SAFETY INCIDENT REPORT

THUNDER RIVER RAPIDS RIDE

Part I

The Dreamworld Theme Park situated in the Gold Coast, Queensland is Australia’s biggest theme
park and zoo which provides entertainment and unique adrenaline rushing experiences to over one
million visitors a year (Dreamworld, 2022). With over 40 rides and attractions, this theme park caters
to visitors of a wide range of ages and is a popular attraction for many tourists and locals. However,
the thrilling experiences the rides provide does involve risks due to the complexity of these large
mechanical structures that must be appropriately addressed to provide both a fun and safe experience
for all visitors and any malfunctions can have fatal consequences, such as seen with the case of the
Thunder River Rapids Ride.

The Thunder River Rapids ride was established in 1986 at Dreamworld. This water ride imitated a
white-water rafting experience with up to six riders sitting in a circular raft and spanning across a
410m turbulent river track at speeds of up to 45 km/h (Dreamworld, 2010). After 30 years in
operation, on the 25th of October 2016, a safety incident occurred in which one of the water pumps
controlling the ride malfunctioned (Stone, 2018). As a result, the water level of the ride dropped
dramatically causing an empty raft to become jammed upon the support rails of the conveyor belt
before the unload platform. This raft remained stationary in this position for 57 seconds before
another raft on the ride containing 6 passengers; 4 adults and 2 children, collided with the empty one
three times, before both rafts pivoted upwards (Kerin, 2019). The occupied raft then further rose to a
vertical position due to the movement of the conveyor belt and partially flipped backwards. This
movement caused the passengers to fall onto the conveyor belt crushing two of the adult passengers
and drowning another two in the water below, resulting in 4 fatalities. The two children managed to
escape the raft without any physical harm. Following this tragedy, there was immediate the closure of
the ride indefinitely and a coronial inquest into the park which revealed a “systemic failure by
Dreamworld in relation to all aspects of safety” and a fine of $3.6 million to Dreamworld’s operator
company Ardent Leisure (Phillips, 2020). Additionally, the Queensland government introduced
several new regulations in the amusement ride industry to increase safety such as compulsory
inspections by qualified engineers of rides every 10 years and more comprehensive training for staff
to prevent accidents in the future (Grace, 2019).

Part II

Investigation into the safety incident involves careful analysis of causes and contributing factors that
resulted in the system displaying unexpected behaviours in order to learn from and prevent accidents
in the future. As aforementioned in the incident outline, the main cause of this incident can be
attributed to the malfunction of the water level pump, which caused the first unoccupied raft to get
stuck in low water levels and provided an obstruction for which the second occupied raft collided with
and flipped over. This malfunction was thought to have occurred due to earth and temperature faults
which were very frequent in the weeks leading up to the incident and can likely be attributed to the
age of the machine which was overdue for replacement (Stone, 2018). In addition, the design of the
conveyor belt and rafts in that there were large gaps exposing the water below and poor strength of
rider’s seatbelts heavily contributed to the fatalities that occurred as this resulted in the riders falling
into the water below and drowning as well as being crushed under the raft (Wolfe, 2018; Wilson,
2016). However, beyond these immediate elements that were observed as main causes, it is important
to consider the rapids ride as a sociotechnical system in which hardware, software, communication,
societal and organisational factors contributed to the devastation this incident caused. As will be
discussed in this report, the coronial inquest into Dreamworld exposed a poor safety culture, the clear
dismissal of safety recommendations, prior incidents and inadequate auditing and maintenance
procedures which underlies the Thunder Rapids Ride incident (Phillips, 2020). Within this, perhaps
the most concerning episode was that the ride had malfunctioned in a very similar fashion before in
2001 where low water levels had caused rafts to flip over, however as there were no passengers on the
ride, this incident was not evaluated in depth and attributed to the failure of the operator to follow
correct start up and emergency instructions (Kerin, 2019). The engineer at the time had written in an
email “I shudder when I think if guests had been on the ride”, highlighting despite an awareness of the
potential consequences there was an inability of Dreamworld to learn from their mistakes and
recognise the large margin for human error in operating procedures (Kerin, 2019). Consequently,
overall, a clear trade-off by the Dreamworld corporation between safety/durability of the ride and
cost-effectiveness as well as neglect of the concern for their visitors is evident in this case.

