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Death at Dreamworld: Ten pathways to disaster and failure to learn

Published online by Cambridge University Press:  06 September 2024

Sarah Gregson*
Affiliation:
University of New South Wales, Sydney, NSW, Australia
Michael G. Quinlan
Affiliation:
University of New South Wales, Sydney, NSW, Australia
*
Corresponding author: Sarah Gregson; Email: [email protected]

Abstract

Deaths in workplace incidents – of both workers and members of the public – normally spark a number of official responses, including coronial inquests. In many instances, however, these investigations have examined the incident in isolation from the wider context of hazards in that industry and are rarely informed by the extensive research literature on health and safety, and death and disaster, at work. In this examination of a tragic theme park disaster in 2016, we demonstrate that applying a wider lens and drawing on the ‘ten pathways model’ not only provides a more compelling explanation of how and why safety measures failed but may also inform more fatality and injury prevention measures. Drawing on James Reasonʼs concept of latent failures, the ten pathways model identifies latent failures that are repeatedly associated with death and disaster in workplaces across different industries. Using the Dreamworld coronial inquest findings and other related source material, this paper finds that at least nine and possibly all ten pattern failures were present in the Thunder River Rapids ride disaster at the Dreamworld theme park and contributed to the deaths of four visitors. In particular, it highlights the corroding effects of poor maintenance, inadequate management systems, and regulatory failure. The paper also raises questions about why theme parks as high-hazard workplaces marked by injuries, deaths, and ‘near misses’ were not subject to more rigorous oversight prior to the event and how regulatory failures might best be addressed.

Type
Original Article
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of The University of New South Wales

