Tragic Lessons in Work Health & Safety
When a fatality occurs in a workplace it obviously becomes a focus of investigation to discover why it happened. And when it involves the deaths of 4 members of the public, such as in the tragic Dreamworld incident in 2016, the focus of investigation and the public and government attention to the incident becomes intense. In fact this tragedy at Dreamworld on their Thunder River Rapids ride was a major factor in the push for including an industrial manslaughter offence into the WHS Act in Queensland on the 23rd of October 2017. We can learn from other tragedies and perhaps review our workplace and our “reasonably practicable” actions to ensure the health and safety of workers and others in our workplaces (Section 19 WHS Act). The coronial inquest into the four deaths commenced on the 25th June 2018 to hear evidence for the purpose of determining the cause and circumstances of these deaths. The Safety Manager and other current and former employees, have already attended the first section of the Inquest to give evidence and to answer difficult questions. Read more on our website. Dreamworld issued a press statement after the first section of the Inquest. The statement included their acknowledgement that the evidence that had been submitted and the testimonies given by current and former employees to the Inquest were “shocking and deeply concerning”. “Dreamworld is profoundly sorry this tragedy occurred”. The Evidence So Far The Inquest is scheduled to resume in October before a final section in November and no conclusions can be made until all the evidence is at hand. However the evidence presented so far includes that:
The Safety Manager’s view was they needed a six-person safety management team not just one Safety Manager to handle all safety management issues. After the incident Dreamworld employed a team of six safety professionals.
A JAK audit in 2013 showed that there was no single emergency button that could immediately stop the ride. The audit report recommended that, “a single emergency shut down procedure be considered”.
In 2016 when the incident occurred there were stop buttons for different parts of the ride but the evidence by employees about what the buttons did and the sequence and time involved was conflicting. Also there was conflicting evidence from the trainers and the employees who were trained, about the content of the emergency procedure training.
A large water pump fed the Thunder River Rapids ride with the water it needed. On the day of the incident the pump failed and the ride had to be shut down. An electrician attended to the fault and reset the pump’s drive. He also showed a mechanical engineer how to reset the pump’s drive. A different electrician gave evidence that he would not show a mechanical engineer how to reset the pump “because they don’t have experience on drives on the electrical side of things”.
An hour after the first breakdown on the day of the incident, the pump failed again. At the Inquest:
(1) One of the Engineering Supervisors gave evidence that under Dreamworld breakdown policy, if the same fault occurred twice in a 24-hour period then: (i) the ride had to be shut down, (ii) the Supervisor had to be informed, and (iii) a review of the ride had to be carried out. (2) The Engineering Technician who attended the breakdown apparently thought that the policy was three breakdowns in a 24 hour period, not two breakdowns. (3) But the Senior Ride Operator gave evidence that she was unaware of any such policy. The Supervisor was not informed and there was no review. The Mechanical Engineer reset the pump and had never before reset the pump on this ride.
The pump then failed for the 3rd time that day, causing a massive drop in water levels with one boat being caught on the rails of the ride. Before the ride could be shut down four members of the public were dead.
The minutes of an engineering management meeting seven months before the fatal incident states that cutbacks are now being enforced and that repairs and maintenance spending needs to stop. It seems likely that when the Inquest resumes it may seek evidence of the actions that Senior Management took concerning safety and the level of due diligence applied by the Officers of Dreamworld.
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