CORONERS COURT OF QUEENSLAND Inquest into the deaths of Kate Goodchild, Luke Dorsett, Cindy Low & Roozbeh Araghi at Dreamworld, October 2016 Findings and Recommendations February 2020 CORONERS COURT OF QUEENSLAND INQUEST INTO THE DEATHS OF KATE LOUISE GOODCHILD, LUKE JONATHAN DORSETT, CINDY TONI LOW, & ROOZBEH ARAGHI Coroner, Southern Region Credit for the above photograph is given to Mr. Richard Gosling, Newspix CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the deaths of Kate Louise GOODCHILD, Luke Jonathan DORSETT, Cindy Toni LOW, & Roozbeh ARAGHI TITLE OF COURT: Coroners Court JURISDICTION: SOUTHPORT FILE NO(s): 2016/4486, 2016/4485, 2016/4480, 2016/4482 DELIVERED ON: 24 February 2020 DELIVERED AT: BRISBANE HEARING DATE(s): 18 June 2018 to 29 June 2018 8 October to 19 October 2018 12 November to 22 November 2018 6 & 7 December 2018 FINDINGS OF: James McDougall, Coroner CATCHWORDS: Coroners: inquest, Dreamworld, amusement device, Theme Park, safety management systems, ride maintenance, training, amusement device regulation, amusement device designer, amusement device modification, external safety audits. REPRESENTATION: Counsel Assisting Mr Ken Fleming, QC Ms Rhiannon Helsen, CCoQ Family of Cindy Low Mr Matthew Hickey, Counsel instructed by Clayton Utz Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low & Roozbeh Araghi i Families of Kate Goodchild & Luke Dorsett Mr Steven Wybrow, Counsel instructed by Aulich Civil Law Family of Roozbeh Araghi Mr Toby Nielsen, Counsel instructed by Gordon & Barry Law Mrs Kim Dorsett (mother, Kate & Luke) Mr Robert Davis, Counsel instructed by Sneddon, Hall & Gallop Lawyers Office of Industrial Relations (Workplace Health & Safety Queensland) Mr Stephen Gray, Counsel instructed by Crown Law Ms Courtney Williams Mr Peter Callaghan SC, instructed by Gilshennan & Luton Ms Chloe Brix, Ms Sarah Cotter, Mr Wayne Cox, Ms Amy Crisp, Mr Generic Cruz, Mr Francoire De Villiers, Mr Christopher Deaves, Mr Quentin Dennis, Mr Andrew Fyfe, Mr Peter Gardner, Mr Mark Gordon, Ms Nichola Horton, Mr Jason Johns, Ms Jennie Knight, Mr John Lossie, Mr Troy Margetts, Mr Steven Murphy, Mr Grant Naumann, Mr Peter Nemeth, Mr Kamlesh Prasad, Mr Scott Ritchie, Mr Matthew Robertson, Mr Michael Stead, Mr Mark Watkins, Mr Timothy Williams, Mr Jacob Wilson Mr Ralph Devlin QC & Mr Liam Dollar, Counsel instructed by K & L Gates LLP Ardent Leisure Ltd trading as Dreamworld Mr Bruce Hodkinson QC & Mr James Bell QC, instructed by Baker McKenzie Lawyers & DWF (Australia) CEO, Dreamworld, Craig Davidson Mr Gavin Handran, Counsel instructed by Quinn, Emanuel, Urquhardt & Sullivan LLP Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low & Roozbeh Araghi ii Queensland Police Service Mr Adrian Braithwaite, Counsel instructed by QPU Legal Group DANFOSS Australia (Mr Eduardo Gie) Mr Sean Farrell, Counsel instructed by Mills Oakley Mr John Clark, Mr Shane Green, Mr Benjamin Hicks, Mr Nigel Irwin, Ms Rebecca Ramsay, Mr Mark Thompson Mr Anthony Harding, Counsel instructed by Rankin & Co Lawyers Mr Angus Hutchings Mr Craig Eberhardt, Counsel instructed by Robertson O’Gorman Solicitors Mr Tom Polley (Danski Pty Ltd) Ms Polina Kinchina, Counsel instructed by Colin, Biggers, Paisley Lawyers Mr Bob Tan Mr John Bremhorst, Counsel instructed by Australian Business Lawyers & Advisors Findings of the inquest into the death of Kate Louise Goodchild Luke Jonathan Dorsett, Cindy Toni Low & Roozbeh Araghi iii CONTENTS INTRODUCTION ....................................................................................................................... 6 ISSUES FOR INQUEST ............................................................................................................ 7 ABOUT THE DECEASED PERSONS ...................................................................................... 7 BRIEF SUMMARY OF THE INCIDENT .................................................................................... 8 POST MORTEM FINDINGS .................................................................................................... 10 Kate Goodchild .................................................................................................................... 10 Luke Dorsett ........................................................................................................................ 10 Cindy Low ............................................................................................................................ 10 Roozbeh Araghi ................................................................................................................... 10 DREAMWORLD STRUCTURE & OVERVIEW ...................................................................... 11 THUNDER RIVER RAPIDS RIDE (TRRR) ............................................................................. 15 Configuration of the TRRR .................................................................................................. 16 Forensic Crash Unit Investigation .................................................................................................. 16 Configuration of the TRRR at the Time of the Incident .................................................................. 17 Operating Control System ............................................................................................................. 17 Trough ........................................................................................................................................... 18 Raft Supporting Rails ..................................................................................................................... 18 Conveyor System .......................................................................................................................... 19 Water Pumps ................................................................................................................................. 21 Rafts .............................................................................................................................................. 22 Pneumatic Gates ........................................................................................................................... 23 Safety Features of the TRRR .............................................................................................. 24 Emergency Stops (E-Stops) .......................................................................................................... 24 Raft Safety Stop ............................................................................................................................ 25 Chain Break Safety........................................................................................................................ 25 Anti-Roll Back Gates ..................................................................................................................... 25 Water levels ................................................................................................................................... 25 History & Modifications to the TRRR Since 1986................................................................ 25 Issues with the Conveyor and Removal of Slats ........................................................................... 26 Turntable Removal ........................................................................................................................ 28 Pumps ........................................................................................................................................... 29 Raft Collar Quote ........................................................................................................................... 30 General Feasible Improvements ................................................................................................... 31 Changes to the Unload Area ......................................................................................................... 31 Raft Track ...................................................................................................................................... 31 Conveyor Chain Break and Raft Slip Monitoring ........................................................................... 32 PFI Modifications to the Log Ride in 2013 ..................................................................................... 36 Other Suggested Modifications to the TRRR ...................................................................... 37 Automated Raft Rotation System .................................................................................................. 37 Single Button Shutdown ................................................................................................................ 38 Sourcing Further Wood for Conveyor in 2016 ............................................................................... 38 TRAINING & OPERATOR PROCEDURES ............................................................................ 39 TRRR Position Responsibilities and Training ..................................................................... 41 Ride Operator Level 1 (No. 3) Deckhand ...................................................................................... 43 Ride Operator Level 2 (No. 2) Load Operation .............................................................................. 45 Ride Operator Level 3 (No. 1) ......................................................................................................