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References

Anthony, T and Crofts, P (2024) The Dreamworld deaths: corporate crime and the slumber of the law. Current Issues in Criminal Justice, online publication, doi: 10.1080/10345329.2024.2342582 CrossRefGoogle Scholar
Avery, B and Dickson, D (2010) Insight into amusement park ride and device safety in the United States. Worldwide Hospitality and Tourism Themes 2(3), 299315. https://doi.org/10.1108/17554211011052221 CrossRefGoogle Scholar
Jackson, E (2018) Dreamworld prioritised new attractions over maintenance of old rides. Australian Financial Review, 26 June. Available at: https://www.afr.com/property/commercial/dreamworld-prioritised-new-attractions-over-maintenance-of-old-rides-inquest-20180626-h11urb (accessed 14 May 2024).Google Scholar
Gregson, S and Humphrys, E (2020) GBThe West ate ridge collapse: how disaster happens. In Sheldon, P, Gregson, S, Lansbury, R and Sanders, K (eds) The Regulation and Management of Workplace Health and Safety. New York: Routledge, 32–51.Google Scholar
Hopkins, A (1999) Repeat disasters: the lessons of the Moura coalmine. In Peterson, C and Mayhew, C (eds) Occupational Health and Safety in Australia. Sydney: Allen & Unwin.Google Scholar
Hopkins, A (2005) Safety, Culture and Risk: The Organisational Causes of Disaster. North Ryde: CCH Australia.Google Scholar
Hopkins, A (2008) Failure to learn: The Texas City Oil Refinery Disaster. Sydney: CCH Australia.Google Scholar
Hopkins, A (2012) Disastrous Decisions: The Human and Organisational Causes of the Gulf of Mexico Blow-out. Sydney: CCH Australia.Google Scholar
Hopkins, A (2015) Book review: ten pathways to death and disaster: learning from fatal incidents in mines and other workplaces. Economic and Labour Relations Review 26(3), 496509.CrossRefGoogle Scholar
Jackson, H (2021) Recurrent Causes of Occupational Incidents in the NSW, Australia Coal and Metalliferous Mining Industry. Callaghan: University of Newcastle.Google Scholar
Jackson, H (2023) Pathways to single fatality and serious injury incidents in coal and metalliferous mining in NSW, Australia: Can we learn from multiple fatality incidents to prevent serious injury? Safety Science, 165, 106194. https://doi.org/10.1016/j.ssci.2023.106194.CrossRefGoogle Scholar
Jenke, T, Boylan, JL, Beatty, S, Ralph, M, Chaplyn, A, Penney, G and Cattani, M (2022) Fatality risk management: Applying Quinlan’s Ten Pathways in Western Australia’s mining industry.Safety Science, 146, 105494. https://doi.org/10.1016/j.ssci.2021.105494.CrossRefGoogle Scholar
Jenke, T, Oosthuizen, J and Cattani, M (2021). An investigation of the influence of economic cycles on safety performance in Western Australia.. Safety Science 138, 105230. https://doi.org/10.1016/j.ssci.2021.105230.CrossRefGoogle Scholar
Kerin, T (2020) Taming the wild river rapids: how process safety can apply outside the process industries. Process Safety Progress 39(1), 7. https://doi.org/10.1002/prs.12088 CrossRefGoogle Scholar
Matthews, L, Johnstone, R, Quinlan, M, Rawling-Way, O and Bohle, P (2019a) Work fatalities, bereaved families and the enforcement of OHS legislation. Journal of Industrial Relations 61(5), 637–56. https://doi.org/10.1177/0022185619829181 CrossRefGoogle Scholar
Matthews, LR, Quinlan, MG and Bohle, P (2019b) Posttraumatic stress disorder, depression, and prolonged grief disorder in families bereaved by a Traumatic workplace death: the need for satisfactory information and support. Frontiers of Psychiatry 10, 609. https://doi.org/10.3389/fpsyt.2019.00609 CrossRefGoogle ScholarPubMed
Matthews, L, Quinlan, M, Jessup, G and Bohle, P (2022) Hidden costs, hidden lives: financial effects of fatal work injuries on families. Economic and Labour Relations Review 33(3), 586609. https://doi.org/10.1177/10353046221114591 CrossRefGoogle Scholar
Mohun, A (2001) Designed for thrills and safety: amusement parks and the commodification of risk, 1880–1929. Journal of Design History 14(4), 291306. https://doi.org/10.1177/10353046221114591 CrossRefGoogle Scholar
McDougall, J (2020) Inquest into the Deaths of Kate Goodchild, Luke Dorsett, Cindy Low & Roozbeh Araghi at Dreamworld, October 2016: Findings and Recommendations. Southport: Coroner Court of Queensland.Google Scholar
Mulvihill, A and Rossen, J (2020) Action Park: Fast Times, Wild Rides, and the Untold Story of America’s Most Dangerous Amusement Park. New York: Penguin Books.Google Scholar
Ngo, M, Matthews, L, Quinlan, M and Bohle, P (2021) Bereaved family members’ views and experiences of the value of coronial inquests into fatal work incidents. OMEGA - Journal of Death and Dying 82(3), 446466. https://doi.org/10.1177/0030222818819344 CrossRefGoogle ScholarPubMed
Nichols, T and Walters, D (2013) Safety or Profit? International Studies in Governance, Change and the Work Environment. New York: Baywood Publishing.Google ScholarPubMed
Pelletier, A and Gilchrist, J (2005) Roller coaster related fatalities, United States, 1994–2004. Injury Prevention 11, 309312. https://doi.org/10.1136/ip.2005.008425 CrossRefGoogle ScholarPubMed
Perrow, C (1984) Normal Accidents: Living with High-Risk Technologies. Princeton: Princeton University Press.Google Scholar
Queensland Coal Mining Board of Inquiry (2021) Grosvenor Report Part 2. Brisbane: Queensland Government.Google Scholar
Quinlan, M, Johnstone, R and Mayhew, C (2006) Trucking tragedies: the hidden disaster of mass death in the long haul road transport industry. In Tucker, Eric (ed) Working Disasters. New York: Baywood, 19–64.Google Scholar
Quinlan, M (2014) Ten Pathways to Death and Disaster: Learning from Fatal Incidents in mines and other High Hazard Workplaces. Sydney: Federation Press.Google Scholar
Quinlan, M (2020) Five challenges to humanity: learning from pattern/repeat failures in past disasters, Economic and Labour Relations Review 31(3), 444466.https://doi.org/10.1177/1035304620944301 CrossRefGoogle Scholar
Quinlan, M (2024) Subcontracting, repeat latent failures and workplace disasters. In Le Coze, J and Journe, B (eds) Safe Performance in a World of Global Networks: Case Studies, Collaborative Practices and Governance Principles. Cham: Springer.Google Scholar
Quinlan, M (2023) Ten Pathways to Death and Disaster. Alexandria, New South Wales: The Federation Press.Google Scholar
Reason, J (1990) Human Error. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Reason, J (2008) The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Surrey: Farnham.Google Scholar
Reiss, S (1986) Amusement park safety: who should regulate? Cardozo Arts & Entertainment Law Journal 5(1), 195224.Google Scholar
Sheldon, P, Gregson, S, Lansbury, R and Sanders, K (2020) The Regulation and Management of Workplace Health and Safety. New York: Routledge.CrossRefGoogle Scholar
Turner, B (1978) Man Made Disasters. London: Wykeham.Google Scholar
Walters, D, Johnstone, R, Frick, K, Quinlan, M, Gringras, G and Thebaud-Mony, A (2011) Regulating Work Risks: A comparative study of Inspection Regimes in Times of Change. Cheltenham, UK: Edward Elgar.CrossRefGoogle Scholar
Walters, D, Quinlan, M, Johnstone, R and Wadsworth, E (2016) Cooperation or resistance? Representing workers’ health and safety in a hazardous industry. Industrial Relations Journal 47(4), 379395. https://doi.org/10.1111/irj.12147 CrossRefGoogle Scholar
Wolfe, N (2018) Coroner James McDougall requests proof all Dreamworld rides were certified. News.com.au, 19 October. Available at: https://www.news.com.au/national/queensland/courts-law/coroner-james-mcdougall-requests-proof-all-dreamworld-rides-were-certified/news-story/e77275b97b0bbee9c1c541bda6df0035 (accessed 11 May 2024).Google Scholar
Woodcock, K (2019) Global incidence of theme park and amusement ride accidents. Safety Science 113, 171179. https://doi.org/10.1016/j.ssci.2018.11.014 CrossRefGoogle Scholar