Somebody was always going to die at Dreamworld. It wasn't a question of if, but when.
The findings of the inquest into the tragedy that killed four people on the Thunder River Rapids are yet to be delivered but one thing is already clear: that ride was a time bomb.
Over the past two weeks, the families of Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozbeh Araghi have listened to witness after witness describe the many and varied ways Dreamworld executives failed their loved ones, reports news.com.au.
The fatal incident occurred on October 25, 2016 after a pump stopped working on the ride, causing water levels to drop and a raft to become stuck on the conveyor belt.
That raft was hit by another carrying Dorsett, Goodchild, her 12-year-old daughter Ebony, Araghi, Low and her son, Kieran, 10.
The vessel flipped, killing the adults. The children miraculously survived, only to watch their mothers perish.
The inquest has been told there were recurring mechanical problems and operating issues with the ride going back 15 years prior to the October 25, 2016 disaster, including an eerily similar incident in 2001.
On Thursday, former employee Joe Stenning described the "frightening" moment four rafts collided at the end of the conveyor belt shortly after he started his shift as a deckhand for the ride.
One raft crashed into the ride deck, another flipped upside down with a third raft landing on top. The fourth came off the conveyor and ended up perched at an angle on top of the other two.
"As you can imagine, it was pretty unreal to witness," Stenning said.
Stenning said that immediately after the incident, he was separated from the senior ride operator and gave a statement. He was instructed not to speak to his co-worker during the investigation.
A report on the incident cited visitor distraction, the absence of a second operator due to illness and an "employee panicking" as contributing factors to the collision.
It was recommended that emergency drills be carried out but the inquest heard that they never happened.
Stenning said he couldn't recall if he underwent any emergency training or retraining on the Thunder River Rapids ride in the aftermath of the incident.
In November 2014 — just two years before the tragedy — there was another raft collision, resulting in the sacking of an attendant.
But instead of allocating extra funds to improve safety, hire back up operators and improve training, Dreamworld's parent company Ardent Leisure did the opposite.
In March 2016, just seven months before the tragedy, the bosses ordered cutbacks to repairs and maintenance in favour of investing in new attractions, reports news.com.au.
Under questioning by the Low family's barrister Matthew Hickey, former Dreamworld safety manager Mark Thompson admitted "familiarity bred contempt" at Dreamworld, with new rides prioritised over "tried and true" ones like Thunder River Rapids.
At the time, Dreamworld's mandatory ride registration inspections were more than nine months overdue and the theme park had removed the alarm which alerted operators to dropping water levels on the Thunder River Rapids Ride.
Thompson told the inquest he needed six more people to help him operate the park.
"Quite often I was doing the ground work or the grunt work," he said.
"It made it hard for me to do proactive work when I was putting out forest fires."
By October, the park had requested a second extension from the State Government before getting the rides inspected.
"We had engaged a competent person but was let down by them," Thompson said.
"We asked for a further extension of time."
A safety audit conducted in July 2015 found Dreamworld was only 61.5 per cent compliant.
A score of 75 per cent of more is needed to be marked fully compliant on the register.
The audit report, shown to the inquest, showed the 2015 results was a "significant improvement" on the year before which scored 46.1 per cent.
The inquest was also shown minutes from an executive safety team which detailed the park's financial position in March 2016.
"Revenue is up but profit is down, cutbacks are now being enforced," the document said.
"Repairs and maintenance spending needs to stop."
The park, however, would continue to spend on capital expenditure, meaning money would still be available for new attractions. The minutes showed Dreamworld had exceeded its monthly budget by $120,000.
The inquest was also shown a safety policy which was reviewed in June 2015 and showed a crossed out paragraph about an alarm which sounded when a pump shut down.
The words crossed out included: "(An alarm will sound) when the main water pumps stop for this ride. If the pump stops for this ride then there is the potential for rafts to become a hazard to guests riding them. The rafts are very heavy and there are a lot of underwater obstacles that could cause the rafts to flip or entrap a guest".