Part III

The Thunder River Rapids Ride was a large, technical ride comprised of a multitude of components to
provide a 4-minute thrilling experience for amusement park goers. A map outline of the ride can be
seen in Figure I.

Figure I. Park Map displaying the location of the Thunder River Rapids Ride in the Goldrush country
and an outline of the rapids track (Dreamworld, 2010)

The first main component of the ride was the river channel itself, which is a narrow channel with a
slight gradient spanning from the highest point at the beginning to the end of the ride to stimulate
downward water flow. Wooden slats were placed at the base of this river channel, disrupting smooth
water flow to simulate the “rapids” effect, providing a bumpy ride (Hafema Water Ride Systems,
2022).

Next, the water pumps used in the Thunder River Rapids ride were axial flow submersible pumps
manufactured by Danfoss (Stone, 2018). These pumps were crucial to maintain a constant water flow
throughout the ride. The design of these pumps had a large vertical water pumping capacity and thus
were situated at the end of the ride to offset the abrupt change in height from the end of the ride to the
station, due to the gradient of the channel.

The rafts of the Thunder Rapids Ride fit up to 6 people and consisted of a fibreglass body on top of a
rubber ring (Hafema Water Ride Systems, 2022). The circular fibreglass body included seats for
passengers, all facing inwards to the centre of the raft, with simple Velcro strap seatbelts which
required the riders to connect them themselves (Wolfe, 2018). The middle of the raft featured a metal
railing and a small storage space for passengers to place their belongings. The rubber ring provided
buoyancy as well as being a shock absorption buffer when the raft would hit the edges of the channel,
other rafts or any of the obstacles throughout the ride experience.

Another hardware component of the ride were conveyor belts leading to the end of the ride. This
conveyor belt is displayed in Figure II and can be seen to consist of wooden slats which form the belt
support which moves based on a motorised pulley system (Wilson, 2016). Friction allowed the raft to
sit on the conveyor belt and be lifted out of the stream of water completely and carried up the lift hill
to the disembarkation platform, where a rotating platform allowed riders to dismount without stopping
the rafts (Kerin, 2019). Gaps between the wooden slats of the conveyor belt were implemented to let
the water drip from the rafts back into the channel below whilst this process occurred.

Figure II. Conveyor belt on the Thunder River Rapids Ride in 2008. “Each full-width slat is spaced
out by two wooden blocks that leave large gaps in the lift hill” (Wilson, 2016)

The people component of this sociotechnical operating system involved the operators of the ride
themselves. Two attendants were required at all times in order to supervise the ride and were situated
in an operator box at the disembarkation platform. Within this area, there was an operating console
which contained a large network of lights, buttons, and screens and as such this ride was considered
by many operators as one of the most complex and challenging rides to operate in the Dreamworld
Park (Corden, 2018). Attendants followed routine procedures and consistently had to perform 36 tasks
upon the control panel within less than a minute (Kerin, 2019). The operating box was also fitted with
CCTV footage to allow operators to adequately supervise all sectors of the ride.

Finally, the last major components of the Thunder River Rapids were two emergency stop devices,
one positioned next to the operating console and the other next to the disembarkation platform
(Corden, 2018). The former gradually lead to the shutdown of the moving equipment, taking
approximately 8 seconds and was most often used in the case of an emergency as it was positioned
next to where the attendants were situated. By contrast, the other button led to an almost instantaneous
shut down within 2 seconds (Corden, 2018).

Part IV

The Thunder Rapids Ride was an in-house design and construction by Dreamworld, Gold Coast and
its parent company Ardent Leisure (Kerin, 2019). This is significant to note as most rapids rides in
other amusement parks were engineered and manufactured by Intamin. Within the design,
construction and maintenance of this ride, Dreamworld employed a range of third parties, for
example, the water pumps supplied by Danfoss were installed and maintained by Applied Electro
Systems, with Danfoss only being called out to the site once within the existence of Thunder River
Rapids Ride (Stone, 2018). Modifications to the ride were also done by Dreamworld without the
consultation of professionals and were often not passed onto regulators (Wilson, 2016).

