'Shoddy Record-Keeping' Masked True Risk Of Dreamworld Ride
Dreamworld operator Ardent Leisure could face criminal charges following a damning coroner's report into the Thunder River Rapids ride deaths in 2016.
The coroner found the Gold Coast theme park had "frighteningly unsophisticated" systems protecting patrons on the ride.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the ride malfunctioned.
Coroner James McDougall said Dreamworld presented itself as a modern world-class theme park but the safety procedures were rudimentary at best.
"There was a systemic failure by Dreamworld in relation to all aspects of safety to ensure that rides ... were well maintained and safe," he said on Monday.
He described the systems that were in place as "frighteningly unsophisticated".
McDougall said he also found there is 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 ... (and) contributed to the masking of the real risk of the (ride)," he said.
More than a hundred people packed the Brisbane Coroners Court to hear the long-awaited findings.
Low, Goodchild, Dorsett and Araghi died after being flung into a mechanised conveyor when their raft collided with another and partially flipped.
Goodchild's 12-year-old daughter and Low's 10-year-old son survived the incident.
On Monday morning, Goodchild and Dorsett's mother Kim Dorsett spoke of her grief, saying her greatest regret was not being there for her children on the day they needed her most.
"I wasn't there," she said while wiping tears from her face.
"The easier part was burying them, the harrowing part is living without them."
The pair's father, John Goodchild, said his grief was exacerbated after learning the malfunction could have been identified before the accident happened.
Police have recommended no criminal charges against Dreamworld staff over the fatal accident, but the coroner has referred the theme park's operator Ardent Leisure to the office of industrial relations to consider if there is enough evidence to show the company committed breaches of workplace laws.
The wide-ranging inquest, which opened in June, has unveiled a "litany of problems" with some experts declaring the tragedy was an accident waiting to happen.
The malfunction was the third that day, and fifth in a week.
Police uncovered multiple incidents involving the ride in the past with two rafts colliding in 2004, throwing a guest into the trough.
Despite recommendations for a single emergency stop, no single shutdown function was installed.
Queensland introduced new safety regulations for amusement rides including mandatory major inspections of rides by qualified engineers every 10 years and improved training for ride operators.
The state also tightened workplace health and safety prosecution laws.
Premier Annastacia Palaszczuk has promised the government will seriously consider the coroner's findings.
"Anything that is recommended today we owe it to those families to make sure it is implemented," she told Nine's Today program.