A one in a 30-year incident – 30 years in the making

In February 2020, the Queensland Coroner released his report into the tragic deaths of four people at Dreamworld in October 2016.

The report detailed the causes of the tragedy and also highlighted the apparent lack of, or ineffective risk assessments undertaken in the years leading up to the incident.

This is an excerpt of my upcoming e-book How and why the Dreamworld Coroner’s report demonstrates what is wrong with risk management.

After placing a risk management lens over the Coroner’s report, I was continually shaking my head with the constant references to risk assessments. The actual term was used 130 times throughout the report, but it was when I got to Paragraph 904 that I completely lost it.  The paragraph stated:

“It was recognised by the experts that the TRRR had operated successfully and injury/fatality free for almost 30 years. As such, for a majority of its lifetime it seems that the general design and construction of the ride may have posed little risk to patrons. However, at the time of the fatal incident, the design and construction of the conveyor and unload area posed a significant risk to the health and safety of patrons”.

I can’t publish here what I wrote in the margin next to this paragraph, but those of you who know me can probably guess!!!!!

What a bewildering statement! And, given that “it was recognised by the experts” for me,  demonstrates why risk management is absolutely broken – particularly when it comes to safety.

Let’s unpack this …….

  • Firstly, injury/fatality is not the risk – it is a consequence.
  • Secondly, the fact that no-one died or suffered injuries on the ride for 30 years, is not an indicator that the general design and construction of the ride may have posed little risk to patrons
  • Thirdly, the suggestion that it was only on that day that the risk existed is absolute nonsense!!!!

The notion that there was minimal risk until the day of the tragedy was further reinforced by evidence provided by experts during the inquest in respect to “low probability risks”.

One expert recognised that this particular incident was:

 a ‘high risk, low probability incident, similar to an aircraft losing engine power or having to ditch in water’. This type of fault had seemingly not been experienced previously, although pump failure was not a new occurrence on the ride. [Paragraph 871]

Another expert stated:

I can agree that low probability events can be difficult to predict, but I don’t think for a minute that anyone doing a risk assessment on that ride would not observe things which could be regarded as anything other than hazards.” [Paragraph 936]

Based on all of this you would reasonably conclude that everything up until that point had been rosy and that what happened in October 2016 was a complete anomaly that could not be forecast.

But that is not the case, and that is why I have written this White Paper. 

The fact that so many people, including the experts believe this, highlights the very thing that is wrong with risk management across the entire world.

And at the root of all these issues is: the definition of a risk.

It may seem obvious but, fundamental to the effective management of any risk, is understanding what a risk is.

For those who have read my blogs or my previous eBook – Risk is not a Four-Letter Word, it’s no secret that I challenge a number of industry-defined definitions of risk.

The ISO 31000 defines risk as, the effects of uncertainty on objectives[1]

  • effect is defined as “a change which is a result or consequence of an action or other cause[2]”; and
  • in essence, an effect is an outcome or consequence, so if we substitute that into the definition it becomes: the consequence of uncertainty on objectives.

This is confusing, and, quite frankly, utterly ineffectual as a definition. The focus is on identifying the consequences of the uncertainty, rather than what the actual uncertainty is.

The now superseded AS/NZS 4360 defines risk management as, the chance of something happening that will have an impact on objectives.

  • Whilst this definition is certainly more focussed on events (something happening), it is more geared towards the chance of something happening (i.e. the likelihood).

So, this definition can be expressed as: the likelihood of something happening that will have an impact on objectives.

And then there is the definition of risk in the WHS Code of Practice which I discussed in my blog: Crazy Stuff in the Workplace Health and Safety Codes of Practice.

The Code of Practice defines a risk as, the possibility that harm (death, injury or illness) might occur when exposed to a hazard[3].

  • This definition is focussed purely on the likelihood of harm that may come from exposure to a hazard. 
  • It does not even consider the likelihood of the event occurring – just the likelihood of harm if there is exposure to the hazard. 
  • What this definition is implying is that the exposure has already occurred (i.e. the risk has materialised) and what we are assessing is the possibility that harm will occur.

Of course, if we define a risk like this, we are going to get very skewed risk levels as the likelihood (possibility) of harm is always going to be high if we are assuming the exposure (risk) has already occurred.

In my opinion, none of these definitions truly captures what a risk is. 

The definition I have developed is focused purely on identifying the event/incident that we are trying to prevent:

“A possible event/incident that, if it occurs, will have an impact on the organisation’s objectives”

This definition focusses on the event, not the consequence or the likelihood.

When you hear people say: they obviously didn’t manage the risk very well, it is always after an incident, so, this definition makes much more sense. 

So, if the experts all seem to believe that this was a low probability risk, then it follows that the incident in October 2016 was the first such incident to be observed on the TRRR.

But that was not even remotely the case ……

Very soon I’ll be publishing my next e-book How and why the Dreamworld Coroner’s report demonstrates what is wrong with risk managementand I’ll explain why this one in a 30-year incident was 30 years in the making.


[1] AS/NZS ISO 31000:2009: Risk management — Principles and Guidelines

[2] AS/NZS 4360:2004, Risk management

[3] SafeWork Australia, Code of Practice: How to Manage Work Health and Safety Risks, December 2011, p4.

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