The design and construction of Dreamworld's Thunder River Rapids ride - which claimed the life of New Zealander Cindy Low and three others in 2016 - posed a "significant risk" to patrons' safety, a coroner has found.
Queensland south-eastern coroner James McDougall is handing down his findings into the deaths of four people, including Low, on the ride in October 2016.
Low, Kate Goodchild, her brother Luke Dorsett and his partner Roozi Araghi died when the Thunder River Rapids ride malfunctioned at the Gold Coast theme park.
McDougall told a Brisbane court Dreamworld had a reputation as a "modern, world-class theme park" yet its safety and maintenance systems were "rudimentary at best".
"[There were] frighteningly unsophisticated systems in place at Dreamworld," he said.
"It was simply a matter of time. That time came on October 25 ."
McDougall said there was no proper engineering oversight, nor were there any holistic risk assessments ever conducted on the Thunder River Rapids ride.
"Whilst there were various occasions … hazard identification risk assessment should have been triggered … this was never done," he said.
"Owners should be risk-averse. That was not the case with respect of [this ride].
"Dreamworld placed significant reliance on ride operators to identify risks of issues.
"It is unfathomable that this serious and important task fell to staff … who didn't have the requisite qualifications or skill sets to identify such risks."
McDougall said "shoddy record keeping" was a significant contributor.
He said it was unclear why basic engineer controls - such as a water level monitor - were not installed on the ride.
He concluded a basic automated detection system would have been inexpensive.
Accident 'may be an offence'
McDougall noted "significant changes" in ride audit and inspection systems at Dreamworld since 2016.
He said while this was positive, it also highlighted the deficiency of safety management at the theme park before the tragedy.
"Such a culpable culture can exist only when leadership from the [company] board down are careless in respect of safety," he said.
"That cannot be allowed."
McDougall said he would refer Dreamworld's parent company, Ardent Leisure, to the Queensland Office of Industrial Relations.
He said Ardent Leisure "may have committed an offence under workplace laws".
"Whether there is sufficient evidence to proceed to prosecution is [a matter for them]," he said.
He said he would also refer his findings to the Board of Professional Engineers Queensland.
'Heart aches daily'
Ahead of the coroner's findings, family members of those who died in the 2016 tragedy read out victim impact statements.
Matthew Low, the husband of Cindy Low, told the court his wife had the "heart of a tiger" and was "soft, nurturing, unpredictable and confident".
"Our heart aches daily as we try to be grateful for the decades we had. There just weren't enough," he said.
Low also read out a statement from their 9-year-old daughter, who wrote she missed her "hugs and cakes that she used to make for us".
Kim Dorsett said her son Luke had a compassionate and loving nature, and that "if you were loved by Luke you were loved 100 per cent".
Dorsett also spoke about her daughter Kate Goodchild, telling the court she "was the love of many people's lives".
She said Goodchild was "the best mummy to her two girls".
"My huge regret is the day she needed me most I wasn't there," she said.
"The three of them loved the theme parks on the Gold Coast - the scarier [the ride], the better."
She thanked emergency services, first responders, the coroner and "the people of Queensland who took these four souls into their hearts".
Shayne Goodchild, the father of Ms Goodchild and Mr Dorsett, said words alone could not express their family's grief.
"Kate was taken so dramatically, so publicly, and we'll never be the same again," he said.
In a statement, Low's mother Donna Cooke said she wrote a note to the young ride operator.
"I know my daughter wouldn't want her to carry the burden," she said.