News.com.au's Joe Hildebrand reports on the Dreamworld inquest
The confounding combination of tragedy, idiocy and innocence that led to the death of four people at Dreamworld all comes down to one sad, simple word: Yes.
It is a word that has been heard over and over again at the inquest into the Thunder River Rapids horror, yet always uttered softly and sorrowfully.
As the Coroner's Court has picked apart what happened on that day two years ago, almost every procedure, every safety check, every layer of the once-iconic Gold Coast theme park has unravelled like a rotten ball of yarn.
Even the most precocious pulp fiction writer would never dare put to paper such a litany of incompetence and neglect. It would simply never be believed.
And yet here it is, laid out under oath, in a court of law, in arguably the most advanced, well-regulated Western democracy in the world.
At the coalface of this black comedy of errors is a junior female ride operator, who was handed a job that gave her responsibility over people's safety and yet was not given any specific training on how to do that.
She was within reach of an emergency stop button which could have stopped the ride in two seconds and yet, incredibly, she wasn't sure what the button was for.
In fact, Dreamworld management appeared to have actively discouraged staff from pressing the button.
Giving evidence at the inquest, Detective Sergeant Nicola Brown was asked by the barrister for two of the victims if it was the case that the emergency stop button was not even clearly labelled.
"Yes," she said.
Meanwhile, the senior ride operator who was in the main control room had access to another emergency stop button except it wasn't really an emergency stop button. It was in fact a "slow stop" button that took some seven seconds — seconds which cost four people their lives.
Forensic crash investigator Steven Cornish was asked if there was a real emergency stop button in the control room that would have avoided the tragedy.
"Yes," he said.
Not only that, the senior ride operator in the control room didn't even know that the other button would have stopped the ride almost immediately. Instead he frantically kept hitting what he thought was the emergency stop button in front of him and was shocked when nothing stopped.
The operator was asked by the lawyer for another victim if, had he known, he would have run to the other button and hit it, saving precious seconds.
"Yes," he said.
Yes, yes, yes. This is the word that will haunt the families of the dead. So many things that could have been done and not one of them was.
If the story ended there it would already defy belief. But it doesn't.
There was no automatic shutdown if the water on the ride reached a catastrophically low level.
And the water pump had failed twice in the hours leading up to the accident.
And the park had been warned by a staff member after a similar incident in 2001: "I shudder when I think if there had been guest on the ride."
And the safety manager had been told earlier in 2016 to cut "repairs and maintenance spending".
And the senior ride operator had less than a minute to conduct 36 checks.
And neither he nor his junior counterpart had any first aid training.
And in 2013 an audit recommended a single emergency stop system be put on the ride but it was never done.
And Dreamworld failed to get an independent audit of its big nine rides to ensure they were compliant with state safety laws.
And it emerged just this week that newer rides were given priority over older ones, like the Thunder River Rapids.
"Yes," former safety manager Mark Thompson said.
When tragedies like this occur there are typically two types of response: Some people call for heads to roll while others seek to blame "the system".
Yet the Dreamworld fiasco is such a layer cake of incompetence, so unprecedented in its dysfunction, that neither seems sufficient.
Individual staff members appear to have been so wholly unprepared and untrained for what now looks to be a wholly foreseeable incident that it is difficult to imagine how they could have reacted differently.
And as for blaming the system, that is also impossible for one simple reason: There was no system. Like pulling back the curtain on the Wizard of Oz, it has now become clear that a ride on which thousands of happy holiday-makers were unwittingly risking their lives was held together by nothing but luck. And then one day that luck ran out and four people paid for it.
With their lives.
Dreamworld is not just a Gold Coast icon, it is a national symbol. For years it was Australia's answer to Disneyland, a place that represented countless children's — well — dreams.
And that is why the death of these four innocent people has so tortured the national psyche. People die in wars every day, from famine and natural disaster. This is no less tragic but it is not shocking.
What offends the human soul is that in a place dedicated solely to happiness and innocence and pleasure there could be such callous disregard for human life, a contempt so careless and pervasive that it infected every aspect of a treasured national institution without anyone even knowing it was there.
The husband of one of the victims, who was there at the scene where his wife died, screamed out in the aftermath: "Why didn't you stop the ride?"
And yet it seems that the whole system was so utterly chaotic, the whole management so utterly unmanaged, that nobody could. Indeed, the whole emergency stopping mechanism never really existed.
This is what is so unbelievable about this rotten, tragic tale. If only there was someone or something to blame then perhaps we could dig some meaning from the ashes. Yet somehow everyone and everything is to blame. Everything is wrong. It is as though a mechanic opened up the bonnet of a car and found that instead of an engine there was a bowl of spaghetti.
It is tempting to write the whole thing off as another example of corporate greed putting profits before people and yet that is too easy.
For corporate greed may be evil but it is at least rational. And for a corporation to make profits, for its executives to enrich themselves, it must carry on existing and they must carry on working. Even if the fat cats did only care about money, it would still be in their financial interests that nobody died and people continued to spend money on their overpriced attractions.
Besides, the one thing that could have most easily averted the tragedy — the junior operator being told to hit the emergency stop button in the case of an emergency — would have cost absolutely nothing. Yet even that wasn't done.
The truth is in fact far worse. The terrifying thing is not that the management was so greedy but that it was so breathtakingly incompetent — literally to the point where it took away people's very breath.
Already there have been senior resignations and the park will likely be exposed to multimillion-dollar compensation claims and workplace safety prosecutions that could cripple it, yet at the same time police have been unable to recommend any criminal charges because the problems were so many and so pervasive that the disaster couldn't be sheeted home to a single individual.
The cumulative incompetence is so great, the catastrophe so absolute, that when the smoke clears there may well be no one and nothing left standing to blame.
And so the families of the victims are left alone with their anguish and their fury, in a tale in which nothing is just, nothing is fair and nothing is right.
And that is perhaps the greatest injustice of all.
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