Lessons Learned from a Fatal Accident
Lessons Learned: in this 30-minute video, we learn lessons from an accident in 2016 that killed four people on the Thunder River Rapids Ride in Queensland. The coroner's report was issued this year, and we went through the summary of that report. In it, we find failings in WHS Duties, Due Diligence, risk management, and failures to eliminate or minimize risks So Far As is Reasonably Practicable (SFARP). We do not 'name and shame', rather we focus on where we can find guidance to do better.
https://youtu.be/QaSoFld7W0g
In 2016, four people died on the Thunder River Rapids Ride.
Lessons Learned: Key Points
We examine multiple failings in:
- WHS Duties;
- WHS Due Diligence;
- Risk management; and
- Eliminating or minimizing risks So Far As is Reasonably Practicable (SFARP).
Transcript: Lessons Learned from a Theme Park Tragedy
Introduction
Hello, everyone, and welcome to the Safety Artisan: purveyors of fine safety engineering training videos and other resources. I'm Simon, and I'm your host and today we're going to be doing something slightly different. So, there are no PowerPoint slides. Instead, I'm going to be reading from a coroner's report from a well-known accident here in Australia, and we're going to be learning some lessons in the context of WHS workplace health and safety law.
Disclaimer
Now, I'd just like to reassure you before we start that I won't be mentioning the names of the deceased. I won't be sharing any images of them. And I'm not even going to mention the firm that owned the theme park because this is not about bashing people when they're down. It's about us as a community learning lessons when things go wrong to fix the problem, not the blame. So that's what I'd like to emphasize here.
The Coroner's Report
So, I'm just going to I'm just turning to the summary of the coroner's report. The coroner was examining the deaths of four people back in 2016 on what was called the Thunder River Rapids Ride. Or TRRR or TR3 for short because it's a bit of a mouthful. This was a water ride, as the name implies, and what went wrong was that the water level dropped. Rafts, these circular rafts that went down the rapids, went down the chute, got stuck. Another raft came up behind the stuck raft and went into it. One of the rafts tipped over. These rafts seat six people in a circular configuration. You may have seen them. They're in - different versions of this ride are in lots of theme parks.
But out of the six, unfortunately, the only two escaped before people were killed, tragically. So that's the background. That happened in October 2016, I think it was. The coroner's report came out a few months ago, and I've been wanting to talk about it for some time because it illustrates very well several issues where WHS can help us do the right thing.
WHS Duties
So, first of all, I'm looking at the first paragraph in the summary, the coroner starts off; the design and construction of the TRRR at the conveyor and unload area posed a significant risk to the health and safety of patrons. Notice that the coroner says the design and construction. Most people think that WHS only applies to workplaces and people managing workplaces, but it does a lot more than that. Sections 22 through 26 of the Act talk about the duties of designers, manufacturers, importers, suppliers, and then people who commissioned, installed, et cetera.
So, WHS supplies duties on a wide range of businesses and undertakings, and designers and constructors are key. There are two of them. Now, it's worth noting that there was no importer here. The theme park, although the TRRR ride was similar to a ride available commercially elsewhere, for some reason, they chose to design and build their version in Queensland. Don't know why. Anyway, that doesn't matter now. So, there was no importer, but otherwise, even if you didn't design and construct the thing, if you imported it, the same duties still apply to you.
No Effective Risk Assessment
So, the coroner then goes on to talk about risks and hazards and says each of these obvious hazards posed a risk to the safety of patrons on the ride and would have been easily identifiable to a competent person had one ever been commissioned to conduct a risk and hazard assessment of the ride. So, what the coroner is saying there is, “No effective risk assessment has been done”. Now, that is contrary to the risk management code of practice under WHS and also, of course, that the definition of SFARP, so far as reasonably practicable, basically is a risk assessment or risk management process. So, if you've not done effective risk management, you can't say that you've eliminated or minimized risks SFARP, which is another legal requirement. So, a double whammy there.
Then moving on. “Had noticed been taken of lessons learned from the preceding incidents, which were all of a very similar nature …” and then he goes on. That's the back end of a sentence where he says, you didn't do this, you had incidents on the ride, which are very similar in the past, and you didn't learn from them. And again, concerning reducing risks SFARP, Section 18 in the WHS Act, which talks about the definition of reasonably practicable, which is the core of SFARP, talks about what ought to have been known at the time.
So, when you're doing a risk assessment or maybe you're reassessing risk after a modification - and this ride was heavily modified several times or after an incident - you need to take account of the available information. And the owners of TRRR the operators didn't do that. So, another big failing.
The coroner goes on to note that records available concerning the modifications to the ride are scant and ad hoc. And again, there's a section in the WHS risk management code of practice about keeping records. It's not that onerous. I mean, the COP is pretty simple but they didn't meet the requirement of the code of practice. So, bad news again.
Due Diligence
And then finally, I’ve got to the bottom of page one. So, the coroner then notes the maintenance tasks undertaken on the ride whilst done so regularly and diligently by the staff, seemed to have been based upon historical checklists which were rarely reviewed despite the age of the device or changes to the applicable Australian standards. Now, this is interesting. So, this is contravening a different section of the WHS Act.
