River of tears

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 crush 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 immediate environs were declared a crime scene pending further investigations via the Queensland Police Service, Work Health and Safety Queensland and an extensive coronial inquiry. During the immediate aftermath disturbing allegations emerged regarding operation and maintenance of equipment, which forced the organisation to defend its safety performance and corporate reputation. No significant nonconformance issues were identified during a recent mandatory safety inspection and at the time of the incident the theme park was allegedly compliant with statutory safety certification requirements. Dreamworld reiterated that the safety of guests, staff and wildlife is a core value of its business and…..Rides and slides are checked daily by its experienced team before the theme park opens. This is reinforced via a statement from the theme park’s independent auditor who claimed…..Annual audits have resulted in continuous improvement in the management of safety. ³²²⁷^–³²⁴²

However, evidence from heavily redacted documents obtained by the Australian Workers’ Union under freedom of information and media reports during the subsequent coronial inquiry suggest otherwise. The Thunder River Rapids Ride began operating during the 1980s and was modified extensively during its lifecycle. It was considered by many attendants as one of the more challenging and complex rides to manage and a catalogue of mechanical faults and operator errors emerged over recent years. ³²⁴³^–³²⁴⁶

During a trial run without passengers back in 2001 several empty rafts collided near the unloading bay. A junior assistant who was operating the ride that day provided vague accounts 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. ³²⁴⁷^–³²⁵⁰

In early October 2004, a person fell into the water near the alighting dock although no serious injuries were reported. The following year in August 2005 three vessels were involved in a significant collision when the ride operator became distracted. More recently in 2014, a pump was inadvertently shut down and water levels on the ride quickly subsided. A raft laden with several passengers became stranded on the conveyor and was struck by another occupied vessel. Following an internal investigation or witch hunt, a ride operator was dismissed although no significant asset damage or serious injuries were sustained. ³²⁵¹^–³²⁵⁴

The ride’s 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 available 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 the substandard wiring. ³²⁵⁵^–³²⁵⁷

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 water levels. Pump faults, inspections and resetting were normally assigned to an electrical mechanic or licensed electrician in the maintenance team. ³²⁵⁸^–³²⁶¹

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. It allowed water pumps to malfunction three times before the ride was shut down by the operator, which breached prescribed requirements within the Dreamworld operating manual. ³²⁶²^–³²⁶⁶

The Thunder River Rapids Ride was equipped with two emergency stop devices. One was located near the console and gradually de-energised the ride after it was activated. Another button near the unloading dock immobilised the entire drive almost instantaneously. Evidence from the senior operator and a junior attendant who were on duty that day confirmed they were unaware of the variable mechanisms and response times. The emergency button near the unloading jetty was never activated as the tragic events unfolded and its operation may have limited the devastating consequences. Supplementary engineering controls including water level sensors and reliable limit switches could have provided additional layers of protection to reduce the risk. Several operators had not received emergency response training or participated in simulated evacuation drills. ³²⁶⁷^–³²⁷⁴

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 was provided that registration of the entire amusement ride sufficed and registering individual critical components was considered unnecessary duplication. This raises serious concerns about 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. ³²⁷⁵^–³²⁸⁹

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 incongruous with the object of safety legislation. This was reflected immediately following the tragedy via deplorable crisis management protocols and woeful behaviour from a didactic chairman and an embattled chief executive officer in a nefarious attempt to preserve their performance bonuses. ³²⁹⁰^–³²⁹⁶

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 it 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. Ardent Leisure held its annual general meeting in Sydney several days after the tragedy and its socially autistic chairman decided to step 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 her $843,000 performance incentive scheme, which included substantial cash payments over the next four years. Claims that Dreamworld and the police had contacted all of the families were disputed by several close relatives during a press conference following the meeting. ³²⁹⁷^–³³⁰⁴

The ignominy continued as the organisation attempted to block the release of sensitive documents under freedom of information. The theme park 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 inquiry 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. 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 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. ³³⁰⁵^–³³¹²

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