A Queensland coroner has recommended Dreamworld's owners should be prosecuted over the deaths of four people at the theme park.
In 2016 Cindy Low, Kate Goodchild, Luke Dorsett and Roozi Araghi died when the water pump on the amusement park's Thunder River Rapids ride malfunctioned. A dramatic decline in water levels caused two rafts to collide and flip.
Three of the four riders were flung into a mechanical conveyer belt which carried the rafts to the beginning of the ride.
A delay in manually stopping the ride caused a jammed raft to shake, plunging the fourth victim into the machinery.
The inquiry into the tragedy began in June 2018 and Coroner James McDougall produced his 300-page report on Monday.
He referred Ardent Leisure, which owns Dreamworld, to the office of industrial relations and recommended it be prosecuted as it may have committed an offence under workplace law.
His report found staff had been insufficiently trained, and the ride malfunction was the third that day and the fifth in a week.
Missing slats on the conveyor belt created a large enough gap for the raft to be sucked into the machinery.
In the months before the accident, Dreamworld's staff had stopped spending money on maintenance and repairs.
McDougall told the court it was "unfathomable" hazard management fell to ride operators rather than formal engineering inspections.
Dreamworld's safety team was poorly structured, and had no formal risk management in place.
"It was simply a matter of time. That time came on October 25 2016," McDougall told the court.
McDougall says it was "very fortunate" there were no deaths prior to the 2016 tragedy.
"Previous incidents on [the ride] particularly in 2001 and 2004 should have alerted Dreamworld to hazards on the ride."
"The hazards were significant and included the wide spacing of the slats on the conveyor, the pinch point at the head of the conveyor, the effect of pump failure and the absence of the emergency stop button.
"Each of these obvious hazards...would have been easily identifiable to a competent person had one ever been commissioned to conduct hazard assessments."
Queensland Premier Annastacia Palaszczuk said the coroner's findings will allow closure.
"Dreamworld was a place where everyone went and took their families and loved ones for a day of enjoyment and the unspeakable happened on that day," she told Today on Monday.
"It has taken its toll on everybody and today the coroner will hand down its findings and hopefully everyone will have answers and hopefully everyone will have closure."
