: https://www.news.com.au/national/queensland/dreamworld-sought-to-withhold-information-from-australian-workers-union-relating-to-safety-and-incidents/news-story/4b7eb1c7460257b1952eab14ee0ebeef

20. Australian Workers’ Union and Queensland Treasury; Ardent Leisure Limited (Third Party) [2016] QIC 28 (28 July 2016) [Internet]. Office of the Information Commissioner – Queensland. 2016 [cited 11 October 2018]. Available from: https://www.oic.qld.gov.au/__data/assets/pdf_file/0019/31447/decision-312543-external-review-28-07-16.pdf

  1. Dreamworld failure happened ‘frequently’, inquest hears [Internet]. SBS News. [cited 11 October 2018]. Available from: https://www.sbs.com.au/news/dreamworld-failure-happened-frequently-inquest-hears

22. Reason J. Human error: models and management. BMJ [Internet]. 2000;320(7237):768-770. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/

23. Stone L. Four Dreamworld rafts collided in ‘frightening’ 2001 incident: Inquest [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/four-dreamworld-rafts-collided-in-frightening-2001-incident-inquest-20180628-p4zo8b.html

  1. Sibson E. Dreamworld inquest: Timeline of the key evidence from ride operators and police [Internet]. ABC News. 2018 [cited 11 October 2018]. Available from: http://www.abc.net.au/news/2018-06-25/dreamworld-tragedy-coronial-inquest-timeline/9900552

26. Root cause analysis [Internet]. Wikipedia. [cited 11 October 2018]. Available from: https://en.wikipedia.org/wiki/Root_cause_analysis

27. Jackson E. Dreamworld inquest: First day of investigation into Thunder River Rapids deaths [Internet]. News.com.au – Queensland News. 2018 [cited 11 October 2018]. Available from: https://www.news.com.au/national/queensland/news/dreamworld-inquest-first-day-of-investigation-into-thunder-river-rapids-deaths/news-story/3b350a8e379d7e39212590c6447458fe

  1. Gribbin C. Dreamworld inquest to probe previous breakdowns when hearings resume [Internet]. ABC News. 2018 [cited 11 October 2018]. Available from: http://www.abc.net.au/news/2018-10-08/dreamworld-ride-tragedy-inquest-resumes-heres-what-we-know/10343898

30. Jackson E. Dreamworld worker fired for ‘almost identical’ accident on the Thunder River Rapids ride [Internet]. News.com.au – Queensland News. 2018 [cited 11 October 2018]. Available from: https://www.news.com.au/national/queensland/news/dreamworld-worker-fired-for-almost-identical-accident-on-the-thunder-river-rapids-ride/news-story/4e3b406a18b18f0159099cf010caf9c6

31. Stone L. The Dreamworld tragedy: what we know as the inquest resumes [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/the-dreamworld-tragedy-what-we-know-as-the-inquest-resumes-20181005-p50804.html

  1. Wiring inside fatal Dreamworld ride was a ‘rats nest’, inquest told [Internet]. The Guardian – Australia Edition. 2018 [cited 11 October 2018]. Available from: https://www.theguardian.com/australia-news/2018/jun/28/wiring-inside-fatal-dreamworld-ride-was-a-rats-nest-inquest-told

33. Stone L. Dreamworld ride’s ‘rat’s nest’ wiring was raised with supervisors: Inquest [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/dreamworld-ride-s-rat-s-nest-wiring-was-raised-with-supervisors-inquest-20180629-p4zoi2.html

34. Moore T. Dreamworld electrical staff ‘distracted’ by faults that day: inquest [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/dreamworld-ride-rafts-collided-in-2014-20180622-p4zn2y.html

  1. Family blames Dreamworld for tragedy [Internet]. SBS News. [cited 11 October 2018]. Available from: https://www.sbs.com.au/news/family-blames-dreamworld-for-tragedy

37. Classes of licences [Internet]. WHS Queensland. [cited 11 October 2018]. Available from: https://www.worksafe.qld.gov.au/licensing-and-registrations/electrical-licences/classes-of-licences

38. Dreamworld failure happened ‘frequently’, inquest hears [Internet]. SBS News. [cited 11 October 2018]. Available from: https://www.sbs.com.au/news/dreamworld-failure-happened-frequently-inquest-hears

