Dreamworld's handling of safety risks at the time of a horrific fatal ride tragedy was a "total failure" and the theme park's "shoddy record keeping was a significant contributing factor", a coroner has found.
Coroner James McDougall today handed down his long-awaited findings, totalling 300 pages, from the inquest into the deaths of four people on a ride more than three years ago.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the Thunder River Rapids malfunctioned.
McDougall referred Ardent Leisure, the company behind the Gold Coast theme park, to the Office of Industrial Relations to consider whether there is sufficient evidence to show it committed breaches under workplace laws.
He said there was a "systematic failure" by Dreamworld in relation to "all aspects of safety".
In Brisbane Magistrates Court today, the coroner said it was clear from expert evidence - which emerged over six weeks in 2018 - the design and construction of the ride "posed significant risk" to patrons.
He said maintenance and safety records for the ride were scant and ad hoc.
He found there is no evidence Dreamworld conducted a thorough engineering risk assessment of the ride in the three decades it was open to the public.
"I find that shoddy record keeping was a significant contributor to this incident," he said. "Failure to record the changes have contributed to the masking of the real risk of the (ride)."
He said the ride was completely unsafe when the tragedy occurred, with safety procedures described as "unsophisticated" and "rudimentary at best".
"It was simply a matter of time. That time came on October 25 (2016)," McDougall said.
Police at Dreamworld the day after four people died on the Thunder River Rapids ride, Coomera. Photo / News Corp Australia
In addition, McDougall said the responsibilities placed on staff to operate the stressful ride and supervise others were "clearly unreasonable and excessive".
He described the ride as "complex, confusing" and lacking "required labelling".
Queensland Premier Annastacia Palaszczuk has all but confirmed the state government will adopt every coronial recommendation.
Police recommended no criminal charges against Dreamworld staff over the fatal incident, but the coroner could still recommend prosecutions or substantial fines for the company and its executives.
"Let me make it very clear today that the recommendations that the coroner makes, we will have to implement, regardless of what they say," Palaszczuk told Seven's Sunrise today.
She was asked if she was "guaranteeing" they would adopt every coronial recommendation.
"Well I'd like to say yes, of course we'll have to look at them all, but I can't see why we wouldn't, honestly," Palaszczuk said.
"This is so important to everyone out there.
"At the end of the day, everyone wants to know that they are going to a theme park or an amusement park and that the rides are safe."
She said the families of the victims and the public all want closure.
"We want the answers," Palaszczuk said.
Annastacia Palaszczuk outside Dreamworld in 2016. Photo / News Corp Australia
Three of the four victims were flung instantly into a mechanised conveyor when their raft collided with another and partially flipped on October 25. A crucial delay in manually stopping the ride caused the jammed raft to shake, plunging a fourth person into the machinery.
The inquest heard the malfunction was the third that day and the fifth in a week.
Inexperienced staff panicked, sending out a radio call stating there was a "raft in the conveyor" — the first indication something disastrous had happened, the inquest heard last year.
Despite the efforts of paramedics, the four had no chance of survival. Goodchild's 12-year-old daughter and Low's 10-year-old son survived the incident.
The wide-ranging inquest, which opened in June 2018, revealed a "litany of problems" with some experts declaring the tragedy was an "accident waiting to happen".
Dreamworld's training systems were heavily criticised, with revelations staff operating the ride on the day of the disaster were given just 90 minutes of training.
A memo sent to staff days before the tragedy warned the emergency stop button should not be pushed.
Dreamworlds Thunder River Rapids Ride getting removed. Photo / News Corp Australia
To cut costs, Dreamworld also stopped spending money on repairs and maintenance in the months before the fatal accident.
Kate and Luke's mother, Kim Dorsett, spoke to Nine's Today on Monday morning. "The biggest thing from the inquest was that if someone were to push that (emergency stop) button, Luke would still be alive today," she said.
"I think that no parent should ever bury a child, and I buried three of them."
In a dramatic conclusion to the first week of the inquest, relatives of two victims spoke of how the event has "throttled" their family.
"We are tired and devastated and horrified by the evidence that has come out this week," they said in a statement in 2018.
"We hold Dreamworld totally responsible for this tragic event that could have so easily been avoided. It has throttled our family."
Staff admitted there had been a "total failure" to identify risks with the ride and a series of equipment failures before the accident should have been investigated.
The ride was also heavily criticised as "unsafe" with no proper maintenance schedules, extensive cracking and corrosion, with parts of the structure "propped up with timber".
Theme park staff removed slats from the conveyor belt and made unapproved structural alterations to the attraction that had been installed more than 30 years ago.
The Queensland government pre-empted the inquest findings, introducing new safety regulations for amusement rides including mandatory major inspections of rides by qualified engineers every 10 years and improved training for ride operators.
The state also tightened workplace health and safety prosecution laws, including the introduction of industrial manslaughter as a charge.
Individuals guilty of industrial manslaughter will face up to 20 years behind bars while corporate offenders are liable for fines of up to $10 million.
Palaszczuk on Monday also said she believes there "really needs to be a good look" at the age of operators used to run the rides.
"You need the experience of an engineer, not the experience of someone who has just started work," she said.
Dreamworld is expected to formally respond to the coroner's findings at a press conference at the theme park early on Tuesday.