In 2016, four lives were lost in a tragic accident at Dreamworld. The Thunder River Rapids Ride (TRRR) malfunctioned, causing the raft to flip and claim the lives of four adults within it. Two children in the raft survived.
An inquest into the deaths of Cindy Law, Kate Goodchild, Roozbeh Araghi, and Luke Dorsett was held in Queensland with the findings released by Coroner James McDougall in late February. Investigations following the incident uncovered irrefutable evidence to show that Dreamland’s poor record of safety measures and a lack of regular and rigorous maintenance procedures are to blame for the accident.
The report contains a scathing assessment of Dreamworld’s oversight in regards to the design of the TRRR, general safety standards, maintenance practices, robust training and education practices for staff, as well as leadership and board’s knowledge and failure to address and correct them.
Best-practice was not a priority for Dreamworld, nor was it followed during the lifecycle of the asset, particularly in relation to compliance Australian Standards, introduced and designed to ensure the safety of guests at the theme park. The inquest discovers beyond a doubt that ‘Dreamworld failed to undertake…a holistic examination of the TRRR by a suitably qualified engineer, so as to ensure its safe operation1‘.
Further, there is no evidence throughout the thirty years of operation that Dreamworld ever undertook a proper engineering risk assessment into the safety of the ride, even following modifications to the asset and two separate incidents in 2001 and 2004.
Despite Dreamworld’s reputation as a modern and world-class theme park, the report uncovered how departments within the business operated in silos, and indicated there were numerous missed opportunities to improve the safety of guests if only a competent person had ever been commissioned to conduct a risk and hazard assessment of the ride2.
The inquest and subsequent report reiterates some well-known truths about asset management, particularly within the maintenance and reliability sector. The culture of the business is a crucial element of asset management. It is highly critical that leaders understand culture as a factor which structures the actions of the business. Culture dictates the rules, values, behavioural patterns, and myths in business. As the incident at Dreamworld catastrophically highlights, when the culture of a business tacitly approves wilful ignorance of maintenance procedures, scant and ad hoc record keeping, unsafe operating systems, and unsophisticated reporting processes, the result is tragic. At Dreamworld, the result was the unnecessary loss of four lives.
If you’ve ever been privy to a conversation where leadership bemoans the costs associated with maintenance procedures on assets, speak up. Remind leaders that maintenance of assets is fundamental to the smooth operation of the business in general. Maintenance saves on future costs to the business, extends the life of the asset; maintenance increases the safety in operations, and it saves leadership and stakeholders on possible future court proceedings and expensive legal expenditure. And, as the Dreamworld inquest highlights, maintenance could very well save lives.
What are your thoughts on the Dreamworld tragedy and the subsequent coroner’s report? Let us know by emailing communciations@amcouncil.com.au. If you’re working in the maintenance and reliability arena of asset management we’d particularly enjoy hearing from you. Please get in touch to advise us how you’re achieving maintenance goals and how your business balances cost, risk and performance.
1 Sourced: http://www.courts.qld.gov.au/_data/assets/pdf_file/0004/641830/10545784-final-dreamworld-draft-6-for-upload.pdf p260
2 Sourced: http://www.courts.qld.gov.au/_data/assets/pdf_file/0004/641830/10545784-final-dreamworld-draft-6-for-upload.pdf p256