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Thunder River Rapids Incident Coronial Inquest

591 posts in this topic

Also, we are talking about panicked operators here.  We haven't yet ascertained at which point they even became panicked as far as I have read.  Was the dropping of the water level (when it was even noticed) enough to create panic?  Probably not, given it had already happened a few times that day.  Was a raft approaching another raft near the conveyor even a cause for concern much less panic?  From what I'm reading we haven't even established that yet - all the more so when you consider that the police tried this a number of times and couldn't recreate the problem.

It's well and good to talk about E-stop buttons and how effective they are, but what if we eventually establish that none of the staff (even with a full training package) could foresee that one raft coming into contact with another was going to cause a roll-over until said roll-over began, by which time even a two-second e-stop would have been too late?

By that stage it wouldn't matter if the first aid kit was missing band-aids or "incomplete" and it wouldn't have mattered if the staff weren't first aid ninjas.

Edited by webslave
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24 minutes ago, AlexB said:

To tell this father that in his efforts to help, he caused that childs death is disgusting.

Of course nobody on scene told the father he just killed his child.  (and no it wasn't a drowning)

24 minutes ago, AlexB said:

You can't kill someone if you perform CPR on them incorrectly - because without your intervention they will certainly die.

For the record Alex I'm not telling people to not perform CPR because you might kill them.  (All I said was you can kill them if done incorrectly)

You're missing the point.  DW have staff that are fully trained to preform CPR, but you want somebody who has never performed it before to preform it on a child inside a pressure cooker for the first time. 

nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn.JPG.7cf72c06ea22eaa4d0a44ed2409f19d7.JPG

As i said the ride operator who has now shut down is not the person you want performing CPR.

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21 minutes ago, webslave said:

Also, we are talking about panicked operators here.  We haven't yet ascertained at which point they even became panicked as far as I have read.  Was the dropping of the water level (when it was even noticed) enough to create panic?  Probably not, given it had already happened a few times that day.  Was a raft approaching another raft near the conveyor even a cause for concern much less panic?  From what I'm reading we haven't even established that yet - all the more so when you consider that the police tried this a number of times and couldn't recreate the problem.

It's well and good to talk about E-stop buttons and how effective they are, but what if we eventually establish that none of the staff (even with a full training package) could foresee that one raft coming into contact with another was going to cause a roll-over until said roll-over began, by which time even a two-second e-stop would have been too late?

By that stage it wouldn't matter if the first aid kit was missing band-aids or "incomplete" and it wouldn't have mattered if the staff weren't first aid ninjas.

^This is abso-flogging-lutely bang on.

Couldn't have said it better.

5 minutes ago, Skeeta said:

Of course nobody on scene told the father he just killed his child.  (and no it wasn't a drowning)

For the record Alex I'm not telling people to not perform CPR because you might kill them.  (All I said was you can kill them if done incorrectly)

You're missing the point.  DW have staff that are fully trained to preform CPR, but you want somebody who has never performed it before to preform it on a child inside a pressure cooker for the first time. 

nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn.JPG.7cf72c06ea22eaa4d0a44ed2409f19d7.JPG

As i said the ride operator who has now shut down is not the person you want performing CPR.

 

 

So how do you come to the determination that he was responsible for the death of his child, because he performed CPR inappropriately? Was there a coroner's report that stated this? Is there any shred of evidence you can point to online that verifies this?

Yes, you said you can kill if done incorrectly - and my counter point is that you can't kill someone who is already dead.

It is statements like yours, that scare people into some misconception that they might hurt the casualty if they do something wrong, and humans being humans, the natural response to that is 'not to to anything'. Which is how people die. Idle hands standing by watching someone who needs help, but not doing anything to help them - THAT is how people die. So stop perpetuating a statement that serves only to scare more people away from rendering help to someone in need.

If i'm unconscious and not breathing, I don't GAF if you break my ribs, puncture my lungs and perforate my stomach (all possible injuries sustained from vigorous CPR), the fact will be that I am alive, and regardless of whether i'm hospitalised, suffer through surgeries, have to carry a piss-bag with me everywhere I go for the rest of my life, these are all more desirable than the alternative of death...

