An amusement ride connected to the death of an eight-year-old girl had not been specifically approved for use in Australia, an inquest in Adelaide has heard.
On the opening day of the inquest, counsel assisting the coroner Sally Giles outlined how the breach was one of a litany of failures linked to the death of Adelene Leong, who visited the Royal Adelaide Show on September 12, 2014 while on holiday from Malaysia.
Adelene slipped out of restraints, which suffered from serious design faults, and was flung from the Airmaxx 360 ride in excess of 100km/h before landing on the ground headfirst, the court heard.
"What took place was nothing short of horrendous for everyone who witnessed it," Ms Giles said on Wednesday.
"[The ride] was unsafe, and a tragedy waiting to happen."
Adelene died from multiple injuries, Ms Giles noted, but a rapid deceleration injury to the brain alone was enough to kill her.
The counsel also noted that the ride was the first of its kind to be imported into Australia in 2013, but did not undergo a required design registration process, instead using the certification for a similar ride.
"How and why the owners obtained this registration will be one of the subjects of this inquiry," she said.
The Airmaxx 360 ride was imported from Spain and was linked to a number of accidents involving minors in Australia before the Adelaide tragedy.
Jenny-Lee Sullivan, a director of ride operator C J And Sons Amusement, told the court via video link she believed that air tanks needed to be certified before the ride could obtain its own design certification number. In the meantime the ride was operating using a number provided by consulting engineer Brian Bradley, who is now deceased.
Asked by Ms Giles if she had been told by Mr Bradley she could not continue to operate a ride with a "dodgy" certification number, Ms Sullivan denied that specific terminology had been used.
In emotional testimony interrupted by technical problems, Ms Sullivan said she supported the need for an inquest.
"More than six years later I still think of Adelene and her mother every single day," she said.
"My own children went on the Airmaxx 360, and I cannot begin to imagine the pain of the mother."
Ms Sullivan said she could not recall details of the registration of the ride and whether there were incidents recorded in a safety logbook that were not brought to her attention.
She attributed her inability to recall to the lingering emotional impact of the accident.
"I could not remember how to cross the road, this accident has mentally ruined me," she said.
Other failures outlined by Ms Giles include the ride owners requiring a ride height minimum of only 120cm, despite a manufacturer recommendation of 140cm.
Following 22 minor injuries reported at the Royal Melbourne Show in 2013, WorkSafe Victoria lifted the recommended minimum height to 130cm, but the Royal Agriculture and Horticultural Society of South Australia was not made aware of interstate incidents.
In a statement to the court Adelene's mother, who asked not to be named for privacy reasons, said that she had to alert the ride operators that her daughter was not strapped into her harness before the ride began.
The inquest heard that the specific seat and restraint used by the girl were in poor condition.
The inquest will also consider amusement ride regulations, the maintenance of the Airmaxx 360, and the emergency response to the incident, including the lack of a centralised emergency response centre at the Royal Adelaide Show.