Tragedy repeating itself? Lessons from the Dreamworld disaster

New research into the Dreamworld Thunder River Rapids incident that killed four people suggests theme parks should be treated as high-hazard workplaces

The 2016 Dreamworld disaster – like other multiple-fatality incidents since it – is a grim reminder that amusement parks are high-hazard workplaces with latent risks. Unfortunately, new research highlights an ongoing “lurch-and-slide” problem that makes these disasters tragically familiar in underregulated industries, suggesting current efforts to tighten safety regimes are insufficient.

By deploying insights from disasters in another high-hazard industry – mining – UNSW Business School researchers Michael Quinlan and Dr Sarah Gregson found amusement parks are subject to the same “10 pathways” model that has helped identify risks in that industry. In the Dreamworld incident, as with most other multiple-fatality workplace disasters, they found most of the latent pathway failures that were likely to ramp up the risk were in play – in the Dreamworld case, arguably all 10.

Failing to recognise the pathways’ relevance to the amusement park industry – and thus failing to subject it to the same stricter standards as other high-risk industries like mining – means these disasters are likely to keep happening, Prof. Quinlan and Dr Gregson argue. “The Dreamworld disaster, sadly, follows a familiar pattern – the implementation of adequate workplace policies and processes around safety was not undertaken until a disaster occurred,” they wrote in Death at Dreamworld: Ten pathways to disaster and failure to learn.

“Without the public attention attracted by multiple deaths, corporate interests decry the imposition of ‘too much red tape’ as an unnecessary drag on commercial activities. Under the pressure created by increased public scrutiny when workers, customers or both are killed, governments commit to belated regulatory activity to deflect criticism.”

Calling out the “corroding effects of poor maintenance, inadequate management systems and regulatory failure” in particular, the paper also questions why theme parks – “high-hazard workplaces marked by injuries, deaths and ‘near misses’” – are not subject to more rigorous oversight and cites the need to address these risks through more stringent regulation.

“This is not a problem specific to Australia, and the failures of Dreamworld were not unique, as these incidents have been happening in other theme parks going back more than a decade,” said Prof. Quinlan, Emeritus Professor in the School of Management and Governance at UNSW Business School. “These rides give people a thrill because they feel like they’re at risk even though they’re not,” he added. “That’s what they think – but they’re at more risk than they realise.”

Thunder River Rapids disaster and the 10-pathways model

In October 2016, four adult visitors to southeast Queensland’s Dreamworld – the largest amusement park in Australia – were killed on the Thunder River Rapids ride when two inflatable rafts collided after a broken water pump allowed the ride’s water levels to drop, grounding the front raft. One senior and one junior operator were the only two staff operating the ride, and they failed to press the stop buttons in time to prevent the collision, among other significant failings identified in a subsequent coronial inquiry.

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The incident sparked significant media coverage that was largely critical of Dreamworld’s senior management and park safety; ultimately, CEO Craig Davidson resigned, and the company faced multimillion-dollar civil suits over the disaster.

In their paper, published in Cambridge University Press’ recent Economic and Labour Relations Review, Prof. Quinlan and Dr Gregson attempted to unravel the disaster’s causes by applying Prof. Quinlan’s “10 pathways” model of repeat causes of death and disaster.

The model identifies 10 latent failures that are “repeatedly associated with death and disaster in workplaces across different industries”, according to the paper. These are: engineering, design and maintenance flaws; failure to heed warning signs; flaws in risk assessment; flaws in management systems; flaws in system auditing; economic, production or reward pressures compromising safety; failures in regulatory oversight; concerns by workers, supervisors and others that were ignored; poor communication or trust around risk; and flaws in emergency and rescue procedures.

The researchers found virtually all the pathway failures were present in the Thunder River Rapids disaster, including significant design, engineering and maintenance flaws that led to problems such as inadequate seatbelts, the difficulty of operators to act quickly and in concert if problems arose, and a lack of basic automation functions that might have prevented the incident.

In addition, a post-incident inspection found the ride in poor condition, with significant corrosion and concrete degradation. It also found confusion amongst staff about correct safety procedures, with evidence of “siloing” that prevented efficient knowledge sharing. The ride had broken down twice already on the day of the incident, which should have prompted a maintenance closure but did not.

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Also instrumental was a failure to heed warning signs of ongoing deficiencies and the potential for a multiple-fatality event. “The main finding is that at least nine pathways, and probably all 10, were there, but there is no learning,” Prof. Quinlan said, pointing to a recent inquest into a similar incident in Tasmania in which six children were killed, as well as other theme park disasters in Queensland, including even at Dreamworld, since the 2016 disaster.

That’s despite Queensland’s implementation of a safety case regime, a stricter, licencing-centred regulatory system that emerged from the nuclear industry; other states have not even done that, according to Prof. Quinlan and Dr Gregson, the continued incidents likely reflect that these systems are not being implemented effectively. “Had Dreamworld management been more reflective and cognisant of their duties under Work Health and Safety legislation, or had the park been subject to more stringent regulatory oversight, the warning signals of impending disaster may have led to more effective preventative measures,” they wrote.

Insights from mining safety

Asking the right questions is critical to better understanding and preventing workplace disasters, which tend to fit a pattern that Dr Gregson, a Senior Lecturer, called “lurch and slide”: “They have a knee-jerk response immediately after, and then they let it slip.”

