Most organisations believe “it couldn’t happen here.” Yet the events of 25 October 2016, when four people lost their lives on Dreamworld’s Thunder River Rapids ride, show how fast a preventable tragedy can unfold — and how quickly a safety failure becomes a criminal matter.
“That process happened in 19 seconds,” recalls Aaron Guilfoyle, former Queensland Work Health and Safety Prosecutor. “From the moment the two rafts met to when the conveyor stopped — 19 seconds.”
As Guilfoyle told The Art of Safety Leadership podcast, the Dreamworld case reshaped Australia’s legal landscape. It exposed weaknesses in board oversight, culture, and readiness — and became the catalyst for the industrial manslaughter laws that now exist in every Australian jurisdiction.
The New Legal Reality for Safety Leaders
Industrial manslaughter has moved from concept to conviction. Introduced in Queensland in 2017, it allows prosecutors to pursue both individuals and corporations where negligence or recklessness leads to a worker’s death.
“Industrial manslaughter is prosecutable. The history shows it’s not hypothetical,” says Guilfoyle.
When Guilfoyle became Australia’s inaugural independent WHS Prosecutor in 2019, he saw immediate resistance to the legislation — but he also saw how many past incidents would have met the new test. The threshold was lower than many expected: proof of gross negligence or reckless indifference, not intent.
Within two years, Queensland recorded Australia’s first successful prosecution. Since then, every jurisdiction — including the Commonwealth — has introduced its own version of the law.
The message for boards and executives is clear: safety failures can now trigger criminal liability.
Understanding the Culpability Gap
Guilfoyle explains that culpability is not always proportional to tragedy. Some of the most serious breaches he has reviewed involved near-misses rather than fatalities.
“It’s not always the gravity of the outcome that speaks to how much, if at all, a business or an individual fell short of their duty.”
This nuance is vital for directors who equate “no fatalities” with “low exposure.” In Guilfoyle’s experience, most catastrophic events are preventable, but culpability often lies in what leaders did — or didn’t — do long before the incident.
When the Call Comes In
For CEOs, board chairs and directors of safety, the first hours after a fatal event are critical.
Guilfoyle’s warning: few organisations have truly rehearsed that moment.
“People don’t step through or role-play what that’s like,” he says. “And when that call comes in, fear kicks in — because now industrial manslaughter is on the table.”
Modern boards are conscious of the potential penalties: multi-million-dollar fines and even imprisonment. But awareness is not the same as readiness.
In Guilfoyle’s view, leaders must plan both the human and the legal response. That means having the right advisers on standby — independent safety counsel, a people-and-culture lead to manage wellbeing, and communications experts to engage media and shareholders.
“Good business will help its people,” he says. “But the question is — what’s the form of how we do that in a way that also protects the business?”
The Dreamworld Case: 19 Seconds That Changed Everything
Dreamworld had long been a household name — a place associated with fun and family memories.
Few could imagine that its most popular ride would become the scene of one of Australia’s worst workplace tragedies.
The facts, as Guilfoyle recounts them, are stark:
- A pump failed, dropping the water level.
- One raft became stranded.
- A second raft collided with it at the top of the conveyor.
- Both inverted; one was drawn into a gap.
- Four people died. All within 19 seconds.
Guilfoyle’s office reviewed the coroner’s findings but conducted its own full evidentiary review. The prosecution identified three failures by Dreamworld’s parent company, Ardent Leisure:
- Inadequate training and instruction for ride operators.
- Poor design and maintenance of the plant.
- Unsafe method of work.
The company pleaded guilty and was fined $3.6 million — Australia’s largest corporate penalty for a safety breach at the time.
“That day was absolutely the toughest day for me as a prosecutor,” Guilfoyle reflects. “No one but those sitting in the courtroom could understand the feeling and the loss suffered by the families.”
The case reinforced that safety prosecutions are not regulatory formalities — they are criminal proceedings with human consequences.
Post-Incident Actions That Increase (or Reduce) Risk
One of Guilfoyle’s most practical messages is that how an organisation responds after an incident can dramatically affect its legal exposure.
Avoid impulsive statements.
In the heat of the moment, leaders often speak out of empathy — but uninformed comments can later be used as admissions.
Bring in independent advisers.
Those one step removed from the business can act objectively and prevent well-intentioned mistakes.
Document the process.
