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Dreamworld Thunder River Rapids Ride Accident 25th October 2016…
Dreamworld Thunder River Rapids Ride Accident 25th October 2016
Workplaces
No alarm or automatic shut down to advise of pump malfunctions
Failure at design stages (Mansfield 2010)
Inadequate maintenance schedules
Management procedure failure (Mansfield 2010)
Anti corrosion materials not considered during construction
Failure at design stage (Mansfield 2010)
Staff observations required to determine water levels
Failure at design stage (Mansfield 2010)
People
Inadequate operator knowledge, junior operator unaware emergency stop button within her reach
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
No emergency drill training for staff
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Inexperienced operator
Failure at Operation Stage People expectation issue (Kumar, R. & Nathwani, A. 2012)
Stress, unrealistic expectations on staff to monitor multiple activities
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Inadequate training
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Ride malfunction caused unexpected machinery behaviour
Failure at design stage (Mansfield 2010)
Senior staff unfamiliar with emergency shut down procedures
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Management
Budgetary concerns prevented appropriate repairs and maintenance expenditure
Management procedure failure (Kumar, R. & Nathwani, A. 2012)
Poor job design, excessive expectations on employees
Management procudure failure (Mital, A 1999)
Understaffed
Management procedure failure (Kumar, R. & Nathwani, A. 2012)
Inadequate staff training
Mnagement procedure failure (Kumar, R. & Nathwani, A. 2012)
Failure to act on previous safety recommendations
Management procedure failure (Conti, R 1999)
Inadequate emergency procedures communicated to staff
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Failure to cease ride operations after previous similar incidents (Kumar, R. & Nathwani, A. 2012)
Management Safety procedure failure (Conti, R 1999)
Safety warnings advising that rafts could flip was deleted by safety manager
Management information transfer procedure failure (Kumar, R. & Nathwani, A. 2012)
Sequence of Events
Previous raft collision incidents in 2001, 2004, 2005 and 2016 ignored and safety recommendations not implemented
(Sibson E 2018)
Scheduled maintenance and repairs were ceased due to budgetary issues (Sibson 2018)
Limited training supplied to junior ride operator (Sibson E 2018)
Pump ceased functioning causing water level to drop (Sibson 2018)
Empty raft ahead of deceased became trapped on steel railing (Sibson 2018)
Raft with 6 occupants collides with empty raft causing it to flip (Sibson, E 2018)
2 occupants are thrown free of the ride, whilst 4 are lifted vertically and dragged into the conveyor causing instant death
(Sibson 2018)
