Inquiry into the fire and deaths at Luna Park
Deceased
John Robert Godson, Damien Paul Godson, Craig Godson, Jonathan Shaun Godson, Richard Charles Carroll, Michael David Johnson, Shamus Patrick Rahilly
Demographics
unknown
Date of death
1979-06-09
Finding date
1979-09-03
Cause of death
Carbon monoxide poisoning and burns (or burns only in one case), accidentally suffered when the Ghost Train building caught fire
AI-generated summary
Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigarette or match in flammable litter near an imitation fireplace display. The coroner identified critical safety failures: absence of the required internal patrol attendant, lack of emergency lighting and hose reel systems (mandatory upgrades not yet completed), poorly marked or hidden escape exits, and absence of smoke alarms or evacuation procedures. The building's maze-like layout, darkness, and low-hanging smoke made escape extremely difficult. The coroner found a serious breach of duty of care by Luna Park management despite earlier fire safety recommendations. While not concluding criminal negligence, the coroner noted inadequate fire precautions and insufficient spending on safety measures. Key recommendations included expanding fire brigade inspection powers, extending fire safety legislation to amusement attractions, and ensuring compliance with mandatory safety upgrades.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Absence of internal patrol attendant on night of fire
- Likely ignition of flammable litter by carelessly discarded cigarette or match
- Accumulation of food wrappings and litter in building
- Flammable timber construction with bitumen-impregnated roof
- Poor building condition with holes in roof and loose supporting studs
- Maze-like layout with dark timber-painted partitions and black doors
- Inadequate and unlit emergency exits
- Lack of emergency lighting system (required but not installed)
- Lack of hose reel system (required but not installed)
- Lack of smoke alarm or smoke exhaust system
- Incomplete evacuation procedures and staff training
- Inadequate fire hydrant hoses (one lacking nozzle)
- Dense black smoke produced rapidly due to bitumen roofing materials
- High fire risk inherent to building design and construction
- Failure to comply with fire safety recommendations from 1977
- Lack of fabric fire retardant treatment
- Inadequate cleaning of floor and exhibits
Coroner's recommendations
- Further examination of Luna Park with attention to River Caves and other buildings with similar fire risk
- Expansion of fire prevention function of fire brigades and extension of right of entry and inspection powers
- Provision of concurrent power to fire brigades to serve and enforce notices
- Local councils should not hesitate to invoke powers under Section 317D(2) of Local Government Act to direct buildings not be used until works are carried out
- Department of Industrial Relations and Technology should enforce emergency lighting requirement more rigidly for amusement devices registered under Construction Safety Act
- Consideration given to extending scope of Theatres and Public Halls Act and Regulations to include buildings of public resort for amusement such as the Ghost Train
- State-wide policy and control by Fire Brigades and/or Department of Services to address fragmented enforcement authority
- Any further lease of Luna Park area should contain stringent conditions for safety of public
- Implementation of detailed recommendations from Inter-Departmental Committee on Fire Safety in Buildings by local councils
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