Dreamworld's ad-hoc management of the deadly Thunder River Rapids ride masked the risk it posed to patrons, a coroner has found.
Cindy Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died in October 2016 when a water pump on the Gold Coast theme park ride malfunctioned.
Coroner James McDougall says maintenance and safety records for the ride were scant and ad-hoc.
The victims that lost their lives in the Dreamworld tragedy. Source: SBS News
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 on Monday.
"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 "rudimentary" and "unsophisticated".
More than a hundred people packed the Brisbane Coroners Court to hear the long-awaited findings.
Source: AAP
Ms Low, Ms Goodchild, Mr Dorsett and Mr Araghi died after being flung into a mechanised conveyor when their raft collided with another and partially flipped.
Ms Goodchild's 12-year-old daughter and Ms Low's 10-year-old son survived the incident.
On Monday morning, Ms Goodchild's and Mr Dorsett's mother Kim Dorsett spoke of her grief, saying her greatest regret was not being there for her children on the day they needed her most.
"I wasn't there," she said while wiping tears from her face.
"The easier part was burying them, the harrowing part is living without them."
The pair's father, John Goodchild, said his grief was exacerbated after learning the malfunction could have been identified before the accident happened.
Kim Dorsett, mother of siblings Kate Goodchild and Luke Dorsett. Source: AAP
Police have recommended no criminal charges against Dreamworld staff over the fatal accident, but the coroner could still suggest prosecutions or substantial fines for the company and its executives.
The wide-ranging inquest, which opened in June, has unveiled a "litany of problems" with some experts declaring the tragedy was an accident waiting to happen.
The malfunction was the third that day, and fifth in a week.
Police uncovered multiple incidents involving the ride in the past with two rafts colliding in 2004, throwing a guest into the trough.
Despite recommendations for a single emergency stop, no single shutdown function was installed.
Queensland introduced 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.
Premier Annastacia Palaszczuk has promised the government will seriously consider the coroner's findings.
"Anything that is recommended today we owe it to those families to make sure it is implemented," she told Nine's Today program.
