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Court has convened. @Jdude95 and I will be covering updates. All counsel have made their appearances and the court has invited the family members to make a statement.

We are adjourned for the day

The findings are being uploaded to the coroners court website NOW

The systems in place at Dreamworld were frighteningly unsophisticated. Records in regards to the ride were sparse. This poor record keeping continued through its 30 years or commission. The records that did exist, lacked information. Maintenance records and training were severely lacking. Incident exposed the widespread lack of record keeping over the past 30 years. It is significant that the GM of engineering had no prior knowledge of any incidents that occurred. Shoddy record keeping was a significant reason for this incident.

I'll be at the findings as with the actual inquest. I'll be keeping track of things and live(ish) posting on here.

ABC News is mixing narratives:

Ride controls were complex, confusing and lacked clear labelling. The safety of the ride was all undertaken at a staff level, no automated safety systems. The south pump tripped multiple times earlier that day. Pump was reset and brought back into operation as it wasn’t investigated further. There was confusion as to how the breakdown policy should apply. Confusion in regards to how many breakdowns would need to occur before a problem is investigated and escalated. Maintenance staff weren’t trained that there were any risks or failures with the ride. There was a significant breakdown in the procedure prior to the incident. Coroner can’t understand why actions weren’t taken earlier in the day as the faults were known and apparent. Training times was dependant on complexity of the ride but seemed inadequate. All training was word of mouth that would be passed from operator to operator. There was a lack of proper training for new ride operators. There was nothing that specified what an emergency was in terms of when to use emergency stop buttons. There were no emergency drills undertaken at the park either. Had this had been done, it might have reduced the stress and improved the response.

Total failure by everybody at Dreamworld to identify the hazards on TRRR. Safety systems rudimentary at best. departments operated in silos record keeping was ad-hoc. safety systems were frighteningly unsophisticated. ”it was simply a matter of time” Maintenance and inspection was “reactionary” “Widespread lack of record keeping and document management” It is significant that the GM of engineering had no knowledge of the previous raft crashes “Shoddy recordkeeping” was a significant contributor to this accident.

Just confirmed via 9 News Live Stream on FB Memorial Garden will built at Dreamworld Construction timeframe for the garden will be finalised in the coming months

Operating manuals were drafted by ops department without input from maintenance or safety departments. 5 breakdowns of TRRR in the prior 7 days due to the failure of the south pump. Ride was reset without investigation. no specific training provided to staff on how to manage a ride with multiple failures. “Regardless of training provided, it would never have been sufficient to overcome the design and engineering faults...”

Guests in unloading and loading rafts gave evidence that was contradictory to other statements provided. There is no way to tell if and when and how many times the lead operator his the e-stop button on his control panel. The conveyor takes 11 seconds to perform a slow stop which is seen happening after the rafts have already collided. The unload operator didn’t press the e-stop button near her as the lead operator was still in control of his panel and she was not told that the e-stop near here stopped the conveyor. There are 38 checks undertaken by the ride operators which is excessive. There was no training in regards to what checks and tasks took priority. Unload operator was told in a memo to not press unlabelled e-stop at unload platform unless lead operator was incapacitated.

It was only 20 seconds from when the water began to drop until raft 6 became stranded Approximately 50 seconds after when raft 5 collided. It is not clear when the operator initiated the shutdown from CCTV, or if in fact he did. Testing found no issue with the controls. CCTV shows conveyor began a slow stop 11 seconds after the collision. It is clear that the 38 signals and checks to be undertaken by the ride operators were excessive.

Failure of south pump which caused a drop in water level. Conveyor continued to operate. Ride should not be operated with one pump as per process. There were no alarms or warnings to suggest the water level has changed. There was no automated safety system in place with no audible or visual alert in regards to the water level. It is unknown why the gap between the end of the conveyor and the rails in the troughs was so large. A raft valleyed on the support rails through the station. The spacing of the slats allowed the doomed raft to get pinched and dragged into the conveyor mechanism. Proper record keeping and maintenance would have identified such issues and rectified them. It is unknown why a simple water level sensor was never implemented. It would have been inexpensive and prevented the incident from occurring. The emergency stop buttons were inadequate. Maintenance suggested in early 2016 that a simple one button shut down process should be implemented but it was never put in place. This is contrary to Australian Standards.