You're missing the point. For a trained responder located near the front entrance to get to say... vintage cars, how long do you think it would take them? So let's assume someone is knocked down and run over by the car, or perhaps the engine explodes and knocks someone out... You've got 10 minutes until they're clinically brain dead, but damage occurs from 3 minutes. For every minute, survivability reduces by 10%. If there is nobody else there who is trained, should we all stand around and wait for the nurse to run through the park (which, due to Thunder river's closure, means a stupid roundabout way up stairs and down ramps)???

Not to mention first responders don't generally run in these situations either... so how long would it take you to reach vintage cars from the main gate at a brisk walk, assuming that you are not impeded by train or guest?

Provided it is safe to do so (Danger being the first step in DRSABCD) if the person is not responsive, and not breathing, doing ANYTHING to help is better than nothing...

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44 minutes ago, webslave said:

Also, we are talking about panicked operators here.  We haven't yet ascertained at which point they even became panicked as far as I have read.  Was the dropping of the water level (when it was even noticed) enough to create panic?  Probably not, given it had already happened a few times that day.  Was a raft approaching another raft near the conveyor even a cause for concern much less panic?  From what I'm reading we haven't even established that yet - all the more so when you consider that the police tried this a number of times and couldn't recreate the problem.

I would probably just think it would just push the raft, but would probably slow the lift speed just in case.

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Well according to the report today, the senior Ride op said he noticed the drop in water levels so pressed the slow stop button prior to the incident to stop the conveyor,  but nothing happened. He went and unloaded the next group, still nothing had happened, so he went and pressed it more times.. that was when the second raft continued to move down the conveyor 

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@AlexB @AlexB @AlexB  breath. 

You're asking stupid questions that you already know the answer.   A child dies there's going to be a coroner's report.  Have I read the report? No.  Have I seen the report? No.  I was told by an officer after the investigation concluded. 

 

53 minutes ago, AlexB said:

It is statements like yours, that scare people into some misconception that they might hurt the casualty
 

 

Statements like mine are in relation to this topic and not to joe blow walking down the street.  You', my friend, are dissecting my thoughts on how a theme park First Aid should run and turning it into how Joe would/should react in the street.

Just for you Alex.  SKEET SAY "IF YOU SEE JOE OR HIS SON REQUIRING FIRST AID YOU SHOULD RENDER ASSISTANCE".

We need to move on -

1 hour ago, AlexB said:

You're missing the point. For a trained responder located near the front entrance to get to say... vintage cars, how long do you think it would take them? So let's assume someone is knocked down and run over by the car, or perhaps the engine explodes and knocks someone out... You've got 10 minutes until they're clinically brain dead, but damage occurs from 3 minutes. For every minute, survivability reduces by 10%. If there is nobody else there who is trained, should we all stand around and wait for the nurse to run through the park (which, due to Thunder river's closure, means a stupid roundabout way up stairs and down ramps)???

Not to mention first responders don't generally run in these situations either... so how long would it take you to reach vintage cars from the main gate at a brisk walk, assuming that you are not impeded by train or guest?

Provided it is safe to do so (Danger being the first step in DRSABCD) if the person is not responsive, and not breathing, doing ANYTHING to help is better than nothing...

1

If it turns out DW don't have enough people to respond to a medical emergency to offer First Aid in the correct time frame, don't give this responsibility to a ride operator. 

Next time you check what jobs are going at DW and you see nurses wanted, check out what experience is required.  Heads up, it's not a one-day first aid course.  If one nurse/first responder isn't enough to respond in an emergency than DW need to hire 2 and if 2 isn't enough DW needs to hire 3.

Instead of the operator doing a one-day first aid the operator can spend they the day doing the emergency shut down procedures and you wouldn't even need the first responders.

