by Moira Zeilinga
On the 24 February, 2020 the coroner’s findings were released into the fatal Dreamworld tragedy. The coroner found that Dreamworld’s handling of safety risks at the time of the tragedy was a "total failure" and the theme park's "shoddy record keeping was a contributing factor”.
Four people died in the tragic event on 25 October 2016. It is imperative that we in the water industry take the key learnings from this event to ensure we don’t have any catastrophic failures that could have been avoided in our workplaces.
Key areas of concern included:
- Lack of risks assessment from design and construction
- Lack of maintenance
- Poor record keeping
- Lack of suitable training for staff
- Lack of recording changes made to equipment
- Unsophisticated safety procedures
- Unreasonable expectations placed on staff who operate and supervise others
- Complex equipment with poor labelling
I’m sure these are only a few of the items raised in coroner James McDougall's 300-page long report, however it is a sufficient list for water industry professionals to consider how effective your systems are.
This was a systemic failure. Many of you operate and maintain equipment that was built in days where safety standards were less stringent. This means that it may be difficult for you to produce a safety-in-design risk assessment for equipment that may have been built in the 60’s. What are your current processes to regularly review complex equipment and the safe operation of this equipment? Conducting a random (or even 12 monthly) Hazard and Safety Inspection of your entire Water or Sewage Treatment Plant will not be sufficient to identify any inherent risks. Expecting a single staff member to do this inspection on a complex site is also unreasonable. Often we do not “see” things that we are familiar with so it is important to include people who don’t regularly operate and maintain a site to conduct inspections.
A few questions to ponder:
- When did you last a detailed risk assessment and risk workshop on complex equipment that you operate and maintain?
- Do you randomly press your emergency-stop buttons on equipment and are these included in routine maintenance inspections and training?
- How confident are you that all your staff fully understand all your emergency procedures around complex equipment (including trainees)?
- How good is your record keeping really? Are your job plans for maintenance just opened and closed or is there space for recording of text from maintenance inspectors and how well are their requests or concerns raised followed up and actioned?
- Do you have clear labelling on how to operate your complex plant and equipment?
These are only a few items for consideration. I urge all water industry professionals to consider all findings and what role you can play to stop a tragic event from happening in your workplace. If you have a concern, make sure your raise it with management so that it can be addressed.
There would not be a board or an executive team that would not be concerned and supportive of addressing risks if they knew there were safety risks in their workplace. Tragedies happen from complacency and accepting “the norm”. Next time you are wandering around your worksite, stop and take a minute to really think about all the risks around you. Your next step could save a life.
Moira Zeilinga is the Founder and Director of Clear Idea.
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