Goodchild, Kate; Dorsett, Luke; Low, Cindy & Araghi, Roozbeh

Contributing factors

• Failure of south pump causing rapid water level drop
• Raft 6 stranded on steel support rails due to insufficient water level
• Conveyor continued to operate independently despite pump failure
• Arbitrary gap of 430mm between conveyor end and support rails (nip point)
• Removal of every 2nd and 3rd conveyor slat, creating excessive spacing
• Absence of automated water level monitoring system
• No audible alarm for pump failure
• No interlock to stop conveyor when water level dropped
• Failure to investigate recurring 'earth fault' on south pump in preceding week
• Delayed operator response to pump failure
• Excessive workload and stress on ride operators
• Inadequate emergency stop controls
• No single emergency shutdown button for entire ride
• Poor labelling and design of control panel
• Ambiguous and poorly worded operating procedures and memorandums
• Absence of emergency scenario drills
• Thirty years without holistic engineering risk assessment of ride
• No formal designer or competent person overseeing modifications
• Poor record keeping and document management
• Insufficient operator training

Coroner's recommendations

1. Implementation of mandatory major inspections of amusement devices every 10 years or as recommended by manufacturer
2. Appointment of a qualified 'designer' or competent person (registered engineer) for every amusement device with clear delegation and accountability
3. Conduct full risk assessments on all rides at commissioning, after major modifications, and every 5 years
4. Installation of automated water level monitoring systems with automatic shutdown of conveyor if water level falls below safe operating level
5. Interlock systems between pumps and conveyor to ensure conveyor stops if pump fails
6. Installation of single emergency stop button capable of complete ride shutdown
7. Closure of gap between conveyor end and support rails to minimum necessary for operation (approximately 100mm)
8. Reinstatement of all conveyor slats to ensure conveyor slips beneath rafts rather than engaging forcibly
9. Installation of labelled emergency stop buttons at both main and unload control panels
10. Mandatory emergency scenario drills and testing (e.g. pump shutdown, water level decrease, raft collision scenarios) conducted regularly
11. Comprehensive formal training program for ride operators with documented competency assessment
12. Mandatory training on hazard recognition and emergency response for all staff
13. Implementation of robust record-keeping and document management system accessible to all relevant staff
14. Establish formal safety management system with documented hazard assessments and control measures
15. Involvement of Safety Department and Engineering Department in drafting operating procedures
16. Clear definition of emergency situations and explicit authority for operators to activate emergency controls
17. Regular independent external safety audits conducted by qualified engineers with reference to Australian Standards
18. Spot audits by regulator to verify effectiveness of safety systems and proper conduct of inspections
19. Mandatory notification to regulator of all modifications to registered amusement devices
20. Implementation of proposed regulatory amendments including safety case licensing system for major amusement parks
21. Development of Code of Practice for amusement device operators
22. Enhanced regulator training and resources for inspection of amusement devices, particularly regarding safety-related control circuits
23. Consistent application of Breakdown Policy with clear escalation criteria and definition of 'immediate danger'
24. Immediate investigation and remediation of recurring mechanical faults before ride returns to service
25. Use of properly qualified registered professional engineers for annual inspections rather than internal staff
26. Development of comprehensive maintenance program based on manufacturer specifications and Australian Standards
27. Regular testing of emergency controls and systems
28. Implementation of automated raft collision detection systems at unload area

Further listening

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