  1. Adams D. Dreamworld Inquest Hears Ride Failed Twice in Hours Before Fatal Accident [Internet]. Pedestrian. 2018 [cited 11 October 2018]. Available from: https://www.pedestrian.tv/news/dreamworld-inquest-begins-ride-failure/

42. Stone L. Dreamworld tragedy footage played at inquest into four deaths on ride [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/dreamworld-tragedy-footage-played-at-inquest-into-four-deaths-on-ride-20180628-p4zoc2.html

43. Dreamworld inquest: emergency stop button failed to shut down ride [Internet]. The Guardian – Australia Edition. 2018 [cited 11 October 2018]. Available from: https://www.theguardian.com/australia-news/2018/jun/19/dreamworld-inquest-emergency-stop-button-was-not-pushed

  1. Sibson E. Dreamworld deaths could have been prevented by press of a button: inquest [Internet]. ABC News. 2018 [cited 11 October 2018]. Available from: http://www.abc.net.au/news/2018-06-18/dreamworld-fatal-accident-ride-had-broken-down-inquest-told/9871898

50. Stone L. Emergency drills not practised at Dreamworld, inquest hears [Internet]. Brisbane Times. 2018 [cited 11 October 2018]. Available from: https://www.brisbanetimes.com.au/national/queensland/emergency-drills-not-practised-at-dreamworld-inquest-hears-20180621-p4zmwv.html

51. Find an inspector – Certified Inspectors [Internet]. AICIP Australian Institute for the Certification of Inspection Personnel. [cited 11 October 2018]. Available from: http://aicip.org.au/inspector-find/?sname=langdon&qual=ISI&state&reg

  1. AICIP – Examinations, Information for applicants [Internet]. Australian Institute for the Certification of Inspection Personnel. [cited 11 October 2018]. Available from: http://aicip.org.au/examinations/

58. Pressure vessels – Air receivers [Internet]. WorkSafe Victoria. [cited 11 October 2018]. Available from: http://squiz.worksafe.vic.gov.au/__data/assets/pdf_file/0020/210782/ISBN-Pressure-vessels-air-receivers-2009-03.pdf

  1. Tragic Dreamworld incident raises safety concerns [Internet]. Asset Management Engineers. [cited 11 October 2018]. Available from: https://asseteng.com.au/tragic-dreamworld-incident-has-raised-many-safety-standard-concerns/

65. AS/NZS 3788:2006 (R2017) Pressure equipment – In-service inspection Standards Australia [Internet]. Standards Australia. 2006 [cited 11 October 2018]. Available from: https://infostore.saiglobal.com/en-au/Standards/AS-NZS-3788-2006-R2017–116832_SAIG_AS_AS_244324/

66. Dreamworld chief resigns after damning evidence at inquest [Internet]. The Guardian – Australia Edition. 2018 [cited 11 October 2018]. Available from: https://www.theguardian.com/australia-news/2018/jul/01/dreamworld-chief-resigns-after-damning-evidence-at-inquest

67. Ardent Leisure – Board Charter [Internet]. Ardent Leisure. 2016 [cited 11 October 2018]. Available from: https://www.ardentleisure.com/wp-content/uploads/2016/06/Board-Charter-160623.pdf

  1. Holmberg S, Schmitt M. The Milton Friedman Doctrine Is Wrong. Here’s How to Rethink the Corporation. [Internet]. Evonomics. [cited 11 October 2018]. Available from: http://evonomics.com/milton-friedman-doctrine-wrong-heres-rethink-corporation/

69. Model Work Health and Safety Act [Internet]. Safe Work Australia. 2016 [cited 12 October 2018]. Available from: https://www.safeworkaustralia.gov.au/doc/model-work-health-and-safety-act

  1. Durkin P. Dreamworld accident: How to avoid a PR disaster [Internet]. Australian Financial Review. 2016 [cited 12 October 2018]. Available from: https://www.afr.com/leadership/war-games-how-to-stop-a-crisis-turning-into-full-blown-pr-disaster-20161028-gsd3rr