Additionally, Dreamworld was also responsible for advising the training of operators and operating
manual which form a fundamental role in the knowledge and competence of the ride attendants. The
training session for this ride was 90 minutes long and was unstructured, with trainers generally
showing the trainees key features of the ride, emergency stop buttons and a basic outline of the
control panel (Nine Digital Pty Ltd, 2018). The operating manual was large and complex and did not
form a part of the training session but rather was for trainees to look through themselves and trainers
would sign off on this when they had completed it (Kerin, 2019). There were no tests of proficiency
or competence at any stage throughout the training and trainers were left to their own imagination for
how they wanted to conduct and mentor trainees.

Maintenance is another aspect of the design system. Maintenance crews were on-site daily and could
tend to up to 20 malfunctioning rides on a busy day which were classified as “code 6” faults to avert
unnecessary public panic (Corden, 2018). Consumable replacements such as nuts and bolts were often
replaced on the ride by regular maintenance crews, however issues with the pump had to be dealt with
by a licensed electrician or mechanic in the team. Furthermore, there was only one engineer each day
at Dreamworld Park who would attend to the most urgent problems (Stone, 2018). The ride also
meant to be shut down annually for review and major maintenance by licensed professionals (Kerin,
2019).

The Queensland government acted as the regulator of Dreamworld Park and the Thunder Rapids Ride.
The Work Health and Safety Regulation Act required amusement rides to be registered, logbooks and
operating manuals maintained as well as the routine testing, inspection and maintenance of rides to be
conducted (Queensland Government, 2021). Throughout the period of operation, the CEO of Ardent
Leisure described that “Ardent and Dreamworld engaged frequently with the regulator with
unwavering cooperation” (Wuth, 2020). Direct safety assessments by the regulator themselves were
not required, but rather third-party audits, inspections and reviews were carried out. The Thunder
River Rapids Ride required a certificate to operate which was due to expire in January 2016, in the
year the incident occurred. At the time, Dreamworld were granted an extension of this license as they
were “unable to find a competent person as defined under legislation to inspect the ride” (Kerin,
2019). In the week prior to the incident, a third-party engineer had inspected the ride and declared it
safe and structurally sound, however this was based upon visual inspection alone and did not include a
full safety audit (Kerin, 2019).

Finally, managers of the Dreamworld Park and Ardent Leisure played a significant role within the
safety culture. This component of the design system relates to the workplace culture and values. The
motto of Dreamworld is “to create happy memories that last a lifetime” and the organisation claims to
value “great service, fun and celebration, efficiency and innovation, and safety and quality.”
(Dreamworld, 2022). Consequently, it is evident that safety should have constituted a major part of
training and maintenance, however as the former safety manager testified “everyone thought it
[safety] was somebody else’s responsibility”, and Dreamworld dismissed previous incidents that had
occurred, where rafts had flipped, as no harm had been caused (Kerin, 2019). Additionally, junior
employees believed there was a culture of fear, lack of support from supervisors and Dreamworld was
constantly in conflict with the union over lack of rest breaks (Miles, 2016).

Part V

The examination of individual components as well as their interaction with other elements is a crucial
part of understanding this complex sociotechnical system and reveals deeper insight into the causes of
the incident to help avoid more amusement park safety incidents. Within the large range of
components identified in Part III/IV, two operational and two design components have been selected
from each section. However, it is important to note that other components were also significant to this
incident and their involvement has been highlighted through interactions with these four main
components.