Section 27, talks about the duties of officers and effectively that sort of company directors, and senior managers. Officers are supposed to exercise due diligence. In the act, due diligence is fairly simple- It's six bullet points, but one of them is that the officers have to sort of keep up to date on what's going on in their operation. They have to provide up-to-date and effective safety information for their staff. They're also supposed to keep up with what's going on in safety regulations that apply to their operation. So, I reckon in that one statement from the coroner then there's probably three breaches of due diligence there to start with.
Risk Controls Lacking
We've reached the bottom of page one- Let's carry on. The coroner then goes on to talk about risk controls that were or were not present and says, “in accordance with the hierarchy of controls, plant and engineering measures should have been considered as solutions to identified hazards”. So in WHS regulations and it’s repeated in the risk code of practice, there's a thing called the hierarchy of controls. It says that some types of risk controls are more effective than others and therefore they come at the top of the list, whereas others are less effective and should be considered last.
So, top of the list is, “Can you eliminate the hazard?” If not, can you substitute the hazardous thing for something else that's less hazardous- or with something else that is less hazardous, I should say? Can you put in engineering solutions or controls to control hazards? And then finally, at the bottom of my list are admin procedures for people to follow and then personal protective equipment for workers, for example. We'll talk about this more later, but the top end of the hierarchy had just not been considered or not effectively anyway.
A Predictable Risk
So, the coroner then goes on to say, “rafts coming together on the ride was a well-known risk, highlighted by the incident in 2001 and again in 2004”. Now actually it says 2004, I think that might be a typo. Elsewhere, it says 2014, but certainly, two significant incidents were similar to the accident that killed four people. And it was acknowledged that various corrective measures could be undertaken to, quote, “adequately control the risk of raft collision”.
However, a number of these suggestions were not implemented on the ride. Now, given that they've demonstrated the ability to kill multiple people on the ride with a raft collision, it's going to be a very, very difficult thing to justify not implementing controls. So, given the seriousness of the potential risk, to say that a control is feasible is practicable, but then to say “We're not going to do it. It's not reasonable”. That's going to be very, very difficult to argue and I would suggest it's almost a certainty that not all reasonably practicable controls were implemented, which means the risk is not SFARP, which is a legal requirement.
Further on, we come back to document management, which was poor with no formal risk register in place. So, no evidence of a proper risk assessment. Members of the department did not conduct any holistic risk assessments of rides with the general view that another department was responsible. So, the fact that risk assessment wasn't done - that's a failure. The fact that senior management didn't knock heads together and say “This has to be done. Make it happen”- That's also another failing. That’s a failing of due diligence, I suspect. So, we've got a couple more problems there.
High-Risk Plant
Then, later on, the coroner talks about necessary engineering oversight of high-risk plant not being done. Now, under WHS act definitions, amusement rides are counted as high-risk plant, presumably because of the number of serious accidents that have happened with them over the years. The managers of the TRRR didn't meet their obligations concerning high-risk plants. So, some things that are optional for common stuff are mandatory for high-risk plants, and those obligations were not met it seems.
And then in just the next paragraph, we reinforce this due diligence issue. Only a scant amount of knowledge was held by those in management positions, including the general manager of engineering, as to the design modifications and past notable incidents on the ride. One of the requirements of due diligence is that senior management must know their operations, and know the hazards and risks associated with the operations. So for the engineering manager to be ignorant about modifications and risks associated with the ride, I think is a clear failure of due diligence.
Still talking about engineering, the coroner notes “it is significant that the general manager had no knowledge of past incidents involving rafts coming together on the ride”. Again, due diligence. If things have happened those need to be investigated and learned from and then you need to apply fresh controls if that's required. And again, this is a requirement. So, this shows a lack of due diligence. It's also a requirement in the risk management code of practice to look at things when new knowledge is gained. So, a couple more failures there.
No Water-Level Detection, Alarm, Or Emergency Stop
Now, it said that the operators of the ride were well aware that when one pump failed, and there were two, the ride was no longer able to operate with the water level dropping dramatically, stranding the rafts on the steel support railings. And of course, that's how the accident happened. Regardless, there was no formal means by which to monitor the water level of the ride and no audible alarm to advise one of the pumps had ceased to operate. So, a water level monitor? Well, we're talking potentially about a float, which is a pretty simple thing. There's one in every cistern, in every toilet in Australia. Maybe the one for the ride would have to be a bit more sophisticated than that- A bit industrial grade but the same principle.
And no alarm to advise the operators that this pump had failed, even though it was known that this would have a serious effect on the operation of the ride. So, there are multiple problems here. I suspect you'll be able to find regulations that require these things. Certainly, if you looked at the code of practice on plant design because this counts as industrial plants, it's a high-risk plant, so you would expect very high standards of engineering controls on high-risk plants and these were missing. More on that later.
In a similar vein, the coroner says “a basic automated detection system for the water level would have been inexpensive and may have prevented the incident from occurring”. So basically, the coroner is saying this control mechanism would have been cheap so it's certainly reasonably practicable. If you've got a cheap control that will prevent a serious injury or a death, then how on earth are you going to argue that it's not reasonable to implement it? The onus is on us to implement all reasonably practical controls.
