Deceased
John Robert Godson, Damien Paul Godson, Craig Godson, Jonathan Shaun Godson, Richard Charles Carroll, Michael David Johnson, Shamus Patrick Rahilly
Demographics
unknown
Coroner
Decision ofCoroner Anderson
Date of death
1979-06-09
Finding date
1979-09-03
Cause of death
Carbon monoxide poisoning and burns (or burns only in one case), accidentally suffered when the Ghost Train building caught fire
AI-generated summary
Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigarette or match in flammable litter near an imitation fireplace display. The coroner identified critical safety failures: absence of the required internal patrol attendant, lack of emergency lighting and hose reel systems (mandatory upgrades not yet completed), poorly marked or hidden escape exits, and absence of smoke alarms or evacuation procedures. The building's maze-like layout, darkness, and low-hanging smoke made escape extremely difficult. The coroner found a serious breach of duty of care by Luna Park management despite earlier fire safety recommendations. While not concluding criminal negligence, the coroner noted inadequate fire precautions and insufficient spending on safety measures. Key recommendations included expanding fire brigade inspection powers, extending fire safety legislation to amusement attractions, and ensuring compliance with mandatory safety upgrades.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
an
1082 20-2=l=pf 3rd September, 1979.
CORONER: .I shall give my findings in the inquest in the fire inquiry arising out of the fire at Luna Park on the 9th ‘Tune, 1979. The seven deceased died in the Ghost Train building when it caught fire on the 9th June, 1979. ‘The
cause of the fire cannot conclusively be stated. It is clear
that it commenced in or in the vicinity of a display representing an imitation fire. Expert evidence has been given of examination of what was left of the electrical _ system, and of tests made after the fire. It has been shown that it was most unlikely that the ignition occurred through electrical fault, the possibility of such a cause cannot be completely excluded. A-statement made to police soon after the fire indicated that it had been deliberately started, that statement has beenn shown to be false and mischievous.:+ Patrons had the habit of discarding food wrappings and other litter during the ride, such flammable material could lodge in or on the imitation fire-place. Para-floodlights were used in that display, it is very unlikely that litter would be ignited by them. Smoking was forbidden within the building, there was a notice to this effect. Employees tried to enforce that prohibition, some patrons nevertheless would commence to smoke after the ride started, the imitation fire place was close to the end of the ride. The most probable cause of the fire was ignition of flammable litter by a cigarette or match carelessly or recklessly discarded by a person riding on the train. The question arises where the deaths of any of the deceased or the cause of the fire attributable to the act or omission of any person so as to make him guilty of criminal negligence. It was suggested
in-evidence that an attendant Mr. Bessell, dispatched a carriage containing two children after he was told of the fire. No clear picture emerges from the evidence of what happened at about that time or the sequence of events. It cannot be said that he knowing of the fire dispatched a laden carriage. The indications are that that the two children described as being in a carriage which entered the building at about that time were aged about seven, they were vrobably the two young girls rescued by Miss Partington and Mr.
Schiano, they were none of the deceased children.
1109
1083
BENCH: (cont'd) Mr. Bessell was questiened about drinking intoxicating liquor, he admitted drinking some beer that day, he claimed that he was sober, there is na evidence to the contrary. The ghost train building was of mainly timber construction, the external walls were mainly timber with corrugated iron at the northern end, the internal partitions - were of hardboard plywood and wood. The roof was of timber overlaid with layers of bitumen impregnated building paper and was finished on its top surface with | hot mopped bitumen, Part of the roof was of corrugated iron. Expert evidence is that once the fire had begun and involved the roofing Materials, the spread would be very rapid, the heat would be intense and very dense black smoke would be developed.
Evidence shows also that the building was in a poor state of repair, there were holes in the roof, the studs supporting partitions were in some cases loose and rotten, the roof was unsafe to walk on, the floor in the vicinity of the track was in places worn and uneven. Mr. Grant, a fire ventilation expert, inspected the building in October, 1977. His description of the interior reads in part:- "It was a maze, I think most people know what a maze is, pitch dark, I went in there when the maintenance lights were on and ‘I had to find out what material was being used in there. It was timber, all painted black, Partitions, and then you get to a scare area, which owas usually hessian, plastics and electrics. As a matter of. fact even with the lights on I was bumping into the partitions and the wall. It was a timber ceiling, I would have got lost even with the lights on. The only way I could keep going was to follow thé railway track. One
effect—of the winding course of the track was to disorient Passengers. There were three sets of doors on the western side of the building, from which escape was possible in case of fire. These were the track entrance and exit doors, and a set of double doors fitted with panic bars and an illuminated exit sign near the track entrance. There was a small door on the eastern side of the building leading into the river caves, it was not clearly marked and was probably indistinguishable from the walls. Mr. Jacob had worked on
the ghost train for four months and did not know of that door.