The policy had been changed to say: "The Rapid Ride alarm will be sounded if there is a potential risk to any guest or staff member in the ride area — example: a guest or staff member has fallen in the water.
"This is a change from previous where the alarm would be activated due to the water pumps stopping."
Some of the most explosive testimony has come from Dreamworld training and compliance officer Amy Crisp, who instructed junior ride operator Courtney Williams on the day of the tragedy.
Williams was working her first shift as a load operator on the 30-year-old ride when the tragedy occurred.
She told the inquest she wasn't aware what an emergency stop button near the unloading area did and hadn't pushed it during the tragedy because she believed she needed authority from the senior ride attendant.
Crisp said Williams had "nodded in acknowledgment" when she had explained the function and when to use the emergency stop button that morning.
She did not press the button to show Williams how it operated and said at no point in her time at the park had she herself had to push the button.
"Touching of that button was not encouraged?" counsel assisting the coroner Ken Fleming QC asked Crisp.
"In an emergency it was," Crisp replied.
Fleming also queried how water levels were monitored on the ride, with a "scum line" the only indicator of whether they had dropped or not.
"The water stain on the wall, that was the only measure you had to determine the water level?" Fleming asked.
Crisp replied it was but agreed it would have been easy for a maintenance staff member to paint a depth indicator on the wall if it had been deemed necessary.
On Tuesday video of a walk-through with police involving Crisp days after the tragedy was played to the inquest.
Crisp defends her training of Williams in the video.
"I know that I showed her everything … not once did I question my training," Crisp tells detectives.
"As long as the rafts are bobbing around, you know that the water level is enough. As soon as they're not moving, or as soon as you notice the water level drop, that's how you know the water level is not right."
The words Dave Turner shouted at Dreamworld staff moments after witnessing his wife, brother-in-law and two other people die at the Gold Coast theme park, were heard at the inquest yesterday.
Turner had screamed at Dreamworld staff, "Why didn't you stop the ride?"
The inquest has heard the emergency stop button located next to Williams at the time — which would have stopped the ride's conveyor in two seconds — had not been pressed.
Asked if she believed Williams had done something wrong by not pressing the button, Crisp said she was not able to give an opinion.
"I think that you don't know what you're capable of if you're in shock," Williams said. "I can't say." But if she had been in the same situation, Crisp said she would have "hit the E stop".
Crisp, who was promoted from trainer to supervisor after the tragedy, defended her training of Williams.
"The way I gave my training, no, there couldn't have been anything improved," she said. "The systems behind it could always use additional information and resources. But the way I trained her, no I don't think anything could have been added to that."
She said "more engineering systems" to shut down the ride quickly was one way the tragedy could have been avoided.
Crisp also told the inquest the emergency button was only to be pressed if the senior operator was "incapacitated" and couldn't reach the main control panel, or when there was a risk to someone's safety.
At the time of the tragedy, the senior operator was Peter Nemeth.
"If Pete was not responding to her, then she should have gone to the main control panel," Crisp said of Williams. "If he wasn't responding to her, then I count that as (being incapacitated)."
Nemeth has testified that he repeatedly pushed a stop button on the main console, unaware that it stopped the conveyor about six seconds slower than the emergency button that Williams was next to at the time.
The inquest was also shown Ardent Leisure's response to questions from Workplace Health and Safety about the Thunder River Rapids ride.
In response to a question about why the fast emergency stop button at the unload platform was not labelled, Ardent Leisure said the button was "clearly marked on 25 October 2016".
The inquest was then shown a picture of the button taken by police that night.
In the picture the red, mushroom-shaped button on a yellow box did not have any label or markings which clearly showed it had an emergency function.
Ardent Leisure faces a payout of up to $5 million payout in civil damages claims if found negligent.
The inquest continues.
— With AAP
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