Complex, emotional case facing Coroner
WHAT THEY SAID
ANALYSIS
WHAT became clear very early at the start of the coronial inquiry into the Dreamworld tragedy was the enormity of the task before Coroner James McDougall.
As Ken Fleming, QC, council assisting the Coroner, began his address just after 10am in Court 17 at the Southport Courthouse yesterday, it was apparent this inquest would stretch beyond finding out when persons died, how and why.
The inquiry was told this was a “significant catastrophic event”. For many Gold Coasters, their lives had a “before and after the incident” edge.
The mechanics of the leadup – training of staff, their age, ride breakdowns, safety checks and internal memos to employees about what they should and shouldn’t do with emergency buttons – make for a complex case.
Before the Coroner, Mr McDougall, sat up to 30 people, most of them barristers and legal staff appearing for Dreamworld or the families, along with a handful of friends and relatives. The media packed out nearby Court 16.
The Bulletin in its reporting and pre-hearing has confirmed that just after 2pm on October 25, 2016, a pump stopped on the Thunder River Rapids ride, a raft was stuck on a conveyor and another hit it and flipped.
On that raft that flipped were Canberra tourists Kate Goodchild, 32, her brother Luke Dorsett 35, and his partner Roozbeh Araghi, 38, and Gosford resident Cindy Low, 42. They were killed. Also on board were two children, Ms Low’s 10-year-old son Kieran and Ms Goodchild’s 12-yearold daughter Ebony, who survived the accident.
“We understand that these issues are going to be gravely emotional for them (the families),” Mr Fleming told the hearing.
“We acknowledge the fortitude of families and we note that it will be difficult for them throughout the inquiry.”
Every attempt would be made to ensure the process was as least difficult as possible — distressing video footage was not shown yesterday — and Mr Fleming explained an inquest was different to a civil or criminal trial where lawyers were less restrained.
“Your honour is a not a trier of fact but rather a sifter of facts, and reaching a conclusion on cogent evidence from those facts,” he said.
But a coroner could go further than finding the basic facts, delving deeper if it related to “public health and safety, administration of justice and make recommendations to prevent deaths occurring in similar circumstances”.
“There can be no doubt about that aspect of your honour’s findings,” Mr Fleming said.
Detective Sergeant Nicola Brown, the first witness and chief investigator, was questioned about aspects of her statement, agreeing that young Dreamworld staffer Courtney Williams responded very quickly.
“Yes, so Courtney was at the unload area. In her witness statement, she realised the water level had dropped. They were in a code six situation,” Sgt Brown said.
A more senior ride operator colleague initially alerted a Code Six situation and it was upgraded by a security officer who reviewed the CCTV footage and saw that the raft was in a vertical position.
Mr Fleming: “And then you described what Courtney Williams did … she assisted people.’’
Sgt Brown: “Once obviously the incident had unfolded she went into emergency mode and assisted everybody she could. She was also assisted by some other people including those that were in raft six that became stranded, who managed to get themselves out of the raft and managed to provide assistance to those in raft five.’’
But what emerged further in Sgt Brown’s questioning, from her statement, was the police investigation uncovered previous incidents with the ride.
An internal investigation in 2005 found “the load operator must perform numerous tasks simultaneously, many which are cognitively draining”.
Four years earlier, after an incident in which an operator was diverted when talking to guests, a recommendation was made for emergency response training.
“I know there’s no practical drill-type scenario situations. I’m aware they do get quizzed on the operational procedures in emergencies, as far as verbal drill goes,” Sgt Brown said.
As questions were asked about dates, one stood out. On October 19, 2016, the south pump had failed, the same as it would again on October 25 with fatal consequences.
Asked if it was checked by engineers or the “drive guys”, Sgt Brown replied: “Not between then and after the incident. I believe they were scheduled for the 27th of October.”
Lawyer Steven Whybrow, in cross examination representing the Canberra families, set the tone by not so much attacking Dreamworld ride staffers but questioning their training.
They were young, under 30, and it was a “no brainer” to have a one-stop emergency button that could stop the ride in two seconds.
Video showed 57 seconds elapsing between the rafts colliding.
Mr Whybrow asked Sgt Brown if she had heard of the “Swiss cheese model of accidents” in which aircraft tragedies many things had to go wrong before an accident due to so many built-in safety features.
“You have to line up all the holes to get to a tragedy,” he said.
“I haven’t actually, haven’t,” she replied.
“In this one though I suggest it’s the opposite. There are a whole lot of things, that any one of them, if it had been addressed, might have averted this tragedy,” he said.
Sgt Brown agreed and revealed her summary had found that if some issues had been addressed, the tragedy could have been minimised or prevented.
BULLETIN VIEW, P14
no I
DETECTIVE SERGEANT NICOLA BROWN
“We’re talking about human beings … it was a human being that has to stop it.”
WE ACKNOWLEDGE THE FORTITUDE OF FAMILIES AND WE NOTE THAT IT WILL BE DIFFICULT FOR THEM THROUGHOUT THE INQUIRY