The coroner is now reading the technical circumstances of the accident. failure of the south pump, drop in water level, conveyor belt not stopped. Dreamworld was aware the pump failure was an issue to ride operation, but no audible alarm to indicate the pump failure. The gap between the rails and the conveyor created a significant “nip point” large enough to grab raft 5. TRRR was “severely lacking in automation” A basic automated detection system for the water level would have been inexpensive and may have prevented the accident. a one button shutdown was recommended, and was unfortunately not undertaken. it is unclear why this action was never taken.

There is no evidence that Dreamworld ever undertook an engineering risk assessment in the 30 years of the rides operation. A great deal of reliance was placed on Bob Tans expertise. He was not a qualified professional in Queensland and Dreamworld should have been aware of that. Bob Tan being in charge of engineering and maintenance was a clear danger. It is surprising that Bob Tan never recognised the risks posed by TRR. Dreamworld placed heavy reliance on Ride Operators to identify risks. Whilst this information can be valuable. It shouldn’t be the sole source of feedback regarding potential risks. There was no risk reporting in place. There were no safety audits undertaken in regards to the human component of the rides. Departments didn’t talk to eachother and share information across departments. DW Management maintained that they were never aware of such issues as they were never raised.

Resounding message From park management: “as such risks and hazards had not been identified, they were unaware and unable to take action”

“While there is always an inherent risk of safety, it is expected that all action will be taken by the owner” ”dreamworld never co ducted a risk assessment for TRRR In it’s 30 years of operation” ”dreamworld places much reliance on Bob Tan’s expertise” ”Bob was not a qualified engineer, which should have been known by the park.” “his involvement with many projects at Dreamworld was dangerous.“ There can be no suggestion the ride operators did not conduct themselves in accordance with their training Staff cannot be the sole means of identifying risks. dreamworlds safety department was not set up effectively. risk management at the park was “immature”

And to think at the end of the day, a water level sensor - that, lets be honest, would seem like a stock standard instrument on ANY ride incorporating water - was all that was required to save 4 lives. In 30 years of operation, and probably 1000s of sets of eyes, no one thought that to be worth the pittance (in relative terms) It would have cost.

Excellent break down provided. Very well done. The whole report is like a textbook of how not to maintain safe operational control of a theme park. I got to about page 180 of the report before i needed a break. Its hard reading, frustrating, makes you angry, makes you mad. Its really all over the place with the complete almost cascading like failure through just about all levels of management. Its literally like a bunch of these people got together and collectively decided nobody told them how to do their jobs, so that absolves them of any responsibility. We will just pretend theres nothing to address. Thats before you get to the actual findings on the ride which basically reduce it down to a few things; Water level. Lack of automated monitoring of water level tied into a safety system that would halt the ride when water level drops below a safe level. Lack of a single dedicated estop that halts all operation and a complex stop proceedure. Gap between conveyor and axle to the supporting rails in the trough was an issue and should have been picked up by any competent engineer. Gaps between slats on conveyor. Staff training, competency and understanding of ride operation, largely due to inadequate operational proceedures all staff should base their training upon. A number of upgrades were proposed that would improve operational safety. It was noted in particular that the lack of warning or automated stoppage due to water level dropping after pump failure was a direct contributor to the deaths. The danger was highlighted with previous incidents, including the last incident that lead to an operators dismissal. At no stage were these issues improved upon or addressed to prevent similar breakdown in operation of the ride both at a mechanical and operations (staff) level. On top of that, these failings were not shared with other staff and a number of managers had no knowledge of previous incidents. There was really, really disturbing insight into the lack of documentation, error reporting and compliance that existed in most departments which was highlighted by a number of independant auditors, even when not tasked with actual ride investigation. Poor implementation of recommendations and lack of improvement were noted, though big improvements had been made in the lead up to the accident. Basically, the short short version of what happened on the day is stuff went wrong. A Combination of existing design, uncontrolled modification, faults during operation and operation of the ride on the day contributed to the deaths. There was enough opportunity to address a number of issues which would have reduced risk or completely prevented the deaths from occuring. None of these actions were taken by ardent or park management and directly contributed to the deaths.

