A relative of Kiwi woman Cindy Low who died in the Dreamworld tragedy said the loss was "heartbreaking" but was relieved for the family that the inquest was finally over.
Coroner James McDougall yesterday handed down his long-awaited findings from the inquest into the deaths of four people on the Thunder River Rapids ride in 2016, saying there was a "systemic failure" by Dreamworld in relation to "all aspects of safety".
He said the ride was completely unsafe, described safety procedures as "unsophisticated" and "rudimentary at best" and said it was simply a matter of time before an accident happened.
• Dreamworld tragedy: Queensland coroner to release findings into fatal ride
• 'Total failure': Coroner delivers findings into fatal Dreamworld tragedy
• Dreamworld inquest: Kiwi victim Cindy Low's daughter shares heartfelt tribute
• Dreamworld deaths - coroner's verdict: Family of New Zealand victim Cindy Low speak
Low's mother-in-law, Dianne Bond, who lives in Paraparaumu, told the Herald her and her husband were pleased the inquest was finally over for the grieving family.
"It was never an easy time sitting in the inquest, and the last three years and four months waiting."
"It is heartbreaking. We lost the most wonderful daughter-in-law - she was far too young. She was always so welcoming, so pleased to see us - and always happy to have a wine."
Bond said Low is deeply missed by all her family and her loss had had a "huge" impact on her children.
"We head over [to Australia] regularly to help look after the kids, and it's been really tough for them.
"Cindy used to love baking, with both her children. Isla loves baking now, and desperately misses her mum, especially baking cakes with her."
Yesterday the court heard from Isla who was just six when her mother was killed while on the ride with her brother, Kieran, during a family day out.
"Mum was a wonderful person with a very big heart," the now 9-year-old said in a statement read out by her father, Mathew Low, in the Brisbane Magistrates Court yesterday.
"I miss her hugs and the cakes she used to make."
Matthew, who is originally from New Plymouth, said their hearts ached "daily" at the memory of Low, who lived in Sydney but was born in New Zealand.
He said she "deserved the world".
"She had the heart of a tiger. She had mastered the art of unconditional love."
The inquest also heard a statement from Low's mother, who was in New Zealand when she received the news, read by her lawyer.
She told of how she had written a note to the young ride operator.
"I know my daughter wouldn't want her to carry the burden," she said.
Bond said the family were "pleased" with the recommendations handed down by the Coroner, which included referring Ardent Leisure, the owner and operator of the Gold Coast theme park, to the Office of Industrial Relations to consider whether there was sufficient evidence to show it committed breaches under workplace laws.
He also recommended regulatory changes, annual risk assessments and full inspections every five to 10 years.
"We just hope they are all followed up," Bond said.
Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi also died in the October 2016 tragedy which was caused when a water pump malfunctioned.
Three of the four victims were flung instantly into a mechanised conveyor when their raft collided with another and partially flipped on October 25. A crucial delay in manually stopping the ride caused the jammed raft to shake, plunging a fourth person into the machinery.
The inquest heard the malfunction was the third that day and the fifth in a week.
Inexperienced staff panicked, sending out a radio call stating there was a "raft in the conveyor" - the first indication something disastrous had happened, the inquest heard last year.
Despite the efforts of paramedics, the four had no chance of survival. Goodchild's 12-year-old daughter and Low's 10-year-old son survived the incident.
The wide-ranging inquest, which opened in June 2019, revealed a "litany of problems" with some experts declaring the tragedy was an "accident waiting to happen".
In his findings, McDougall said maintenance and safety records for the ride were scant and ad hoc.
He found there was no evidence Dreamworld conducted a thorough engineering risk assessment of the ride in the three decades it was open to the public.
"I find that shoddy record keeping was a significant contributor to this incident," he said.
"Failure to record the changes have contributed to the masking of the real risk of the (ride)."
He said the ride was completely unsafe when the tragedy occurred, with safety procedures described as "unsophisticated" and "rudimentary at best".
"It was simply a matter of time. That time came on October 25 (2016)."
In addition, Mr McDougall said the responsibilities placed on staff to operate the ride and supervise others were "clearly unreasonable and excessive".
Ardent Leisure Theme Parks chief executive John Osborne responded to the findings late yesterday.
"First and foremost, we express our deepest sympathies to the families and friends of Roozbeh Araghi, Luke Dorsett, Kate Goodchild and Cindy Low," he said in a statement.
"Our thoughts are also with the first responders, emergency services personnel, investigators, counsellors and Dreamworld team members affected by this tragedy.
"We would like to acknowledge the attendance and involvement of the families, witnesses and all other participants in the inquest process, as well as the Coroner and his team. We will now review the Coroner's report in detail before providing a further response tomorrow."
Queensland Premier Annastacia Palaszczuk has all but confirmed the state government will adopt every coronial recommendation.
• Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi were killed when Dreamworld's Thunder River Rapids ride malfunctioned on October 25, 2016.
• Two rafts collided on a conveyor when a water pump failed and caused water levels to drop dramatically.
• The malfunction was the third that day, and fifth in a week.
• The victims' raft was pushed into a vertical position and the victims plunged into the ride machinery, causing fatal injuries.
• Police uncovered multiple previous incidents with the ride, including a guest being thrown into the trough in 2004 when rafts collided.
• Despite recommendations for a single emergency stop, no single shutdown function was installed.
• Dreamworld electricians described the control panel wiring as a "rat's nest".
• Staff insisted the ride was one of the most complex to operate.
• The operator in charge on the day was given only 90 minutes of training.
• A supervisor said pump failures were frequent in the week preceding the tragedy.
• Staff were unaware of the theme park's policy to shut down an attraction after two failures in 24 hours, believing a third was needed for a supervisor to be notified.
• Engineering general manager admitted the ride "should never have opened" after the malfunctions.
• Government registration of Thunder River Rapids and other rides at the park were more than nine months overdue.
• Dreamworld executives announced cutbacks to maintenance and repair spending in 2016 due to falling profits.
•Workplace Health and Safety inspectors identified a "litany of concerns' on the ride's maintenance, including missing slats on the conveyor belt, excessive corrosion, crumbling concrete and unidentified controls.
• Modifications made to the attraction had never been approved by WPHS.
WHAT THE VICTIMS' FAMILIES HAVE SAID
• Relatives of two victims said in a statement they held Dreamworld "totally responsible" for the deaths.