V.I Water Pump

The water pumps on the Thunder River Rapids ride were installed a decade prior to the incident and
due to be replaced every ten years (Stone, 2018). Thus, late October 2016, when the incident occurred
was approximately end of the pump’s lifespan, yet no procedures to replace the pump had been
mentioned. Earth faults in the south pump had been recognised in 2015, and Danfoss was called to the
site and at the time a technical solution resolved this issue (Stone, 2018). In the three days leading up
to the incident, three pump failures had occurred and on the day of the incident itself, the pump had
already failed twice (Corden, 2018). The input that exactly led to these pump failures were discovered
post-incident in the fault logs as “heat seek temperature too high”, relating to heat issues, in
conjunction with several other earth faults as previously identified (Ludlow, 2020). The output of
pump failure resulted in cease of water flow and water draining back to the end of the ride where the
water is collected in a lake, leaving dangerously low water levels wherein the raft got stuck. The
pump was also thought to originally have interacted with software to output an alarm in the case of
pump failure, as outlined in the safety procedure manual however, this function was likely removed or
did not exist in the first place as it had been crossed out in the manual (Kerin, 2019).

Furthermore, the pumps were known to fail regularly, and it was considered verbal axiom of ride
attendants to simply reset the pump and continue with operation until the third failure, in contrast to
instructions in the operating manual (Corden, 2018). Hence, poor training and management of safety
culture at Dreamworld interacted as inputs with the technical faults in the pump, leading to tragedy.
Finally, this incident may have been avoided if additional inputs to the water pump operation
including water level sensors that automatically shut down the ride when the water level was too low
were installed. These were deemed by the coroner and engineers to be a relatively inexpensive
measure to enforce safety (approximately $3000), because at the time of the incident the ride relied on
the attendants to recognise the water level was too low by observing the water stain on the edge of the
river channel (Australian Associated Press, 2018; Kerin, 2019).

V.II Timber Slats

The arrangement of the timber slats on the conveyor belt as outlined in Part IV can be considered to
have played a direct role in at least one of the deaths that resulted from the Thunder River Rapids ride
as one individual had fallen out of the raft through the large gaps between these slats in the conveyor
belt and drowned in the water below (Wilson, 2016). The modifications to the ride in which timber
slats were removed, leaving larger spaces between each slat did not appear to have any apparent
necessity, however potential benefits may have included less maintenance work or increased surface
area for the water to drip off the raft back into the ride below. This modification which was not passed
onto the regulators and deviated from the original manufacturer’s guidelines, hence demonstrating
failure on behalf of the organisation to follow safety requirements as well as impaired communication
between Dreamworld and the Queensland government.

In addition, the fatality caused by this component also interacted with the use of Velcro seatbelts in
the rafts of which the Velcro had worn down over time affecting the ability of passenger to securely
fasten them, hence leading to the seatbelts coming undone as the raft was lifted by the movement of
the conveyor belt and the other raft it had collided with (Kerin, 2019). This could have been avoided
through the use of mechanical buckle seatbelts which are easy for the riders to correctly engage
themselves whilst also providing more durability and security.

V.III Training

Training contributed to this tragedy as lack of knowledge by ride operators led to many human errors,
which if properly addressed could have easily prevented this incident. At the time of the incident there
were two operators, Peter Nemeth, who had 4 years of experience as a ride operator and Courtney
Williams, a junior ride assistant who had received training that morning (Nine Digital Pty Ltd, 2018).
Inadequate training (as outlined in Part IV) was an overarching concept that interacted with a wide
range of components in this sociotechnical system as inputs and outputs. Firstly, the management and
poor safety culture instilled into employees at the park was a significant input into lack of a structured
training session that did not involve emergency response training or simulated evacuation drills,
which is especially concerning due to the many safety hazards and issues the ride had been recently
having (Corden, 2018). Additionally, lack of proper instruction on how to interpret the operator
manual as this had been noted as a difficult manual to understand and assessment of the knowledge
and competence of operators are crucial missing inputs that led to incomplete training. This is evident
as Courtney Williams had only been trained that morning and in her testimony alleged the trainer had
told her “don’t worry about it, you won’t need to use it” when showing her the emergency stop button
at the unload platform, thus displaying more value had been placed on efficiency and speed in training
to have employees available to supervise the ride on a superficial level, rather than focusing on safety
(Stone, 2018). As an output, the failure of training to educate trainees effectively is thus highlighted
by the fact that the junior ride operator did not know how to react in this circumstance as she was
awaiting instructions from the senior ride operator who was non-reactive (Stone, 2018).