1116
1084 : 3rd September, 1979,
BENCH: (cont'd) There were some doors in the Partitions and they too were painted black like the walls and were difficult to distinguish. There was another door on the western wall, fitted with a panic bar, but it had been enclosed on three sides to create a room used for car storage, it gave no | escape from the main building. The fire escape doors near the track entrance would be seen by passengers only very briefly as they past. Because of curves in the track and the presence of partitions those doors could not be seen from a point two or three metres further along the track, nor any part of the track thereafter. There is evidence that the
Premises were regularly cleaned, there is other evidence from
a number of witnesses of a general dirtiness of the Place and of the presence of little and other rubbish. Because of ~ its construction internal layout and use the building presented a high fire risk and unique safety problems. Tr turn to the question of what precautions were taken for fire safety. The ghost train building was inspected in May, 1977, by Mr. Renn, a Senior Health Inspector of North Sydney Municipal Council and Mr. Roberts, a District Officer of the Fire Prevention Department of the Fire Brigades. It was part of an inspection of the whole of Luna Park. Subsequently the
‘Board of Fire Commissioners made extensive recommendations to
the councfl. In October, 1977, council officers conferred with the Luna Park management at Luna Park by notice dated the llth November, 1977, the council dnder Section 317 D of the Local Government Act, directed the Secretary and General Manager of Luna Park New South Wales Pty. Limited to carry out certain works recommended by the Board of Fire
Commissioners. As to the ghost train the works were 1, the provision of an illuminated exit sign at the escape doors and the availability of those doors for public use, 2, the installation of safety emergency lighting,
1085 .
. ‘ 20-2-2=bs, 3rd September, 1979.
CORONER (Cont'd) 3. The installation of a fire hose reel System affording protection to all sections of the Park.
Hoses were to be of sufficient length that taking internal partitions into consideration ail areas contained within the building would be within reach of the nozzle end of a fully extended hose reel. 4. All curtains, drapes and fabricd throughout the premises should be treated bi-annually with an approved fire retardant. These works were to be completed within eighteen months. On 9th May, 1979 the Council allowed a further twelve months to complete the works. At the tine of the fire outstanding requirements in respect of the Ghost Train were the provision of emergency lighting and a hose reel system. In making his reports upon which the recommendations of the Board were based Mr. Roberts took into account what he had been told that there was always at least Oné person inside the Ghost Train who could detect a fire, take action in respect of it, warn the other attendants and lead people out. There is no doubt on the whole of the evidence that the usual practice was to have a person patrolling inside the building. That precaution was not observed on the night of the fire. Mr. Roberts regarded the track exit doors as the primary means of escape, he thought that passengers would normally stay in the carriages*and be carried td safety along the track. He considered that if passengers did leave the cars emergency lighting recommended by him would suffice to guide them back to the emergency exit. It appears to me that there was a distinct likelihood that passengers some of them young children in carriages moving at less than walking pace would leave the ears even in
the-early stages of a fire, they would then have to find their way to an exit through what has been aptly described as amaze. Amongst the hazards they faced was that of being struck by following cars. An attendant, Mr. Jacob, who guided a number of people to safety during the fire was himself struck and felled by a car. Upon a build up of dense smoke such as did occur emergency lighting would not be very effective. Mr. Jacob has described the darkness of the smoke filled passages when he was trying to rescue people. Fire extinguishers were available and were used upon the fire but it had gained such a hold that they were ineffectual. 1112
1086
. 20=2=2=bs,
: 3rd September, 1979.
CORONER: There were two hoses from fire hydrants at either end of the Ghost Train frontage, deal effectively with this fire,
they were not long enough to
one of them lacked a nozzle.
I agree with Mr. Dunford, Counsel for the relatives, that
some or all of the following precautions should have been taken and were not:
3, Provision of a smoke alarm system and a smoke exhaust ‘system.
It is clear that if items 1 to 6 in that list Were not provided the Ghost Train should not have been operated in the absence of an attendant whose duty it was to patrol inside the building. The evidence shows for instance, that a number of passengers detected a smell of smoke, some five minutes or more before the fire was discovered but took no action thinking it might have been one of the Ghost Train's special effects. An attendant inside the building would have been in
a position to detect the smoke and, to give earlier warning.