72. Farrell P. Dreamworld boss Deborah Thomas regrets company’s response to fatal ride [Internet]. The Guardian – Australia Edition. 2016 [cited 12 October 2018]. Available from: https://www.theguardian.com/australia-news/2016/nov/02/dreamworld-boss-deborah-thomas-regrets-companys-response-to-fatal-ride

73. Pierce J. Dreamworld’s botched response to tragedy [Internet]. The Courier Mail. 2016 [cited 12 October 2018]. Available from: https://www.couriermail.com.au/news/queensland/dreamworlds-botched-response-to-tragedy/news-story/07a2725554726e8a0911a1b2fae27764

  1. Reynolds E. Dreamworld’s grim reopening cancelled at last minute [Internet]. News.com.au – Queensland News. 2016 [cited 12 October 2018]. Available from: https://www.news.com.au/national/queensland/news/dreamworlds-macabre-reopening-in-doubt/news-2c0b76e4#itm=newscomau%7Cnews%7Cright-now-in-

76. Pascoe M. Ardent has failed at every step over the Dreamworld tragedy – except deciding to reopen [Internet]. The Sydney Morning Herald. 2016 [cited 12 October 2018]. Available from: https://www.smh.com.au/business/ardent-has-failed-at-every-step-over-the-dreamworld-tragedy–except-deciding-to-reopen-20161027-gscgat.html

77. Pash C. The CEO, her bonus and the Dreamworld tragedy [Internet]. Business Insider Australia. 2016 [cited 12 October 2018]. Available from: https://www.businessinsider.com.au/the-ceo-her-bonus-and-the-dreamworld-tragedy-2016-10

78. Ardent chairman Neil Balnaves departs [Internet]. Property Observer. 2016 [cited 12 October 2018]. Available from: https://www.propertyobserver.com.au/forward-planning/investment-strategy/property-news-and-insights/58031-ardent-chairman-neil-balnaves-departs.html

  1. Doherty B. Deborah Thomas set to receive $840,000 in bonuses despite Dreamworld deaths [Internet]. The Guardian – Australia Edition. 2016 [cited 12 October 2018]. Available from: https://www.theguardian.com/australia-news/2016/oct/27/deborah-thomas-set-to-receive-840000-in-bonuses-despite-dreamworld-deaths

80. Daniel S, MacMillan J. Dreamworld under fire for failing to contact victims’ families directly, CEO to donate bonus [Internet]. ABC News. 2016 [cited 12 October 2018]. Available from: http://www.abc.net.au/news/2016-10-27/dreamworlds-shareholders-ask-parent-company-to-support-victims/7970104

81. Craw V. Dreamworld sought to withhold information from Australian Workers’ Union relating to safety and incidents [Internet]. News.com.au. 2016 [cited 12 October 2018]. Available from: https://www.news.com.au/national/queensland/dreamworld-sought-to-withhold-information-from-australian-workers-union-relating-to-safety-and-incidents/news-story/4b7eb1c7460257b1952eab14ee0ebeef

  1. Dreamworld deaths: police say no park staff should be prosecuted [Internet]. The Guardian – Australia Edition. 2017 [cited 12 October 2018]. Available from: https://www.theguardian.com/australia-news/2017/oct/21/dreamworld-deaths-police-say-no-park-staff-should-be-prosecuted

88. Eric Clapton [Internet]. Wikipedia. [cited 12 October 2018]. Available from: https://en.wikipedia.org/wiki/Eric_Clapton

Bernard Corden

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4 Replies to “River of tears”

  1. Amazing when all these disasters unravel just how much the power of the powerful and the weakness of the weak plays out across the capability of corporate bank accounts and vested interests that seek to maintain empire via the payment of shekels to make problems disappear. The culture of corporationalism is predictably on show as key players use their definitions of safety in objects to dissolve collective responsibility for incompetence and underlying cultures of greed. Then when it all settles down they can re invoke zero and employ consultant Peter Pan from Neverland to regurgitate old promises so the narrative continues.

  2. Only real mention of culture, p.270 Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety. Feeble.
    Culture is what all this stuff breeds in.

  3. Given the condemnation of Ardent Leisure I am still somewhat intrigued why the coroner did not return a finding of unlawful killing to a criminal standard and merely referred the issue to OIR to consider prosecution.

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