Coroner's Finding: Leong Yi Hui, Adelene

Contributing factors

• Minimum height set at 120cm instead of manufacturer-specified 140cm
• Inappropriate restraints (Type 4 instead of Type 5)
• Hydraulic fluid contamination in restraint locking mechanism
• Failure to obtain legitimate design registration
• Inadequate commissioning inspection by Mr Rode-Bramanis
• Poorly maintained logbook with misleading entries
• Insufficient annual inspection by Mr Munro
• Lack of inter-jurisdictional information sharing
• Operational at maximum speed (10 rpm instead of recommended 8.5 rpm)
• Absence of safety checklist completion
• Poor maintenance including inappropriate hydraulic fluid injection
• Defective electrical connections exposed to water
• Exposed threads in primary lock cylinder connection
• Sensors failing to detect improper harness positioning

Coroner's recommendations

1. Create and implement a nationwide regulatory process to verify and record design registrations for amusement devices to ensure every amusement device is subject to the same process across all Australian jurisdictions
2. Establish a common application procedure for plant registration to ensure consistent criteria regardless of registration location in Australia
3. Introduce legislation requiring that plant registration will not be granted unless a design registration certificate has been endorsed and verified by the relevant State or Territory regulator
4. Establish a national database of design registration numbers and plant registration numbers accessible by regulators of all States and Territories
5. Establish a nationwide panel of qualified persons to assess annually the skills of competent persons inspecting amusement rides to verify their areas of expertise
6. Require annual assessment of competent persons including mandatory participation in continuing education schemes
7. Implement a mandatory national electronic logbook system for all amusement devices and rides accessible by all authorised people for inspections and audits in any jurisdiction
8. Legislate that logbooks must include design registration certificate, plant registration certificate, and manufacturer's statement confirming criteria for patron eligibility
9. Enforce that notices issued by regulators in any jurisdiction concerning safety improvements, injury reports, and critical safety issues be available in the logbook and on a national database
10. Royal Agricultural and Horticultural Society of South Australia initiate action with corresponding Societies in other jurisdictions to establish a database for sharing information on amusement devices operating at Shows
11. Conduct a review of the Venue Control Centre configuration at the Showgrounds to ensure emergency responders are easily accessible and can respond quickly to incidents
12. Ensure a competent person is present on behalf of the Society during any inspection or audit of an amusement ride at The Show
13. Standards Australia review AS3533 to provide clear direction on inspection requirements for competent persons
14. Standards Australia define terms and criteria for initial or commissioning inspections of amusement devices
15. Standards Australia conduct comprehensive review of Australian Standards for amusement devices to clarify detailed inspection requirements for all jurisdictions
16. Urge all Australian governments to ensure Australian Standards have the same legal status as rules of law rather than merely codes of practice
17. Review the definition of a competent person for amusement devices in Australian Standards and State and Territory legislation