In mining, regulations require companies to define principal hazards – ones that can result in one or more deaths – and develop a detailed management plan. Such rigorous requirements, however, generally aren’t in place for theme parks.

Moreover, official investigations tend to rely overly on technical experts. Experts are a crucial part of investigations, “but you also need to listen to people at all stages of the organisation, particularly the workers who are actually doing the jobs and their safety representatives,” Prof. Quinlan said. “The danger of looking only at the technical side is that you can fail to appreciate the broader organisational failures that led to the incident and the business models that lead to employment practices such as a high level of casualisation and poor levels of training, which are common at places like Dreamworld. Put those two together, and you’re going to get safety problems.”

In his previous research, Prof. Quinlan found that safety representatives perform a vital role in mines and are part of why Australia’s mining industry is among the world’s safest. The lack of such a robust system in the theme park industry contributes to dangerous latent failures.

“One of the 10 pathways is failure to listen to those at risk – in this case, workers – and they haven’t addressed that issue,” Prof. Quinlan said, noting that the Dreamworld employees union had identified significant issues with the ride’s operation 18 months before the disaster. “Workers may not completely understand safety at the workplace, but they’re a voice that needs to be listened to because they’re there every day,” he said. “They may not always be right, but if you can’t explain why their concerns are not valid, you’ve got a problem.”

Key pathway failures

One pathway, involving whether profit concerns or cost-cutting compromise safety, is crucial for the theme park industry, where rides are often built in-house and thus not subject to much oversight, but it’s politically less palatable to address. “There’s always this mantra that ‘safety is our first priority’. Unfortunately, in practice, that isn’t always the case, and that’s understating it,” Prof. Quinlan said, noting that these pressures mean Pathway 6 – the existence of pressures that compromise safety – is pivotal but often gets less attention.

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“We call it the Voldemort pathway because no-one wants to talk about it; but if you don’t talk about it, you don’t address it,” he said. “It’s not unique – it’s a tension within our social system. If you recognise it, you’ll get a better outcome. But when you pretend it doesn’t exist? That’s a recipe for disaster.”

Pathway 6 is also an important problem because it can contribute to other failure points, such as maintenance failure. “If you cut back on maintenance costs, you look like a hero for a short time, but eventually something goes wrong when you don’t do routine maintenance anymore,” Prof. Quinlan said. “You do break-and-fix, which is cheaper, but you miss the unexpected failures.”

And while the Dreamworld inquiry found a significant failure was a lack of record-keeping, its evidence did show that there were “managerial decisions to cut back on spending, that the budget had to be trimmed, and that maintenance was a key area where they thought they could do that”, Dr Gregson added.

One contributing factor is that board members aren’t prosecuted, so they can “take credit for the financial success and no responsibility for the health and safety failures”, Prof. Quinlan said, noting that this is “not even logical” from a money-saving perspective because serious health and safety incidents have substantial financial costs.

“We really need to get to the board level with those issues,” he said. “Boards make decisions all the time that have financial and safety consequences for the organisation, but if something goes wrong, it’s usually somebody further down the chain that’s targeted for making that decision, not the context in which they were obliged to make that decision.”

It’s a “completely perverse system in some ways,” Dr Gregson added. “It’s interesting that the ride operators get fired for things that are kind of beyond their control, and the people at the top of the chain don’t bear any responsibility.”

Longer-term learnings needed

Workplace disasters, whether involving employees, visitors or both, spark official responses and often huge media outcries as entire communities are affected. But, like official responses, the media narrative usually overlooks the underlying causes of repeat disasters by focusing instead on incident specifics, Prof. Quinlan said. For instance, media stories typically emphasise the rescue story and fail to focus on the reasons behind disasters.

“I know that the first company appointed after two mine disasters was a public relations company, and you often see with earthquakes and other disasters that the narratives are all about rescue, not what caused or exacerbated the incident,” he said. “The media attention seems to be too personalised in human interest stories, which are important, but we need to look at the underlying story.”

It’s part of a larger issue involving the distillation of good ideas and overcoming barriers that keep them from having an impact. “You can have an idea about what causes disasters, and it could be a good idea that gets proved time and time again, but it doesn’t get picked up by regulators or become part of the media discourse,” Prof. Quinlan said. “That’s what we’re trying to point out – that there need to be longer-term learnings. People have this naïve idea that if someone has a really good idea, things will necessarily change.

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“Media publicity is good in getting some regulatory response,” he added. “But the regulatory response often falls short of doing something that’s really going to make a meaningful change, and, unfortunately, even good ideas take a long time to be accepted.”

And while he doesn’t argue that the 10-pathways model is perfect, Prof. Quinlan says it does have the capacity to improve safety. Currently, the Western Australian mines inspectorate uses the model, and some companies have begun using it as a self-audit tool. “They realise it has value because it targets what we know kills and maims people,” he said.

The paper concluded that amusement parks are “high-hazard workplaces with a real and demonstrable risk of multiple-fatality events, and they should be regulated accordingly”. It recommended requiring an occupational health and safety management system for principal hazards, periodic auditing, more stringent regulatory oversight, and a more robust system for input from health and safety representatives.