Dreamworld inquest: Timeline of the key evidence from ride operators and police

Updated

Day one

June 18, 2018

The inquest is told the Thunder River Rapids ride had broken down twice on October 25, 2016, hours before the fatal raft collision.

It heard a young ride operator did not know there was an emergency stop button (e-stop) within her reach. She was told "not to worry about that button, no-one uses it".

The inquest hears that a memo sent to staff a week prior, instructing them to only use e-stop if the ride's main control panel could not be reached.

It was revealed there was no drill training for Dreamworld staff for potential emergency situations and no automatic switch to shut down the ride if the water level dropped.

The inquest was told of previous collisions and incidents on the ride in 2001, 2004, 2005 and 2016.

Day two

June 19, 2018

The inquest hears that young ride operator Courtney Williams had only been trained on the Thunder River Rapids the morning of the 2016 fatal incident.

Senior ride operator Peter Nemeth said he was "surprised" to learn the e-stop button could halt the conveyor within two seconds.

Mr Nemeth said he hit the slow stop button "two or three times" before two rafts collided and police told the inquest the slow stop button was probably pressed 10 seconds after the fatal raft collision.

Mr Nemeth said the ride was "more stressful" than others in the park to manage because the job involved monitoring so many things at once.

Day three

June 20, 2018

Ride operator Courtney Williams says she felt "pressured" by a park manager not to talk to police after the fatalities.

Ms Williams told the inquest she had 90 minutes' training on her first day operating the ride.

She said she "didn't know" the emergency button would stop the conveyor from moving and did not believe she received "sufficient training" from Dreamworld.

Senior ride operator Peter Nemeth told the inquest it was "impossible" to manage responsibilities, with 36 checks required in less than a minute. He said senior and junior ride operators had no first aid or CPR training.

Day four

June 21, 2018

Courtney Williams' barrister Peter Callaghan tells the inquest his client feels "highly distressed" after giving evidence.

Senior ride operator Timothy Williams told the Coroner's Court hearing he had not participated in any emergency drills or simulations since the fatalities in 2016.

He said he did not consider a water pump failure to be an emergency and would initiate a normal shutdown procedure.

The inquest heard there was no alarm to signal when a pump had malfunctioned and that staff used a stain on the wall or "scum line" to monitor the ride's water levels.

Day five

June 22, 2018

The family of two of the victims of the 2016 tragedy release a statement saying they are "devastated" by evidence at the inquest and hold Dreamworld completely responsible.

Dreamworld employee Chloe Brix told the inquest she heard "through gossip" a ride operator was fired after a collision on the Thunder River Rapids in November 2014 that was "almost identical" to the fatal 2016 accident.

Park technician Matthew Robertson told the inquest he reset the ride's water pump after its second breakdown hours before the fatal raft accident, because the park's electrical team was "distracted" with other problems.

Mr Robertson said he was not taught how to assess whether a ride fault could be dangerous and had to use his "own judgment".

He said technicians could be called to about 20 ride shutdowns in one day because of faults.

Day six

June 25, 2018

Dreamworld's safety manager at the time of the incident tells the inquest about cutbacks in repairs and maintenance, which were ordered seven months prior.

The court heard the monthly expenditure in March 2016 — the same month Mark Thompson was hired — was $125,000 over budget on a year-to-date basis and Mr Thompson needed to stop "repairs and maintenance spending".

Mr Thompson said he needed the support of a team of six people to help manage the theme park's workplace health and safety, and after the incident, the court heard, six safety professionals were employed.

He was shown the theme park's first aid policy on the ride, from which a warning advising that rafts could flip had been deleted.

Day seven

June 26, 2018

Dreamworld trainer Amy Crisp tells the inquiry the junior employee working on the day understood how to shut down operations in the event of an emergency.

Ms Crisp said she "never questioned" her training of Ms Williams and thought the shutdown procedures "should have worked".

