The coroner published its report into the tragic 2016 accident at Dreamworld theme park, which now could lead to criminal charges.
The report was highly critical of the management’s ‘shoddy record keeping’ and said there was a ‘systemic failure’ in safety culture.
The Thunder River Rapids accident killed four people at the Gold Coast park in October 2016.
"It is clear from the expert evidence that at the time of the incident the construction of the ride posed a risk", coroner James McDougall said.
"Dreamworld could, and should, have identified the safety issues connected to the ride. There was no evidence that Dreamworld ever conducted a proper engineering risk assessment on the ride."
The inquest heard that the malfunction which caused the accident was the third that occurred that day.
"Why safety action was not taken earlier that day I find very difficult to understand," McDougall said.
McDougall made a number of recommendations.
He called for a law change in Queensland to tighten up inspection and licensing of amusement park attractions, and a close look and possible revision of the current Australian Standards for waterborne rides.
Parent company Ardent Leisure is reviewing the coroner’s report and will make a detailed statement.
The coroner’s report said it is ‘reasonably suspected that Ardent Leisure may have committed an offence under workplace law’ and referred it the Office of Industrial Relations for possible criminal charges.