And then similarly, the lack of a single emergency stop on the ride, which was capable of initiating a complete shutdown of all the mechanisms, was also inadequate. And that's another requirement from the code of practice on plant design, which refers back to WHS regulations. So, another breach there.
Human Factors
We then move on to a section where it talks about operators, operators’ accounts of the incident, and other human factors. I'm probably going to ask my friend Peter Bender, who is a Human Factors specialist, to come and do a session on this and look at this in some more detail, because there are rich pickings in this section and I'm just going to skim the surface here because we haven't got time to do more.
The coroner says “it's clear that these 38 signals and checks to be undertaken by the ride operators was excessive, particularly given that the failure to carry out any one could potentially be a factor which would contribute to a serious incident”. So clearly, 38 signals and checks were distributed between two ride operators, because there was no one operator in control of the whole ride- that's a human factors nightmare for a start- but clearly, the work designed for the ride was poor. There is good guidance available from Safe Work Australia on good work design so there's no excuse for this kind of lapse.
And then the coroner goes on to say, reinforcing this point that the ride couldn't be safely controlled by a human operator. The lack of engineering controls on a ride of this nature is unjustifiable. Again, reinforces the point that risk was not SFARP because not all reasonably practicable controls had been implemented. Particularly controls at the higher end of the hierarchy of controls. So, a serious failing there.
(Now, I've got something that I'm going to skip, actually, but - It's a heck of a comment, but it's not relevant to WHS.)
Training And Competence
We're moving on to training and competence. Those responsible for managing the ride whilst following the process and procedure in place - and I'm glad to see you from a human practice point of view that the coroner is not just trying to blame the last person who touched it. He's making a point of saying the operators did all the right stuff. Nevertheless, they were largely not qualified to perform the work for which they were charged.
The process and procedures that they were following seemed to have been created by unknown persons. Because of the poor record-keeping, presumably who it is safe to assume lacked the necessary expertise. And I think the coroner is making a reasonable assumption there, given the multiple failings that we've seen in risk management, in due diligence, in record-keeping, in the knowledge of key people, et cetera, et cetera. It seems that the practice at the park was simply to accept what had always been done in terms of policy and procedure.
And despite changes to safety standards and practices happening over time, because this is an old ride, only limited and largely reactionary consideration was ever given to making changes, including training, provided to staff. So, reactionary -bad word. We're supposed to predict risk and prevent harm from happening. So, multiple failures in due diligence here and on staff training, providing adequate staff training, providing adequate procedures, et cetera.
The coroner goes on to say, “regardless of the training provided at the park, it would never have been sufficient to overcome the poor design of the ride. The lack of automation and engineering controls”. So, again, the hierarchy of controls was not applied, and relatively cheap, engineering controls were not used, placing an undue burden on the operator. Sadly, this is all too common in many applications. This is one of the reasons they are not naming the ride operators or trying to shame them because I've seen this happen in so many different places. It wouldn't be fair to single these people out.
‘Incident-Free’ Operations?
Now we have a curious, a curious little statement in paragraph 1040. The coroner says “submissions are made that there was a 30-year history of incident-free operation of the ride”. So, what it looks like is that the ride operators, and management, trying to tell the coroner that they never had an incident on the ride in 30 years, which sounds pretty impressive, doesn't it, at face value?
But of course, the coroner already knew or discovered later on that there had been incidents on the ride. Two previous incidents were very similar to the fatal accident. Now, on the surface, this looks bad, doesn't it? It looks like the ride management was trying to mislead the coroner. I don't think that's the case because I've seen many organizations do poor incident reporting, poor incident recording, and poor learning from experience from incidents. It doesn't surprise me that the senior management was not aware of incidents on their ride. Unfortunately, it's partly human nature.
Nobody likes to dwell on their failures or think about nasty things happening, and nobody likes to go to the boss saying we need to shut down a moneymaking ride. Don't forget, this was a very popular ride. We need to shut down a moneymaking ride to spend more money on modifications to make it safer. And then management turns around and says, “Well, nobody's been hurt. So, what's the problem?” And again, I've seen this attitude again and again, even on people operating much more sophisticated and much more dangerous equipment than this. So, whilst this does look bad- the optics are not good, as they like to say. I don't think there's a conspiracy going on here. I think it's just stupid mistakes because it's so common. Moving on.
Standards
Now the coroner goes on to talk about standards not being followed, particularly when standards get updated over time. Bearing in mind this ride was 30 years old. The coroner states “it is essential that any difference in these standards are recognized and steps taken to ensure any shortfalls with a device manufactured internationally is managed”. Now, this is a little bit of an aside, because as I've mentioned before, the TRRR was actually designed and manufactured in Australia. Albeit not to any standards that we would recognize these days. But most rides were not and this highlights the duties of importers. So, if you import something from abroad, you need to make sure that it complies with Australian requirements. That's a requirement, that's a duty under WHS law. We'll come back to this in just a moment.
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Simon Di Nucci
https://www.safetyartisan.com/2023/12/06/lessons-learned-from-a-fatal-accident/
