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Ardent Leisure could face prosecution over 'unjustifiable' Dreamworld tragedy
By Lucy Stone and Lydia Lynch
Queensland's coroner has referred Ardent Leisure back to the state's Office of Industrial Relations for potential prosecution, after handing down a damning 300-page report into the 2016 tragedy at Dreamworld that killed four people.
Coroner James McDougall's scathing report into the deaths of Cindy Low, Kate Goodchild, Luke Dorsett and Roozi Araghi highlighted "unjustifiable" failings of Dreamworld and its parent company Ardent Leisure to ensure its rides were safe and up to standard.
The 2016 tragedy at Dreamworld claimed the lives of Cindy Low, Kate Goodchild, Luke Dorsett and Roozi Araghi.
All four were killed while riding on the popular Thunder River Rapids Ride on October 25, 2016, when a water pump on the ride failed, causing an empty raft to be left stuck on railings at the end of the ride.
The raft the victims were in collided with the empty raft at the end of the conveyor belt and flipped over, all four killed almost instantly.
Coroner McDougall said the tragedy revealed a "systematic failure by Dreamworld in relation to all aspects of safety", with details about the theme park's failure to keep accurate risk assessments, ride maintenance logs, and staff raising previous safety incidents without changes implemented all highlighted in his report.
The coroner also recommended stricter regulatory frameworks to improve the registration, licensing and safety inspections for theme parks statewide.
Reading out a detailed summary of his report at Brisbane Magistrates Court on Monday morning, the coroner first invited family members of the four victims to make statements.
Mathew Low, Cindy's husband, was the first to speak. Describing his wife as a woman with the "heart of a tiger", Mr Low also shared a statement from the couples' daughter Isla.
"Mum was a wonderful person with a very big heart," she wrote.
"I miss her hugs and her cakes that she used to make for us all the time."
Michael Cooke, brother of Cindy Low, holds a picture of her as he leaves the Magistrates Court in Brisbane.Credit: AAP
Later in a statement issued to media on Monday afternoon, Mr Low said he was in "full agreement" with the coroner's scathing findings, saying Ardent Leisure had been "dragging their feet" on changing Dreamworld's operations.
"Today’s findings have proven what was glaringly obvious, Dreamworld was a catastrophe waiting to happen because of their barefaced disregard for safety and maintenance," he said.
Kim Dorsett, the mother of Luke and Kate, spoke on behalf of her family and the Araghi family, detailing the closeness between her children and the love shared by Luke and Roozi.
The couple had been together for nine years, enjoying music and theatre and spending time with their nieces, she said.
But, she said, Kate's daughter Evie would never remember her mother.
"She will get to know her mum, Luke and Roozi through stories we share, pictures and trips to heaven, which is what she calls the cemetery," she told the court.
In a separate statement read out by their barrister, their father Shayne Goodchild spoke of Kate and Luke and Roozi with love.
"If someone needed help Luke and Roozi provided it," Mr Goodchild wrote.
"To say we miss them every day does not begin to encompass our grief and loss. We hope Kate, Luke and Roozi did not die in vain."
Floral tributes outside Dreamworld at the time of the tragedy.Credit: Tammy Law
Cindy Low's mother and brother, both from New Zealand, also made statements, detailing how they found out about Cindy's death and the awful grief they suffered through since then.
Her brother lashed Dreamworld for its failings and later shared a photo of his sister with reporters as he walked out of court.
Ardent Leisure chairman Gary Weiss, who was in court to hear the findings, and Ardent Leisure chief executive officer for theme parks, John Osborne, issued a joint statement outside court.
"We express our deepest sympathies to the families and friends of Roozbeh Araghi, Luke Dorsett, Kate Goodchild and Cindy Low," they said.
"Our thoughts are also with the first responders, emergency services personnel, investigators, counsellors and Dreamworld team members affected by this tragedy.
Later on Monday afternoon, the pair fronted media at Dreamworld to read prepared statements but refused to take any questions.
Mr Osborne said a memorial garden would be constructed in consultation with the families of the victims to remember all of the victims.
He said Dreamworld had hired a full, new safety team including experts and executives from the commercial aviation industry to reform the theme park's safety programs and initiatives.
Training for staff was also upgraded, he said, and the theme park had a close working relationship with Queensland's Workplace Health and Safety department.
Dr Weiss insisted the coroner's report came amidst major change to Dreamworld's safety processes to ensure "such a tragedy never happens again".
"Safety is the team's number one priority," he said.
Neither Dr Weiss nor Mr Osborne worked at Dreamworld in October 2016.
Mr McDougall's lengthy summary detailed his belief that Dreamworld was aware of its safety shortcomings but made little effort to improve those problems.
"There is no evidence that Dreamworld ever conducted a proper risk assessment of the ride in its 30 years of commission," he said, adding that a lack of engineering controls to automate the ride safely was "unjustifiable".
Mr McDougall said it was "unfathomable" that hazard management fell to ride operators and staff who identified risks, rather than through formal engineering inspections.
The lax approach to safety, Mr McDougall said, made such a tragedy much more likely.
"It was simply a matter of time. That time came on October 25, 2016," he said.
The amusement park's poor record-keeping and inconsistent approach to safety meant risks were not assessed properly and under the existing regulation, the Office of Industrial Relations expected Dreamworld to self-assess its own potential hazards.
Such a situation, the coroner said, meant the Office of Industrial Relations "unjustifiably" trusted the theme park to conduct its own engineering inspections.
The ride broke down five times in the week before the tragedy and it was reset each time without investigation. On the day of the tragedy, the south water pump had already failed twice before being re-set minutes before the fatal incident.
Mr McDougall said the ride should have been shut down until a proper investigation could be conducted.
In addition to referring Ardent Leisure back to the office of industrial relations, Mr McDougall recommended that regulatory changes be made in Queensland to improve the inspection and safety of major parks, and ensuring annual risk assessments of rides be undertaken by a qualified engineer.
He acknowledged the Office of Industrial Relations evidence that there were few engineers registered in Queensland with the skills and knowledge required to inspect theme park rides.
The coroner also said full inspections of rides should be conducted every five to 10 years.
"It is reasonably suspected that Ardent Leisure may have committed an offence under workplace law," the coroner found.
"I refer my findings and the evidence gathered in the course of the Inquest to OIR for further consideration as to these matters. Whether there is sufficient evidence to proceed to prosecution is a matter for OIR."
The coroner also referred an external engineer, Tom Polley, to the Board of Professional Engineers of Queensland.
Mr Polley was called in by Dreamworld in September 2016, weeks before the fatal incident, to certify the Thunder River Rapids Ride and other rides at Dreamworld as safe.
Mr McDougall said it was "arguable" his issuing the certificate without seeing any documentation for the ride, and his failure to properly inspect the ride, "was a failure which falls below the industry standards".
Ardent Leisure's share price dropped 16.3 per cent to a two-month low of $1.18 after the coroner's findings were published.
Queensland Industrial Relations minister Grace Grace said the majority of the coronial recommendations had already been implemented including more safety inspectors, improved training and greater powers for Workplace Health and Safety Queensland.
However, Ms Grace said the state government was conducting a thorough examination of the coroner’s recommendations and vowed more would be done to improve theme park safety if necessary.
-with Toby Crockford