The court heard that at the time of the incident, Kate Goodchild's partner David Turner asked staff: "Why didn't you stop the ride?"

Ride supervisor Sarah Cotter said her opinion was that the conveyor was never shut down on the day, while mechanical fitter Michael Stead said safety culture at Dreamworld was "very sound".

Day eight

June 27, 2018

Dreamworld trainer Amy Crisp continues to give evidence, telling the court she was promoted to a full-time supervisor two months after the tragedy.

The inquest heard she became a ride instructor one year after starting her employment at the park in 2011.

Ms Crisp said she never knew an emergency e-stop button could stop the conveyor in two seconds, and never demonstrated its use to trainees.

The court heard it would have cost less than $10 a day for Dreamworld to have rostered two senior staff on the Thunder River Rapids ride each day, rather than a senior and junior operator.

Day nine

June 28, 2018

The inquest hears there was a "rat's nest" of wiring at the Thunder River Rapids ride control panel that could have led to dangerous malfunctions.

Electricians did not look for the cause of water pump malfunctions and just kept resetting them when they broke down.

The court heard electricians had a different understanding of the ride breakdown procedure and when to shut it down.

CCTV footage of the fatal accident was played to a closed session of the hearing.

Photos were also shown of a 2001 collision of rafts due to operator distraction, but no-one was on the ride at the time.

Day 10

June 29, 2018

An engineering supervisor tells the inquest the Thunder River Rapids ride "should not have been in service" when it malfunctioned and killed four people.

Peter Gardner told the court that the operational procedure was that a ride should be closed after two breakdowns in one day, and on the day of the tragedy, the ride should not have been in service after it broke down for the second time.

Mr Gardner also denied evidence by other engineering staff who said they understood the procedure to be that rides could break down three times before being shut down.

He also said it would have been "prudent" to call upon the manufacturer to help assess the issues.

Day 11

October 8, 2018

A Dreamworld maintenance boss concedes there was a "total failure by everybody" at the theme park to identify safety issues on the Thunder River Rapids ride.

The inquest was told some ride repairs were delayed for budgetary reasons and Dreamworld's safety guidelines had warned of the potential for rafts to tip.

Dreamworld maintenance planner Grant Naumann agreed the Thunder River Rapids ride was "completely unsafe".

"There were discussions with regards to the cost of a repair or the cost of a replacement and if it was decided that that could be deferred until such a time as it would fit the budget better, yes that happened," Mr Naumann responded.

Day 12

October 9, 2018

The inquest hears evidence that the ride had been declared safe a week before the tragedy, but the third-party inspector had not completed a full audit of the attraction.

On the day of the deaths, the ride would break down twice before the third fatal malfunction.

Details of the triple-0 call from Dreamworld was also revealed, with the park's control room operator Nigel Irwin telling emergency services that one victim was "totally unconscious turning blue".

Meanwhile, lawyers for four Dreamworld staff members announced they would be taking legal action against the park because their clients had suffered "severe psychological injuries".

Day 13

October 10

Former Dreamworld safety officer and paramedic Shane Green says nothing could have been done to save the four victims on the Thunder River Rapids.

Fellow theme park paramedic John Clark, one of the first people on the scene, said he did not immediately know a fourth person was trapped underwater.

He was stationed just 30 metres away from the entrance to the rapids ride on the day of the incident.

He said he realised the gravity of the situation the moment he arrived on the scene, but was initially only aware of three patients.

"When I was attempting to resuscitate the patient I had, I don't know if the water receded or the gentleman floated up, but there was another patient," Mr Clark said.

Day 18

October 17

Families of the four victims were reduced to tears when Dreamworld electrical engineering supervisor Scott Ritchie addressed them from the witness box, offering his sympathies "for everything you're going through".

Under questioning, Mr Ritchie agreed there was a "very significant breakdown of procedure" when the fatal accident occurred in 2016.

Topics: courts-and-trials, emergency-incidents, death, southport-4215, qld, brisbane-4000

First posted