The country was shocked and upset by the Dreamworld Tragedy back in 2018. The malfunction of the Thunder River Rapids Ride was responsible for four deaths and prompted a coroner inquest to uncover why the tragedy occurred. Questions were asked by many, such as, “Why did the ride malfunction?”, “could the tragedy have been prevented?”

Recently, the Coroners’ report was released to the public. QLD Coroners Report, February 2020 – Dreamworld Tragedy

Findings of the Dreamworld Tragedy Coroners Report

The Coroners Report is a sobering read for all facility managers.  The loss of life could have been avoided.  The Coroner cites among a range of factors, safety in design issues, failed equipment and poor records. Further to this, ‘Records as to the design and manufacture of the TRRR are sparse. There is limited context as to the creation of the ride, how certain components were designed and commissioned, and the intended ongoing management and maintenance”.

The Coroner also stated, “The records and document control in place at Dreamworld, including for the rides, safety systems, maintenance and training of staff, was clearly significantly lacking, with only limited information available”.  And added, “This absence of effective and complete record-keeping essentially precluded any staff from being in a position to be able to appropriately and adequately assess and manage the risks”.

While some Project and Facility Managers might see this as an amusement ride problem, the message is very clear.   The requirements of the Work Health Safety Act in each State and Territory and the Commonwealth are there for good reason.

As the various Acts are all based on the model laws, the Commonwealth Act can be used as a guide.  Under Division 3 it requires Designers, Manufacturers, and Suppliers (Contractors) to provide information that meets the following criteria – in summary:

(4) The supplier must give adequate information to each person to whom the supplier supplies the plant, substance or structure concerning:

(a) each purpose for which the plant, substance or structure was designed or manufactured; and

(b) the results of any calculations, analysis, testing or examination referred to in subsection 3), including, in relation to a substance, any hazardous properties of the substance identified by testing; and

(c) any conditions necessary to ensure that the plant, substance or structure is without risks to health and safety when used for a purpose for which it was designed or manufactured or when carrying out any activity referred to in subsection (2)(a) to (e).

The Act specifies the type of activities – Example: Inspection, storage, operation, cleaning, maintenance or repair of plant.

Currently, very few projects provide a Design Manual which includes Safety in Design risk assessments.  And many project managers and their client’s capital works managers are unaware of their responsibilities.   This leaves contractors in a knowledge vacuum where they are not properly checked to ensure the right information is supplied.

The sad fact is an earlier incident on the same ride should have been a warning to address the issues.  The question is, will designers, project managers, contractors and facility managers in the wider industry sectors learn the lessons.


The experts at WebFM can advise on Safety in Design reports, facility maintenance scheduling and the management of operations and maintenance manuals. Contact us.