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Well looks like DW are trying to throw the ride op under the bus by insinuating it’s his fault he didn’t get to the second E-Stop in time. 

What everyone seems to be missing in this is, except for people here is where that button is located. Not at the unload area, but at the top of the lift. Which make DW look better that they had the system in place and incompetent ride op didn’t press. With 2 people trying to run a ride like that, getting to that button Is argue can’t happen, between loading and unloading and watching ride conditions. Walking over to press that button and have the conveyer shut down would take about as much as the 8sec button on the control panel. Even if they were running to it, which I would guess wouldn’t be easy with all that water the catwalk would be slippery.

what should be being asked is why wasn’t such a button placed on both the main control panel and unload panel so either op could notice something and immediately shut it down. Rather than navigate all the way over to where it is placed now.

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Well that’s the other thing we’re talking peoples accounts. I’d assume the ride would record every button that is pressed and when. Almost like a black box for eingineer to go back and see what an op has pushed or for a situation like this. 

And if there was another button that wasn’t pushed you’d think the DW lawyer would have today brought that up with the ride op when questioning him as to why he didn’t push it. 

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It is an old ride. Limited automation. a black box for all rides is wishful thinking . What is odd about what I read today is that the operator hit the stop and went to unload . Thought the stop did not engage and went back to hit the button a few more times. Any control operational defects have not been presented or highlighted thus far besides pump failure and hence if the button was pushed in this event why did the operator need to go back as the ride would have shutdown by then.

In hindsight a loss of water pressure should have been an automatic shutdown. Best risk practice would involve avoiding human intervention. Getting low paid people with  or without a degree of experience to operate these manual machines sometimes can be catastrophic as has occurred . They were setup to fail.

Edited by dbo121

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Set up to fail, perhaps - but in so many years of operation this is the first time we saw this event happen.  The investigators were not even able to recreate it based upon the report of their testimony.  It's easy to get tunnel vision on something like this and start thinking it was always a death-trap.  It's rarely that cut and dry.

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Higher probaility of operator error because of its manual nature of operation. Not saying it was a death trap. Just higher probability of incidents occurring due to manual error and manual panels. To recreate they did not try to operate over the same period of years of operation.  The operators were setup to fail a higher probability of times. Combine that with the capabilities required at a minimum to be hired as a ride operator . An automated system would have reduced the chance of incident .

Edited by dbo121

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1 hour ago, Original said:

Well looks like DW are trying to throw the ride op under the bus by insinuating it’s his fault he didn’t get to the second E-Stop in time. 

What everyone seems to be missing in this is, except for people here is where that button is located. Not at the unload area, but at the top of the lift. Which make DW look better that they had the system in place and incompetent ride op didn’t press. With 2 people trying to run a ride like that, getting to that button Is argue can’t happen, between loading and unloading and watching ride conditions. Walking over to press that button and have the conveyer shut down would take about as much as the 8sec button on the control panel. Even if they were running to it, which I would guess wouldn’t be easy with all that water the catwalk would be slippery.

what should be being asked is why wasn’t such a button placed on both the main control panel and unload panel so either op could notice something and immediately shut it down. Rather than navigate all the way over to where it is placed now.

Someone who finally believes me that the second e-stop is at the top of the hill. 

Sure you have a comment to make @Skeeta

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Seems very logical Joel too otherwise the deckhand should have been trained to hit the button at the actual unload station if it existed.  It seems a weak design to place the instant conveyor stop at a distance away from the deckhand operator existed. That distance would take more than 7 seconds to cover alone. 

I think that there should have been stops for the two operators in their reach and no excuse for that button other than to do an instant cut off for the entire ride. Not just conveyor. This was a big ride with a lot of water so maybe more hesitance and pressure to avoid using though.

When we hear from ardent or the engineering auditor some of these things will arise 

Edited by dbo121

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24 minutes ago, joel said:

Someone who finally believes me that the second e-stop is at the top of the hill. 

