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E76: Dreamworld disaster and the pathways to failure · Safe As Podcast

• 0:00
  When something goes wrong in seconds, do you blame the
• 0:02
  operator or the 10 decisions that made failure virtually
• 0:06
  inevitable? In 2016, Dreamworld's Thunder
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  River Rapids ride malfunctioned and four visitors died.
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  The junior ride operator closest to the emergency stop button
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  didn't press it. A family member of two of the
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  bereaved yelled at the operator. Why didn't you stop the ride?
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  All these feelings are understandable.
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  The question is too narrow to understand the disaster.
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  Instead, the authors in today's study argue that at least nine
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  latent valleys were already in place, quietly weakened the
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  system long before the day of the tragedy.
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  Good day everyone, welcome to Safe as I'm Doctor Ben
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  Hutchinson. Today's study is from Gregson
• 0:43
  and Quinlan 2024, titled Death of Dreamworld 10 Pathways to
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  Disaster and Failure to Learn, published in the Economic and
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  Labour Relations Review. On the 25th of October 2016, the
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  Thunder River Rapids ride malfunctioned.
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  A pump designed to regulate water levels stopped, water
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  levels dropped, a raft became grounded on conveyor belts and a
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  second raft collided, flipped and the adult occupants were
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  thrown into machinery and killed.
• 1:10
  Two children survived. Using Quinlan's 10 pathways to
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  failure model, the authors unpack had drawing well,
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  followed similar patterns, Pathway one engineering, design
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  and maintenance flaws The coroner found multiple failures
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  in design, engineering and maintenance.
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  The ride was built in house in the mid 80s with few surviving
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  records. The authors point out the ride
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  speed and sequencing made key components tightly coupled,
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  meaning little slack for recovery if something fails.
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  After the incident. An inspector found the ride in
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  generally poor condition with significant corrosion evidence
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  throughout the steel components and concrete degradation in
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  tunnels. The coroner noted that the basic
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  engineering controls like an interlocking shutdown if the
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  water pump failed, and a single clear emergency stop may have
• 1:53
  prevented the deaths pathway to failure to heed warning signs.
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  This wasn't a surprise with no signal, at least in hindsight.
• 2:01
  The paper details a history of high potential incidents on the
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  same right in 2001. Moving in stationary rafts
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  collided and a raft flipped before guests bought it.
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  A manager emailed leadership. I shudder what I think if they'd
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  been guests on that riot. There were further incidents in
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  2004 and five in 2008 and 14, including raft spacing issues,
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  sensor faults and evacuations. The authors argued that learning
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  was patchy and often dominated by administrative tweaks rather
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  than deeper redesign or automation.
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  Pathway 3 flaws and risk assessment Risk assessment was
• 2:33
  described as fragmented and poorly documented, the coroner
• 2:36
  observed. It does not appear that risk
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  assessments of rides within the park were carried out.
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  They were very ad hoc. The paper stresses a basic
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  point. There's no record.
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  Investigators and regulators now often assume it didn't happen.
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  And even if it did, undocumented assessments can't be reviewed,
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  tested or improved. Though I suspect some of my
• 2:54
  lawyer friends might disagree with this whole if it's not
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  documented, did it really happen?
• 2:58
  Argument pathway 4 Flaws in management systems The safety
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  management system isn't just a folder of procedures, it has to
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  work in practise. Dreamworld's operating
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  procedures were found to be ambiguous and poorly coordinated
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  across departments. The coroner concluded the
• 3:13
  procedures for the right were ambiguous and poorly worded and
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  that operating procedures were drafted with minimal input from
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  technical and safety staff. Training was also criticised.
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  Operators were not adequately trained to recognise immediate
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  danger conditions for the right. People also cites organisational
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  siloing. The former head of safety
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  described failures to share safety knowledge and a media
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  quote attributed to him says for some risks in the park everyone
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  thought it was someone else's responsibility.
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  Pathway 5. Flaws in system ordinary orders
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  existed. The quality and follow through
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  were major issues. Earlier external audits were
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  criticised for focusing on aesthetic issues rather than
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  proper safety assessment against standards.
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  Later audit scored Dreamworld poorly on safety documentation
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  and compliance and the coroner noted not all recommendations
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  were even implemented. An engineer performing annual
• 4:01
  inspections issued certification without being supplied essential
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  documentation and the coroner referred him to the professional
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  board. Pathway 6 Economic and
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  production pressures compromising safety.
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  This pathway is often hard to investigate and the authors
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  argue it's frequently under examined.
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  Not evidence of budget pressures affecting maintenance and
• 4:18
  safety. Resourcing meeting minutes
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  reportedly stated revenue is up but profit is down.
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  Cutbacks have now been enforced and repairs and maintenance
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  spending needs to stop while capital expenditure and new
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  attractions continued. Pathway 7 failures in regulatory
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  oversight regulation cops some serious criticism registration
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  inspections were overdue and had been granted extensions.
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  The coroner discussed post incident reforms including
• 4:42
  stronger inspection regimes and a safety case approach,
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  recognising that theme parks are high hazard workplaces.
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  Pathway 8 Concerns raised by workers or others that were
• 4:52
  ignored. A key piece of evidence is the
• 4:54
  Australian Workers Union memo to the regulator 20 months before
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  the deaths. It warned that single operator
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  staffing was a disaster waiting to happen.
• 5:02
  It asked for a full investigation ASAP.
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  The authors note this memo is not referenced in the coronial
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  report and question how the inspectorate responded, though
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  notably in hindsight you often do find these rare sort of
• 5:13
  whistleblowers who put their hand up and sometimes it's
• 5:16
  really difficult to sort of differentiate the noise from the
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  real early indicators and in hindsight it's always obvious.
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  Pathway 9. Poor communication or trust.
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  The paper suggests a climate where discipline and blame can
• 5:29
  suppress reporting and speaking up, citing commentary that fear
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  and sanctioning can weaken communication.
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  They also point to weak systems for incident reporting and
• 5:37
  tracking being underused because they weren't user friendly.
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  Pathway 10. Flaws in emergency and rescue
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  procedures in emergencies. Task load control design matter,
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  human factors evidence highlighted time sensitive
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  decision load, confusing emergency stop arrangements and
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  the challenge of coordinating action across separated operator
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  positions. So what can we make of the
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  findings? The 10 pathways model can act as
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  a structured self water template before incidents occur and the
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  kind of checklist for high potential incident
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  investigations. Some take home lessons might be
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  to strengthen maintenance and engineering controls, especially
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  automation and fail safe shutdowns for safety critical
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  functions. Make risk assessments real based
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  on workers done conditions. Tap into the expertise and
• 6:20
  warnings from people updated after incidents.
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  Modification staffing changes include modifications, change of
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  management, staffing changes or repeated breakdowns.
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  Demand audits to test systems in practise and not just
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  aesthetics, and ensure recommendations are completed,
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  tracked and verified even into the future and improve
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  regulatory capability and work of voice.
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  The paper supports safety case oversight and stronger empowered
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  safety representation. That's it on Safe AS.
• 6:49
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• 6:52
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