There is only ever one inquest by the coroner. Civil lawsuits will follow, plus maybe any industrial action like jail time and fines. That all depends on if OIR (office industrial relations) thinks they have enough evidence to launch prosecution.

ENGINEERING & TECHNICAL (E&T) DEPARTMENT RIDE MAINTENANCE AT DREAMWORLD TRRR YEARLY PREVENTATIVE MAINTENANCE INSPECTION RECENT BREAKDOWNS OF THE TRRR

Just saw the report 9NEWS in Sydney. I honestly never knew Richard Simmons ran DW.

No, im pretty sure these are the cars from the broadbeach monorail we were thinking would just be scrapped. Looks like someone kept/purchased them.

Thanks guys!

Findings have been handed down.

Regular ongoing and adequate auditing to be undertaken by the regulator is essential in the industry. Significant changes at Dreamworld since the incident including inspections, emergency drills, training and safety management systems. village roadshow SMS cited also. it is without question more direct oversight and auditing of the industry is necessary. The coroner has now turned to the findings: He has named the deceased to formally identify them. At 2:05, the deceased collided with an empty raft at the unload, causing their raft to lift and be pulled into the conveyor. cause of death was sever internal and external injuries as a result of multiple compressive impacts. Recommendations: change regulatory framework for inspection and licensing. require amusement owners use effective safety management system owner must comply with updated Aus standards. annual risk assessments must be completed by competent persons. operators must be assessed as competent regulator must conduct audits on a regular basis by suitably qualified and trained inspectors. major parks in QLD required to implement effective procedures and processes to ensure safe operation aligned with the new regulations and inspection requirements. new code of practice to establish a minimum standard must be developed. Directions: the coroner has directed the matter to be referred to the office of industrial relations for consideration of whether there is a case for prosecution of Ardent for breaches of WH&S Act. Dreamworld engineer has also been referred to the engineering authority. The inquest is closed.

Suggested updates were never taken on board. Things such as positioning sensors or conveyor speed regulators. Primary source of ensuring raft spacing was undertaken by load and unload staff. This was not sufficient to ensure rafts did not collide or flip. Should have been addressed due to rafts colliding and flipping in 2 previous incidents in 2014 and 2001. The risk of rafts colliding was known to Dreamworld. Investigators were unable to replicate the outcome of the 2016 but are confident that it was still a very high risk. It became apparently during the inquest that best practice was not followed on the ride. These standards are the minimum requirement.

“Primary safety controls were administrative controls reliant on ride operators to maintain safe spacing” “Dreamworld never engaged a person capable of mitigating these risks”

9News confirmed on Twitter the hard copy of the 300 page report will be made publicly today

They are. I'm planning to publish them in full here once available.

Matt Low began with a statement on behalf of his family. Including a statement from their kid. Thanked the coroners team. Kim Dorsett has provided a statement about her family. Cindy Low’s brother has made a statement. Disappointed with how Dreamworld has handled the incident and how the media and public have handled the incident. Lawyer for Shane Goodchild has made a statement on his behalf. Gave thanks to the coronial team. Lawyer for Low Family is providing a statement on behalf of The mother of Cindy Low Proceedings have begun

TPSN also posted these Sky Flyer is gone Part of the path has been fenced off and the hut has been removed And they have painted one of the buildings around Vortex, I really hope it’s hidden by theming or trees, because I doubt there are many box buildings on Atlantis

@Jdude95, earlier today (Sunday), I created a topic separate for the findings itself here. Appreciate if your live blog would be in that topic as I'm sure the findings will generate plenty of discussion.

Looks like we will be getting that theming

Maybe its the weather?

You haven't been around any apartment buildings in Sydney of late?

So this is the final inquest is it?