Sure you have a comment to make @Skeeta

?????????????????????The button at the conveyer belt

 

On 18/06/2018 at 3:26 PM, Skeeta said:

Yes @Brad2912 That's what we have been saying.  The button at the conveyer belt was the button that needed to be pressed to stop it.  Operator 1 and operator 2 disagree if operator 2 was told to push this button in an emergency.

 

2

I will say it again -   The button at the conveyor belt. The button at the conveyer beltThe button at the conveyer belt

On 19/06/2018 at 3:28 PM, Skeeta said:

For people trying to picture the distance from the unload to @joelE-Stop.  I have circled it in red.

 

5668d3f0f8241a90af805689bb0a98d7.thumb.jpg.11870e865204844a97fef8dfe1378d71.jpg

 

 

 

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Here's my commentary:

 

-Training was grosely inadequate and symptomatic of the theme park industry only equipping operators with the bare min knowledge. 

-Even if it's claimed the ops were told by a trainer abc, if operator did not retain abc the training system is at fault, not the operator

 

-Soemone is 100% at fault here. That person is whoever was responsible for the ultimate management of ride control systems at the park. This one was innadequate and they allowed that to remain the case. They are responsible for 4 deaths and 100% should be in goal. 

 

-This should result in an industry shakeup that prohibits reducing staffing levels and adding workloads through assistance like CCTV, etc etc. Rides need more operators. 

 

-A 'blackbox' is 100% possible. All rides should run on a modern PLC capable of fault logging. A failed pump is very easy to monitor whether by current draw CTs, motor RPM via a high speed encoder, or flow via a flow meter. None were in place. 

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100percent at fault to be attributed to someone ( ie 1 entity or person) is not going to occur. There are a number of parties. Ardent, the dreamworld Mangement team, regulator, government, external engineering auditor etc. 

that said one party could bear the brunt of it

Edited by dbo121

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3 minutes ago, djrappa said:

Here's my commentary:

 

-Training was grosely inadequate and symptomatic of the theme park industry only equipping operators with the bare min knowledge. 

-Even if it's claimed the ops were told by a trainer abc, if operator did not retain abc the training system is at fault, not the operator

 

-Soemone is 100% at fault here. That person is whoever was responsible for the ultimate management of ride control systems at the park. This one was innadequate and they allowed that to remain the case. They are responsible for 4 deaths and 100% should be in goal. 

 

-This should result in an industry shakeup that prohibits reducing staffing levels and adding workloads through assistance like CCTV, etc etc. Rides need more operators. 

 

-A 'blackbox' is 100% possible. All rides should run on a modern PLC capable of fault logging. A failed pump is very easy to monitor whether by current draw CTs, motor RPM via a high speed encoder, or flow via a flow meter. None were in place. 

Well, why don't we just blame Jhon Longhurst seen as though he built it himself!

 

Also 1986 there were limited rules and definitely none of that technology of a 'black box'. In 2006 it was probably recommended to install new system but u know, it's Dreamworld. NOV/DEC 2016 the ride would of not been able to further operate in that state.

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On 16/06/2018 at 12:58 AM, Brad2912 said:

Dreamworld staff’s safety fears after tragedy reveals parks rollercoaster of emotion

JUNE 16, 2018

STAFF have accused Dreamworld of refusing to implement key training procedures following the Thunder River Rapids ride tragedy that killed four people.

The Bulletin has obtained internal documents and spoken to whistleblowers as part of an investigation which puts the spotlight on the theme park’s management on the eve of a coroner’s inquest.

Staff claim a manager refused requests for critical response training because “the incident was too raw to get involved”.

Experienced health and safety workers also allege:

* No formalised critical response training had occurred since the tragic events of 2016.

* When it was brought up managers responded by saying that “it is too raw” or talked about cost factors and not having the budget to cover the expense of training.

* Nothing was documented for first respondents on what to do if an incident occurred on a ride which requires guest extraction.

* If a guest sustained an injury on a ride there was no formal response, individual clinicians having to make up their own mind what to do.

* If a ride like the Buzz Saw was stopped, staff lacked formal guidelines on how to get people out.

