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Annotated Mind Map for the Dreamworld Thunder River Rapids Disaster -…
Annotated Mind Map for the Dreamworld Thunder River Rapids Disaster
What and why it happened
Staff were told that the emergency stop button was not important
Pump failure
Water level was too low
Ride had already undergone maintenance twice that day
Conveyor belts were wide enough to trap a body
The raft that was in front was lowered and stuck
The victims raft was forced on top of the stuck raft and flipped due to the conveyor belt pushing it on to the lowered raft, shoving it under the conveyor belt.
Very old attraction
Nature of the system and system parts
Rafts
45km/h speed
6 people could ride at a time
Conveyor belt
Operating station
Track and water flow
410m length
Entrance and exit
Attraction to entertain visitors
Design failures and system life cycle
Concept
Concept behind the ride was made over 30 years ago.
Simulate white water rafting.
Enjoyment and attract customers
Detailed design
Single conveyor belt
Timber and metal materials
Rocky terrain and water rapids
Two tunnels
Hazard prevention and safety systems were not thought about well enough
Construction
Safely constructed
Was not a dangerous attraction to construct
Control panel wiring was confusingly made
Plumbers were very important for the construction
Safe design needed to be better, ways of alerting unsafe water levels could have been implemented to prevent the accident
Commissioning
Opened in 1986
Way of thinking about safe design was different back then
One of a kind ride design
One of Dreamworlds most popular attractions
Operating & Maintenance
Never once had a hazard assessment completed.
It operated well for many years
Needed maintenance as an accident like this was bound to happen without real changes to the construction of the ride.
Staff were not trained properly
Staff were not told about the emergency stop button
Significant corrosion
Water pump failure
Timber slats were replaced causing pinch points
Annual maintenance
Rafts had flipped previously during testing
Hazards and risks to safety were never attended to as the ride had never put anyone in serious danger during the 30 years of operation
Decommissioning
Not designed to last 30 years safely
Decommissioned after the terrible accident
Decommissioning was never considered during the design stage
Issues related to people, workplace & management
Staff members first day operating the attraction on the day of the accident
Was poorly shown how to operate it during 2 hours before the park opened.
Insufficient training
No engineer hired to do a hazard assessment
Control panel wiring was confusing
Stressful ride to operate as it involved monitoring many things at once
36 checks required in less than a minute
Operators had no CPR or first aid training
Water levels were monitored by a stain on the wall
Emergency stop button had no labeling
Similar collision had occurred in 2014, two years before the accident
Knowledge was there but no changes were made
Repairs and maintenance spending was cut back 7 months before