Regulators and police will scrutinise every word and action. The organisation must show control, compassion, and compliance simultaneously.
Recognise that form matters as much as substance.
Guilfoyle notes that two businesses can offer the same support to victims and families – yet only one does so in a structured, legally sound way that protects the organisation.
Culture and the “Paper Safety” Trap
One of the most common findings in prosecutions is the gap between paper systems and real practice.
“Post-incident, that mismatch is obvious,” Guilfoyle warns. “Investigators will find out what safety looked like on the ground.”
Workplace inspectors have extraordinary powers — often greater than police — to compel evidence. When they find spotless audit reports but missing controls on site, the credibility damage is immense. Boards must therefore test the evidence: visit sites, talk to workers, and cross-check what they’re told.
“If you go and test it and ask your workers why they’re not doing it, you’ll get a pretty useful answer,” Guilfoyle says. “You might need a new control — or to get rid of one that was never real.”
Officer Due Diligence: What It Really Means
Ask any board about “officer due diligence,” and you’ll hear different interpretations.
Guilfoyle simplifies it:
“The ultimate obligation is to ensure the business complies. Due diligence is the vehicle that gets you there.”
In practice, that means:
- Knowing the business’s hazards and risks.
- Ensuring systems are in place to manage them.
- Verifying that the systems actually work.
It’s not about mastering legal jargon; it’s about understanding your business well enough to know whether it’s truly compliant.
Governance Lessons for Boards
Directors frequently overestimate their assurance level.
“If I ask most directors whether they think their business is safe, almost always the answer is yes,” says Guilfoyle. “I don’t find it difficult to unwind that belief.”
He advises boards to:
- Challenge “everything’s fine.” Overconfidence is a red flag.
- Interrogate lead indicators. Ask: what are our top three critical risks? How do we know controls are working?
- Document questions in minutes. If you asked — prove it.
- Avoid over-delegation. Directors can’t outsource safety assurance.
- Re-ask regularly. Business contexts change faster than risk systems.
Culture in the Grey Zone
The legal line is rarely black and white. Culture determines what decisions people make when they’re operating “in the grey.”
“Because of culture and leadership, some businesses make the safe decision when it’s grey,” says Guilfoyle. “That’s what good culture looks like.”
He recounts one CEO who jokingly wanted to “ban the phrase reasonably practicable” from his company because it gave people an excuse to do less. That mindset – choosing the safer option when it’s optional – is what prosecutors notice when assessing culpability.
The Strategic Role of Safety Leaders
Guilfoyle believes many organisations still treat safety as a reporting function rather than a strategic capability.
“There are safety leaders who come into the boardroom, present their report, then step outside,” he says. “The other category are those who have input into everything the business does.”
Safety leaders must have a seat at the strategy table — particularly as psychosocial risks, mental wellbeing, and people-related claims rise. This requires close integration between safety, HR, and business strategy, not parallel silos.
“Never before have HR and safety had to work together as they do now,” Guilfoyle notes. “That’s how we avoid the most tragic outcomes — but also how we leverage safety to save money and make money.”
From Compliance to Value Creation
Safe organisations perform better — commercially and culturally. When workers believe they are physically and psychologically safe, productivity, retention, and innovation all rise.
As Guilfoyle puts it:
“If you ask workers whether they feel safe — and they say yes — productivity is better. People are happy to turn up and work.”
Key Takeaways for Leaders
- Industrial manslaughter is real and prosecutable. Treat it as an active risk.
- Prepare for the call. Have your response team identified and trained.
- Align paper and practice. Regulators will find inconsistencies.
- Make safety a strategic function. Involve safety leaders in business planning.
- Culture is the ultimate defence. Safe choices in grey areas protect people — and reputation.
Conclusion: The Human Element of Compliance
Guilfoyle describes standing in court during the Ardent Leisure sentencing as the hardest day of his career.
“You can’t understand the feeling unless you were there to hear the victim impact statements.”
That moment crystallised a truth many boards overlook: safety is not a compliance exercise — it’s a moral and strategic imperative. The cost of failure is counted not only in fines and share prices, but in lives.
The time for boards and executives to act is before the 19 seconds that change everything.
Watch the full episode of “The Future of Safety Teams” on the Safe365 Art of Safety Leadership Podcast.
For safety leaders, executives, and board directors operating in today’s legal environment, this conversation provides essential knowledge that could mean the difference between prevention and prosecution.
