The long-awaited Coroner’s report from the horrific Thunder Rapids Ride fatality at Dreamworld in 2016 has been delivered, with the inquest finding that the theme park’s approach to safety was a “systemic failure”, which ultimately led to the deaths of four people.

Cindy Low, Kate Goodchild, Luke Dorsett, and Roozi Araghi died when the a water pump on the rapids ride malfunctioned on October 25, 2016.

Coroner James McDougall handed down the 300-page report, and said the ride was completely unsafe during its operation. He had found no records of maintenance or risk assessments made on the Thunder River Rapids ride in the 30-odd years it was active at the theme park, and that the accident was “a matter of time”, considering the circumstances.

It was noted that the Gold Coast theme park’s record-keeping of maintenance and safety checks and records were “shoddy”, which may have contributed to the October 2016 tragedy.

The scathing inquest report noted there were many times in the ride’s operation where hazard reduction assessments should have been held and weren’t completed – especially in the seven days leading up to the fatality where the ride had failed multiple times, even in the hours before the accident.

As per the ABC, McDougall also found that Dreamworld staff and ride attendants were relied upon to identify risks, something they were not qualified to do.

“Dreamworld placed significant reliance on ride operators to identify risks of issues,” he found.

“It is unfathomable that this serious and important task fell to staff…who didn’t have the requisite qualifications or skill sets to identify such risks.”

Dreamworld’s owner Ardent Leisure may face prosecution over the deaths, with McDougall delivering his findings to the state Office of Industrial Relations.

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