The provision_of-some- or-all of items I to 6 make have been onerous as to cost even impractical given the age, condition and layout of the structure, but there was an alternative, if the building was not Capable of being made safe it should not have been open to the public, The Company, Luna Park (N.S.W.) Pty. Limited, its Directors and Management were under a duty of care in respect of the safety of patrons. The fire was reasonably foreseeable, the death of or injury to patrons by fire was reasonablly foreseeable. There was a
failure in the duty of care. There was a marked reluctance
1087 20=2-2-bea, ard September, 4979.
CORONER: (Cont'd): spend money upon fire safety measures. That reluctance may be explained but not excused by the lack of security of tenure held by the Company over the site.
Although there was a serious breach of the duty of care there was not, in my view, the high degree of negligence necessary to support a charge involving criminal negligence. “ I will deal now with the question of what measures should:be taken to avoid a similar happening. I have read the report of the Fire Brigade's Committe of Inquiry and the report of the Inter-Departmental Committee on Fire Safety in Buildings. I understand that the Government is in the course of strengthening the role of the fire brigades. I should suggest that the Luna Park fire indicates a need to expand the fire prevention function of the fire brigades and to extend the right of entry and powers of inspection to members ofthe fire brigades. The detailed recommendations of the Inter-Departmental Committee appear to provide proper machinery for implementation and enforcement of fire brigades recommendations by local councils. Consideration might be given to providing the Fire brigades with a concurrent power to serve and enforce notices. The Ghost Train fire ‘has provided knowledge that will be useful in a re-appraisal of fire safety at Luna Park and elsewhere. I recommend that there shotild bea further examination of Luna Park. The River Caves present fire safety problems similar to the Ghost Train, the electrical and fire safety of that building is dubious. It is likely that there are similar buildings elsewhere in the State, the Ghost Train and.other side shows at the Sydney Show Ground were referred to in evidence. It is
important that councils know of an use the services of the Fire Prevention Department of the Fire Brigade. Councils should not hesitate to invoke powers under Section 317D(2) of the Local Government Act to direct that a building should not be used until works are carried out. The Ghost Train was registered as an amusement device under Regulations made under the Construction Safety Act. One requirement of the Regulations is that emergency lighting should be installed and maintained if the device is in a dark Place. The Ghost Train operated in darkness. There was no emergéncy lighting system installed and maintained. The building had been
: 1114
1088 irq September, 1979.
CORONER (Cont'd) inspected at least twice in the six months before the fire by an Inspector of the Department of Industrial Relations and Technology. That Department appears to need to enforce the ‘emergency, lighting requirement more rigidly. Model legislation for fire safety exists in the
Theatres and Public Halls Act and the Regulations which came - into effect on lst January, 1978.
1089
BENCH: (Cont'd) When the meanings of theatre or public hall, public entertainment. and entertainment in Section 4 of that Act are examined it appears that the Ghost Train is a theatre
of public hall and subject to the
20/2/3 = EM 3rd Septemher, 1979,
Act and Regulations.
Whether this is so or not, a place such as the Ghost Train
has historically and administratively never been regarded as’ - being subject to that Act. I recommend that consideration be given to extending the scope of the Theatres and Public Halls
Act and Regulations to buildings of public resort for amusement such as the Ghost Train, they would come under examination by Inspectors of the Department of Services and in Country districts, Police Officers.
Luna Park was held under lease from three different
Government bodies, the Department
of Main Roads, the Public
Transport Commission and the Maritime Services Board, North
Sydney Council's notice to carry out works related in part to
a place called the Palais Ballroom which is on a pontoon floating in the harbour the company successfully took the point that this was outside the Municipality and the jurisdiction of the Council. I mention this by way of illustration of the difficulties of having fragmented enforcement bodies and the need for State wide policy and
control by a body such as the Fire Brigades, the Department
of Services or both. I recommend
the Luna Park area should contain the safety of the public.
I come now to my formal findings.
that any further lease of
stringent conditions for
.I find that John Robert
Godson, Damien Paul Godson, Craig Billings, Richard Charles Caroll,
Godson,—Jonathan—Shaun.
Michael David Johnson,
Shamus Patrick Rahilly died on the 9th June, 1979 at Luna
Park, Milson's Point from carbon monoxide poisoning and burns
or in one case burns only and in my written findings they
will be specified and they are as
stated in the respective
Medical reports in evidence accidentally received when the
Ghost Train building caught fire.
As to the fire enquiry, I find that on the 9th June, 1979 ,
the property known as the Ghost Train at Luna Park,
1146
1080
3rd September, 1979.
