The Dreamworld tragedy and the subsequent coroner’s investigation report issued today by Coroner James McDougall has highlighted a myriad of issues that lie at the heart of effective safety management systems in organisations.
Coroner McDougall said at the heart of the tragedy there was “systemic failure” of the organisation in respects of “all aspects of safety” including record keeping and risk registers.
He added “I find that shoddy record-keeping was a significant contributor to this incident”
“Failure to record the changes have contributed to the masking of the real risk of the (ride)” adding that “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)” Coroner McDougald said.
While It’s clear that while Dreamworld had a range of safety systems in place, the Coroner has emphasised that the organisation did not have some fundamental components of safety in existence such as a register of risks that systematically captured all the risks within the organisation. It had also failed to learn from previous incidents.
In his report, James McDougall said “Irresponsibly, and consequently tragically, the Safety Department at Dreamworld was not structured to operate effectively, with the safety systems in place at the time of the incident correctly described as ‘immature’. Document management was poor, with no formal risk register in place, members of the Department did not conduct any holistic risk assessments of rides with the general view being that the Engineering & Technical Department (E &T) were responsible for such matters. There were no safety audits conducted as to the human components of the ride systems at Dreamworld. Furthermore, members of the Safety Department were not involved in the drafting of Operating Procedures for the amusement rides, a responsibility left solely with the Operations Department. It seems clear that there was a significant segmentation of knowledge between the Departments, which was further exacerbated by a poor record and document management system, making information difficult to obtain and access. It is important to note that evidence suggests that members of the E&T Department were only involved in developing and implementing controls for a potential hazard once it had been brought to the Department’s attention.”
He went on to say that “Since the tragic incident, significant changes have been made at Dreamworld, including the audit and inspection of the amusement devices by qualified Engineering firms, consideration of WHS practices, reviews of operating procedures, changes to the training regime with emergency drills being introduced, as well as the introduction of a safety management system to control safety risks. Whilst these steps are certainly positive, they serve to highlight, particularly given the established safety management systems in place at Village Roadshow, how rudimentary and deficient the safety management practices in place at Dreamworld were prior to this tragedy. Such a culpable culture can exist only when leadership from the Board down are careless in respect of safety. That cannot be allowed.”
The Coroner’s Report raises a range of issues for safety compliance in organisations but most importantly it highlights the culpability for senior members of organisations at the most senior level.
To blindly accept that your organisation has ‘got it together’ in respect of risk management and safety, may just land you before a court or, at the very least a coronial inquiry.
Safetysure believes that at the fundamental level, an organisation must be able to systematically quantify all its’ risks and then make valued judgements about how it proceeds to control those risks. We understand that the budget isn’t endless but if you can’t see the wood for the trees, then you’ve got an accident waiting to happen.
Understanding the things that can kill, maim or give people tragic occupational diseases is at the heart of an effective safety management system. Unfortunately, it appears that this was sadly lost in the case of Dreamworld and its parent Ardent Leisure.
Coroner McDougall highlights “It does not appear from the records available, and the accounts of senior staff, that a full risk assessment of the Thunder River Rapids Ride was ever undertaken internally by Dreamworld. Mr. Deaves states that to his knowledge, there had not been any ‘formal assessment’ of the load and unload area of the TRRR. Whilst the ride was inspected daily by E&T staff, there was no regular assessment process to proactively determine whether hazards existed on rides, including the TRRR. Rather, issues would only be considered reactively, when an incident occurred. Furthermore, staff within the E&T Department were not aware of any previous risk assessments that may have been carried out on the TRRR.
No organisation can build a safety and risk management system on a gut ‘feeling.’ Organisations need to identify and consider all workplace health and safety risks methodically, strategically and periodically in order to consider their impacts.
Don’t be like Dreamworld used to be. Don’t major on minors and minor on the majors. Effective safety management begins with understanding what matters.
Contact us if you’d like some guidance in getting your safety on track.
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