In addition, gaps in knowledge and competence of more senior operators were also illuminated
following the tragedy with some noting they did not know there was a difference in emergency
shutdown time between the two different emergency stop buttons (Corden, 2018)). Consequently,
their ability to train junior staff would have been impaired and a cycle of incomplete safety training
perpetuated throughout the organisation.

Furthermore, hardware inputs of the control panel and emergency stop buttons also interacted with
training regarding their difficulty to understand and use, with unnecessary complications surrounding
both these aspects. Therefore, improvements to the operational system may have improved the
training process and facilitated safety competence. Moreover, there was great responsibility placed on
ride operators to identify risks and issues with the ride, with the absence of automated systems and
inputs from software to perform these roles (Kerin, 2019). Consequently, the importance of proper
training was even more imperative, and it can also be attributed to the failure of the organisation that
individuals without the qualifications or skill set were left to essentially perform risk assessments of
the ride, resulting in human errors having grave impacts upon the function of the entire Thunder River
Rapids Ride.

V.IV Maintenance

A robust maintenance management plan is an essential element of quality assurance and the long-term
safety and effectiveness of amusement park attractions. This incident which occurred highlighted
upon the poor maintenance procedures in place by Dreamworld and the evident trade-off in which
they focused upon cutting costs rather than hiring the appropriate experts to inspect and install
improvements to the ride. In fact, the owners had directed a reduction in spending on repairs and
maintenance in the months leading up to this incident after the records revealed Dreamworld was
approximately $125 000 over the maintenance budget for the financial year (Kerin, 2019). This
resulted in the low number of specialist maintenance individuals and engineers on site, as mentioned
in Part IV, with the only on-site engineer having been attending to another ride on the day of the
incident and was thus unable to address the Thunder River Rapids ride even after the water pump had
failed twice, which would have been considered a “code 6” fault requiring immediate attention
(Stone, 2018).

The coronial inquiry into this safety incident revealed that there had been no proper safety assessment
of the ride by a qualified engineer since the rides opening, despite the number of ad hoc modifications
that had been made to the ride throughout its period of operation (Phillips, 2020). Additionally, a
maintenance planner noted that in the 9 years he worked for Dreamworld he had never seen a licensed
engineer conduct a risk assessment during the annual shut-down and review period (Kerin, 2019). In
particular, regarding the period this incident occurred, October marked the beginning of spring,
drawing more guests to the rapids ride and thus there would have been significant pressure for the ride
to be opened, revealing the interaction between maintenance and societal components. Therefore,
there was hiring of third parties to do quick inspections of the rides in order to get approval for them
to run, without considering the finer details. In particular, the engineer who had signed off on the ride
a week prior as previously noted did not conduct a full safety audit and did not inspect the logbooks as
required by law, thus following the incident he was put before the Board of Professional Engineers
(Kerin, 2019). The Queensland Government has also since implemented much stricter regulations
around the licensing of theme parks and requires senior engineers to perform safety audits (Grace,
2019).

Furthermore, prior to the incident, there had been suggestions to improve the emergency stop button
functions, as it had been noted that the difference between the operating time of the buttons was not
understood and their accessibility of these was also complicated (Kerin, 2019). In addition, water
level sensors that automatically ceased the ride’s operation when the water level was too low had been
installed in other rides at Dreamworld and were also recommended for this ride. However, the
absence of action upon these suggestions displayed inadequate hardware and maintenance interacting
with the poor organisational culture to save on costs and lack of safety thinking.

In conclusion, the safety incident which occurred on the Thunder River Rapids Ride at Dreamworld,
Gold Coast displays lack of safety and security thinking by a number of people involved in the design
and operation of this ride. The repercussions of this incident were widespread and had a profound
effect upon the families of those whose deaths resulted from this tragedy as well as raising questions
for the ‘blind trust’ the public places in amusement park rides. It is important to evaluate all
components this incident as was completed in the coronial inquest in order to enact preventive
measures and tighter regulations to ensure the safety of all visitors to Dreamworld and other theme
parks.
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