Finding into death of Eugene Mahauariki
Deceased
Eugene Allen Tearanhanga Mahauariki
Demographics
6y, male
Date of death
2017-04-21
Finding date
2023-11-24
Cause of death
Complications of Head Injury following a fall from a Fairground Ride
AI-generated summary
Six-year-old Eugene Mahauariki was ejected from the Cha Cha ride at a carnival in Rye, Victoria on 17 April 2017 and died from head injuries four days later. The coroner found the death was preventable due to three critical failures: (1) the restraint system did not comply with Australian Standards AS 3533.1 2009, requiring Type 3 restraints but only Type 2 were fitted; (2) the ride operator, Lukas Kohler, was insufficiently trained and not competent to operate the ride unsupervised; (3) the rules restricting riders under 130cm to ride with adults were not enforced—Eugene rode with another 6-year-old who was only 121cm. The engineer's annual certification that the restraints complied was inaccurate. Systemic failures included lack of design registration for pre-1995 rides, absence of plant registration since 2014, weak WorkSafe audit procedures, and no formal operator training records. The coroner did not formally adopt the 2015 Queensland Safety Alert regarding restraint system improvements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Restraint system not compliant with Australian Standard AS 3533.1 2009 (Type 3 restraints required but Type 2 fitted)
- Engineer Hamish Munro's assessment that restraints complied was inaccurate; he retrospectively claimed to have mentally reduced the restraint factor without documentation
- Ride operator Lukas Kohler was insufficiently trained and not competent to operate the Cha Cha unsupervised
- Failure to enforce height and accompanying adult rules—6-year-old Eugene (132cm) rode with another 6-year-old (121cm) who should have required an adult
- Absence of seat belts or secondary restraint systems on the Cha Cha
- Wittingslow (owner/operator) did not maintain adequate training records and did not verify operator competence
- WorkSafe 2015 Queensland Safety Alert regarding rider restraint system redesign was not formally adopted in Victoria prior to the incident
- Pre-1995 amusement rides exempt from design registration requirement
- Plant registration requirement removed from Victoria regulations in 2014
- National Audit Tool used by WorkSafe limited in effectiveness; WorkSafe inspections do not independently verify engineer certifications
- Informal 'buddy system' training with no standardised competency requirements or documented proof of training
Coroner's recommendations
- All amusement structures (plant) be required to be design registered, with no exemption for pre-1995 rides
- Design registration applicants and verifiers must be located in Australia
- WorkSafe be empowered to refuse design registration applications where necessary information is not provided or design poses a risk
- WorkSafe be empowered to cancel plant and/or design registration where unsafe
- Operators of amusement rides be required to carry the plant manual and logbook at all times
- Plant registration requirement be reintroduced and apply to all amusement structures operating in Victoria
- Operators be required to record and maintain details of training and certification for all ride operators
- Undertake review to improve training standards and accreditation of ride operators and attendants, including consideration of minimum training standards and possible licensing
- Enhance the National Audit Tool used by WorkSafe inspectors to address concerns about limited safety value and improve consistency with ordinary workplace intervention practices
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