BENCH: (Cont'd.) Milson's Point, was destroyed by fire which originated in’ the vicinity of an imitation fire place
but how the fire was ignited the evidence adduced does not enable me to say.
Strike out necessary ords.
New South Wales, mens VhbebS Parramatta Road, GLEBE
To Wit,
INQUIRY held at the CORONER'S COU :T
44-46 Parramatta Rd GLEBE in the State of New South Wales,
day of August 1979 & this 13th-29th / smenanet 3rd day of Sentemherl9 79 ,
Kevin Sidney ANDERSON
at
before me.
one of the Coroners of Our Sovereign Lady the Queen for the State aforesaid being
charged to inquire (on the part of Our said Lady the Queen) into the cause and origin of
a fire by which certain property to wit _A@usement ride known as 'Ghost Train!
and portion of 'Wild West' 'River Caves!'Big Rippers situated at LunaPark (N.S.W.) Pty Ltd OlympicBrive in QP +ex
MILSONS POINT METROPOLITAN Police District in the said State, and then
*UROGEMPRSESr * occupied byMHK__Luna Park (N.S.W) Pty Ltd Clymic Drive
f MILSONS POINT ° . and owned by
Luna Park (N.S.W) Pty Ltd
of
Clympic “rive, Milsons Poiit
9th June 79
the day of , 19 >)
XMMNEO destroyed (as the case may be). And having made such inquiry, I, as such
Coroner, do declare and find that On the 9th June I979 the property known as the Ghost Train at Luna Park, Milsons Point was destroyed by fire which originated in the vacinity of an imitation fire, but how the fire was ignited
the evidence adduced does not enable me to say.
GIVEN under my Hand and Seal at GLEBE - this 3rd
day of September 519 79
22784 D. West, Government Printer
7 place of death, and
{ finding.
CORONERS ACT, 1960 Ana .
New South Wales, pate Parramatta Read, GLEBE To Wit.
INQUEST held at the.____ COROWBRIS COURT at__ fbb | Parramatta Ra in the State of New South Wales,
he 15th-29th _ September 3 on the.____. ana day OF Septenber 1979 Wf? , before me... Kevin Sidney ANDERSON . one of
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
DAMIEN PAUL GODSON death of... _ Bitneonemnmeansiet
hereinafter called the deceased.
And J, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came to h.2S_ death and the manner and cause of hiS_ death, and having made such inquiry, declare and find that the deceased on the
RO 9 th . nn day of ___. . dune . a, 19 79 >
Luma Park, Milsens Point
in the METROPOLITAN Police District,
in the said Statet @ied from whole body burns and- carbon monoxide poisoning accidentally suffered
when the Ghost Train building caught fire.
GIVEN under my Hand and Seal at___ GLEBE this__ 2rd day of September ,19 79,
Coroner
(K.S. ANDERSON) pms..
$1650 D. West, Government Printer
CORONERS ACT, 1960 Goal
New South Wales, pinhG Parramatta Read, GLEBE To Wit.
INQUEST held at the_____CCRONER'S COURT
at HO Parramatta Rd in the State of New South Wales,
GLEBE on the. ____ 13 th-29th | day(s) of. AUgZUSE ,19 79,
and 3rd day of September 1979
hereinafter called the deceased.
And I, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came to h_48. death and the manner and cause
of h_iS_ death, and having made such inquiry, declare and find that the deceased on the
Fined» 9th day of me 79 7 place of - :
leath, ¢ luma Park, Milsons Point
and at T- a — ———- finding.
in the METROPOLITAN Police District,
in the said State died from whole bedy burns following carbon monoxide poisoning accidentally suffered when theGhoest ‘rain building
caught fire,
GIVEN under my Hand and Seal at. GLEBE _this__3ré
day of September ,19 79,
Coroner
(K.S. ANDERSON) pms..
Sc 1650 D. West, Government Printer
Ag * CORONERS ACT, 1960 wa -
New Scuth Wales, panne Parramatta Read, GLEBE To Wit.
INQUEST held at the____CORONER'S COURT -
Bt nnn CS Parramatta RA in the State of New South Wales, 43th-29th August 9 79
on the nn 3rd aay oF or eth er I ia 71 ,
before me... Kevin Sidney ANDERSON one of
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
death of. JCHN ROBERT GODSON
hereinafter called the deceased.
And I, as such Coroner, being charged to inquire (on the part of Our said Lady is the Queen} when and where the deceased came toh. death and the manner and cause
of h3S. death, and having made such inquiry, declare and find that the deceased on the
and” at J. — - _ —. -
F finding.
