The Queensland coroner late last month brought down a 279-page report on the tragic incident at Dreamworld theme park on October 25, 2016 that resulted in the deaths of four people. The document is a scathing indictment of the park’s operators Ardent Leisure and its board of management.

On the fatal day Roozbeh Araghi, 38, Luke Dorsett, 35, Kate Goodchild, 32, and Cindy Low, 42, were killed at the Gold Coast theme park when one of the two water pumps on the 30-year-old Thunder River Rapids ride (TRR) seriously malfunctioned. This produced a dramatic fall in the water level, causing two rafts to collide and flip over. Two children on the capsized raft were flung off and scrambled to safety but the four adults were crushed to death on the ride’s conveyor ramp. The ride was dismantled after the tragedy.

Categorically stating to a packed Brisbane Magistrates Court that Ardent Leisure was responsible for “total and systemic safety failures” that had produced the fatal incident, Coroner James McDougall declared that the company had “a culpable culture” from the board down.

McDougall’s damning conclusions were based on the extensive evidence gathered in a nearly three-and-a-half year investigation. The coroner declared the tragedy “was avoidable.” He referred to a litany of safety failures on the TRR ride over the period of its 30 years of operation. McDougall noted that there had been no proper safety assessment of the ride by a qualified engineer since it opened in 1987, or of “ad hoc” modifications made during its lifetime.

McDougall said that managers of the theme park had ignored previous safety incidents associated with the TRR ride. “I am satisfied that Dreamworld knew of their shortcomings but chose not to do anything about it,” he stated. “Clearly the risk of the rafts colliding was known to Dreamworld. The hazard and risks that caused the rafts to flip should have been identified by a qualified person. Unfortunately, Dreamworld never engaged such a person and the risks were never mitigated.”

Evidence showed that the TRR ride had broken down five times in the seven days prior to the fatal incident. There were three serious faults on the day of the accident that should have led to the ride being immediately shut down.

This information caused McDougall to declare that he found it “difficult to believe that safety action was not taken by the management.” Those breakdowns, however, were not the exception but rather the rule in the history of the ride. It had experienced a string of serious incidents since its inception, including in 2001, 2004, 2005 and 2014.

The “systemic” safety failures uncovered by the investigation included inadequate training for staff, poor emergency and safety procedures, and piecemeal engineering modifications undertaken without risk assessment.

Determined to maximise profits, senior management had reduced safety and maintenance jobs at Dreamworld to a bare minimum and had directed all staff—operators, maintenance workers and supervisors alike—to keep the rides going at all costs.

The tragedy, in other words, stemmed from the subordination of safety to the profit interests of the operators. An email summary of minutes from a March 2016 meeting showed that management had ordered “immediate cutbacks” on repairs and maintenance expenditure because “Dreamworld was $125,000 over budget on a year-to-date basis.”

McDougall also pointed to expert evidence that showed the very design and construction of the ride posed a “significant risk to the health and safety of patrons.” The ride, which was supposed to be a “low risk experience” catering for people as young as three years old, was designed to simulate white water rafting for six persons within each circular raft.

Under the conveyor belt, in a separate confined enclosure, were two water pumps designated “north and south” due to their positioning. While there were separate buttons to stop and start the pumps on the main control panel, there was no emergency stop for the south pump, or one that stopped both pumps simultaneously.

There was no formal water marker in the trough where rafts were loaded and unloaded. “Rather, operators were required to measure the water level by reference to a scum mark on the wall of the trough, which was made from years of the ride operating,” the coroner said. “It is clear the failure of the south pump was to blame for the disaster,” he stated.

Evidence given during the coronial inquiry included that of a young operator who said she was given only 90 minutes’ training before her first day running the ride. She stated that she did not know that the emergency button could quickly stop the conveyor belt.

McDougall noted a series of safety changes belatedly introduced by management after the deaths, including the audit and inspection of the amusement devices by qualified engineering firms. He remarked that though positive, they served to highlight “how rudimentary and deficient the safety management practices in place at Dreamworld were prior to this tragedy.”

McDougall concluded that, given the multiple systemic safety issues, “it was simply a matter of time” before a fatal incident occurred. He said that the risk that was posed “would have been easily identifiable to a competent person, had one ever been commissioned to conduct risk or hazard assessments of the ride.” He also declared he “reasonably suspected” Ardent had committed a workplace offence and confirmed he had referred his findings to the Queensland office of industrial relations to consider a prosecution.

However, even if such a prosecution were instigated and was successful, Ardent, a multi-million dollar company, could be fined no more than $3 million—the maximum penalty that can be imposed for a serious Workplace Health and Safety breach in Queensland. Corporate manslaughter prosecutions cannot be brought against Ardent Leisure directors and management as the relevant laws are limited to culpability for employee deaths only.

Anxious to bring the issue to a close, Queensland Labor Premier Annastacia Palaszczuk said the coroner’s findings would allow family members, and those affected by the tragedy, to finally find closure. Her real concern is not for the victims but to ensure that the state’s tourist trade is not further impacted.

For the year ending 25 June 2019, Ardent’s theme business, consisting of Dreamworld, WhiteWater World and SkyPoint, reported revenue of $67.1 million, up 0.5 percent on 2017-18.

In a statement last week, the CEO of the company’s Theme Parks division John Osborne and Ardent’s chairman of the board Dr Gary Weiss, declared that safety was their “number one priority.” “The new leadership team,” they declared, “is committed to continuing to improve and enhance safety systems and practices.”

One issue that was not probed in the hearings was the role of the trade unions. As the WSWS noted in 2016, the Australian Workers Union (AWU) covered the Dreamworld site. A number of its staff were members. After the tragedy, the AWU claimed to have warned management about a number of safety issues. The union, however, had issued no public statements and had worked to ensure that the theme park operated as per normal despite the grave dangers.

This was a graphic expression of the function of all of the unions, as an industrial police force of governments and the employers committed to the defence of corporate profits, including through the suppression of anger and concern among workers over the gutting of safety measures.