The first stage of the Queensland coroner’s inquest into the death of four tourists at the Dreamworld theme park on 25 October 2016 concluded late last month after hearing evidence from more than a dozen witnesses.

Roozbeh Araghi, 38, Luke Dorsett, 35, and Kate Goodchild, 32, and Cindy Low, 42, died after the 30-year-old, accident-prone Thunder River Rapids ride seriously malfunctioned after a water pump failure at 2 p.m.

The victims were ejected when their raft flipped, after crashing into a jammed vessel. Two children, who had been on the capsized raft, scrambled to safety and survived. Their parents were crushed to death in the ride’s conveyor belt.

Testimony presented during the first hearings suggests that the disaster was not a freak accident but resulted from maintenance cost-cutting and unsafe operating practises.

Dreamworld is owned by Ardent Leisure, which has theme parks, tourist attractions, bowling centres and laser skirmish centres across Australia, New Zealand and the United States. Ardent Leisure registered a $42.4 million profit last August, with its Queensland theme park its biggest earner.

Determined to maximise its profits, senior management reduced safety and maintenance jobs at Dreamworld to a bare minimum and directed all staff—operators, maintenance workers and supervisors alike—to keep the rides going at all costs.

Counsel assisting the coroner, Ken Fleming QC, told the inquest that the Thunder River Rapids breakdown was the third serious fault on the ride that day. One had occurred at 11.50 a.m. and another 1.09 p.m., which should have led to the immediate shutdown of the ride.

Water pump failures also occurred in the week before the fatal incident, on October 19 and 22, but no action was taken to discover what caused the faults. The ride had serious incidents in 2001, 2004, 2005 and 2014.

After the first two breakdowns on October 25, a supervisor incorrectly told the operator to keep the ride going, saying it could only be closed after three breakdowns in a 24-hour period.

One young operator told the inquest she only had 90 minutes’ training before her first day running the ride and did not know that the emergency button could quickly stop the conveyor belt. A memo sent to staff a week before the tragedy instructed operators to use the emergency button only if the ride’s main control panel could not be reached.

Senior operator Peter Nemeth said it was “impossible” to manage the ride’s responsibilities, with 36 checks required in less than a minute. He told the hearing that senior and junior ride operators had no first aid or CPR training.

Matthew Robertson, a Dreamworld technician, gave some indication of the work pressures on maintenance staff at the theme park. He told the inquest he could be called on to rectify up to 20 ride faults per day. He said he was given no framework to assess whether ride faults could be dangerous, and told to use his “own judgment.”

Counsel assisting the coroner said Dreamworld’s workplace health and policy procedure had not been updated in six years. The Thunder River Rapids ride’s registration had been due to expire in January 2016, nine months before the fatal incident. Workplace Health and Safety Queensland (WHSQ) had granted the company two extensions.

The inquest was shown a June 2016 Dreamworld health and safety policy review. It included a paragraph suggesting an alarm should sound when the water pumps failed on the Thunder River Rapids ride.

“If the pump stops for this ride then there is the potential for rafts to become a hazard to guests riding them. The rafts are very heavy and there are a lot of underwater obstacles that could cause the rafts to flip or entrap a guest.” This paragraph was crossed out in the company’s safety review.

Dreamworld’s senior safety officer Mark Thompson, who was hired seven months before the tragedy, told the inquest there were multiple safety problems at the theme park and too few qualified staff.

Thompson said only two of Dreamworld’s 14-member executive safety committee had formal safety qualifications but at least six were needed to properly deal with health and safety issues at Dreamworld. An email from Thompson to WHSQ dated September 2016 said the park was having difficulty finding a “competent person” to inspect its so-called big-nine thrill rides.

Thompson told the inquest a junior engineer had begun the process of auditing all 35 rides at Dreamworld and the company’s nearby sister park WhiteWater World. He said it had taken the engineer about two months to complete one ride and an audit on all rides could take up to five years.

Under questioning, Thompson agreed that the company’s failure to conduct a health and safety policy review indicated a “complete and utter abdication of responsibility.” He also said he had not been notified about past incidents on the Thunder River Rapids ride until after the tragedy.

The most damning evidence, however, was an email summary of minutes from a March 2016 engineering management meeting. It reported that monthly expenditure at Dreamworld was $125,000 over budget on a year-to-date basis and announced immediate cuts.

“Revenue is up but profit is down, cutbacks are now being enforced,” the document declared. “Repairs and maintenance spending needs to stop, only CAPEX [capital expenditure].”

The email points to a drive for profit at the expense human life and the total indifference of corporate chiefs toward basic health and safety standards.

Predictably, corporate media coverage of the inquest has been preoccupied with the Ardent Leisure’s share values and how best to restore attendances at the Dreamworld. Ardent Leisure’s stock price had performed “very well” over the past fortnight, despite the “bad publicity,” one business commentator declared.

A July 3 comment in the Murdoch-owned Courier Mail declared that the theme park was “safer than it has ever been.” Parents, it wrote, should take advantage of discounted season tickets and promotional deals and bring their holidaying school children to the facility. “Dreaded ride queues are virtually non-existent, which means more bang for your buck,” the newspaper enthused.

Additional inquest hearings will be held in October and November, with more than 20 other witnesses due to give evidence. The findings are not expected to be released until next year.

Even if future hearings reveal more shocking evidence about the disaster, the inquest is unlikely to hold accountable Dreamworld and Ardent Leisure chiefs and others politically responsible for allowing the unsafe conditions.

Numerous questions remain, in particular, about the roles played by the Queensland government, the health and safety authorities and the Australian Workers Union. They were all fully aware of the health and safety violations at the theme park, but did nothing to stop them.

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