— ~ in the ~____Police District,
in the said Statek Gied from whole body burns accidentally suffered when the Ghost Train building
caught fire.
GIVEN under my Hand and Seal at....__ GLEBE _this Srd
day of _____September | 19 79,
S$: 1650 D. West, Government Printer
New South Wales,
~ f 44-46 Parramatta Road, GLEBE.
‘o Wit. —
' INQUEST held at the___COROBER'S COURT
44-46 Parramatta Rd
abo os in the State of New South Wales, the ABS th=-29%) August ,19 79,
onvime and 3rd a or ey) char 1979 —
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
death of... RICHARD CHARLES CARROLL
hereinafter called the deceased.
And I, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came toh *® death and the manner and cause
of h8 death, and having made such inquiry, declare and find that the deceased on the
Spor date ge oth day of. June 19 79 7 place of . :
death, at + Luna Park, Milsons Point
and’ at J ~ - - os
tfnding.
in the MEBROPOLITAN Police District,
in the said State} died from carbon monoxide poisoning accidentally suffered whenthe Ghost
Train caught fire.
Bela.
GIVEN under my Hand and Seal at___GLEBE _this 274 day of. September 1979,
Coroner (K.S. ANDERSON) pins...
$e 1650 D. West, Government Printer
G. 121 ISK - CORONERS ACT, 1960 \q
New South Waies,
a } ak-46 Parramatta Road, GLEBE ‘oO ‘it.
INQUEST held at the._CORONER'S COURT
ab hbnA6 Pa : — In the State of New South Wales, 13th-29th Aucust 9 he... (s) of CBSE ; ; on the wig spa G3 ter T9757 i before me__...._Mevin Sidmey ANDERSON _ one of
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
secs
death of.
hereinafter called the deceased.
And I, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came to n2® death and the manner and cause
of h._is death, and having made such inquiry, declare and find that the deceased on the
Insert date ye - oth _. day of __.. June _ “19 79 T place of
ie at f _____ Luna Park, Milsons Point
t finding.
_ _— in the MEPROPOLIZAN Police District,
in the said Statef died from carbon wonoxide peisoning and severe whole body burns accidentally suffered when the Ghost Train building
caught fire.
GIVEN under my Hand and Seal at_GLEBE _—this ard
panne EE EE Sy
Coroner
St 1650 D. West, Government Printer
Gl.
CORONERS ACT, 1960 \ {ost
New South Wales, pAa-te Parramatta Read, GLEBE To Wit.
INQUEST held at the....__ CORCNER'S ee ab __ 44-46 Parramatta Fd _____in the State of New South Wales,
GLEBE on the......_ 1 3ehe29th pee da y(s) of _AUgUStT , 19 7% and 3rd day of Sepvenber IS78,
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
hereinafter called the deceased.
And 1, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came to h.*5_. death and the manner and cause
of h_*5 death, and having made such inquiry, declare and find that the deceased on the
death, at to ___luma Park, Milson's Point .
} finding,
an _ in the_ METROPOLITAN Police District,
in the said State} Gied from carbon monoxide poisoningand severe whole body turns accidentally suffered when the Ghest train building
Caught fire.
GIVEN under my Hand and Seal at_.. GLEBE this___ 3rd
day of. September _ 19 73,
“Coroner (K.S. ANDERSON) pms..
$e1650 D. West, Government Printer
CORONERS ACT, 1960 a4
ic
New South Wales,
f Alia Parramatta Roed, GLEBE, To Wit. =
INQUEST held at the..._CORCNER'S COURT
_day(s) of August os 19 7S & Sra day
— — one of
the Coroners of Our Sovereign Lady the Queen for the State aforesaid concerning the
death of
hereinafter called the deceased.
And I, as such Coroner, being charged to inquire (on the part of Our said Lady the Queen) when and where the deceased came to h.is_ death and the manner and cause
of has. death, and having made such inquiry, declare and find that the deceased on the
Ths le
Tasert u eo Oth 7 day of June 19 79 , 7 place o: + Lune Park, Milsen's Peint and at }----__- = t finding.
an _ in the MEFROPOLITAN Police District,
in the said Statet died from carbon monoxide poisoning and max
severe whole body burns, accidentally suffered
when the Ghest Train building causht fire.
GIVEN under my Hand and Seal at GLEBE this: 3rd
day of ____._Sentember 1979,
“Coroner (K.S. SNDERSON) pus.
Se 1650 D. West, Government Printer
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