* Inexperienced staff had been appointed to senior safety roles and some multi-hired staff have basic first aid but need more training.

* First aid staff had been excluded from some training, and safety concerns were raised in an inhouse survey.

* Some staff were refusing to operate certain rides because they had concerns about safety.

* Staff were operating rides after only four to five months working in the theme park despite previous practice requiring 18 months.

A pre-inquest hearing in April found a faulty water pump and raft were the likely trigger for the ride malfunction which killed four tourists in October 2016.

Kate Goodchild, 32, her brother Luke Dorsett, 35, and his partner Roozbeh Araghi, 38, and Gosford woman Cindy Low, 42, died in the tragedy.

The Bulletin revealed the pump malfunction as the cause, and in a special report detailed how safety concerns had surfaced four years earlier.

Fresh documents detailing notes from interviews and emails with staff show an offsite meeting chaired by Arden Leisure’s chief audit officer was held at Hope Island in late April.

Workplace Health and Safety Queensland said it had received a complaint last month about a range of alleged issues at Dreamworld, and an inspector and engineer attended the theme park to investigate.

“No contraventions of WHS legislation were identified and the investigation into the alleged issues has concluded,” the spokesperson said.

But the Bulletin has been told the investigation did not consider cultural and management issues.

Dreamworld yesterday issued a statement indicating the theme park would “continue to co-operate with the Coroner and those assisting him”.

A Dreamworld spokesman said the theme park was not in a position to provide information which may be dealt with by the inquiry.

“Every complaint relating in any way to a safety matter is fully investigated. Where appropriate external advice is sought to ensure every safety complaint is dealt with thoroughly,” the spokesperson said.

AWU acting branch secretary Steve Baker said union members were concerned about Dreamworld’s approach to safety matters. Documents were provided to police for the Coroner.

“A major concern has been a culture of secrecy in the behaviour of Dreamworld management,” Mr Baker said.

“Whenever the union sought documentation from Dreamworld regarding safety issues, these requests were refused by management. This meant the union had to pursue matters through other means including Right to Information.”

At April’s safety audit meeting, some staff said some managers were suffering from post-traumatic stress disorder

“I get asked by every second guest was I there on the day. It is referred to as ‘the incident’. The effects of this incident are still being felt among the staff,” a staffer said.

Aquatics at the park had staged incident response training in a room so as “to not be visible because of sensitivities”.

A plan for a major health and safety training day at the water park was abandoned after the Rapids Ride tragedy.

“They said it was too fresh, we shouldn’t be doing CPR, it will harm others in the park,” a Dreamworld source said. “The lifeguards needed that training. We now know these events are real and can happen.”

Despite rides being deemed safe and passing engineer testing, some staff were reluctant to be operators.

“I know people who refuse to operate,” another Dreamworld source said. “I know some who say it took me three years to get Rapids, now they (newer employees) are getting high-level rides in 18 months.”

Another theme park insider told the Bulletin: “The staff are committed, dedicated and professional. They were pushed down and out.

“A number of people who were first responders — they’re gone. They saw the clinicians being decimated and decrease with expertise.”

What do they mean by “clinicians”?

I have been following what has been going on at the inquest. Some of it has confused me. The person running the ride at the time said he pushed the slow stop button 2-3 times before the raft flipped yet the person who has seen the CCTV footage says that a button wasn’t pressed until 15 seconds after the raft flipped. How can both be true. Also the fact that the new trainee when asking about the emergency stop button was told “don’t worry about that. You won’t need to use it.” If that is true then Dreamworld are screwed

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2 minutes ago, Brad2912 said:

Just a friendly suggestion @razza1987 maybe just quote the relevant part, especially when the quoted post is as large as that. You asked about clinicians and I had to re-read that whole thing to find the context when you could have just quoted that one paragraph. 

Thanks for telling me to do something I already tried to do. I tried doing that and after selecting the portion to delete all these ads for cars came up and it wouldn’t let me scroll up to the post

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