A grief-stricken mother who fought for an inquest into her youngest son's death on a carnival ride has called for the amusement industry to change "so this doesn't happen to another family".
Eugene Mahauariki, 6, died in hospital four days after slipping from his seat on the Cha Cha, at Rye Easter Carnival in April 2017.
A coroner on Friday found his death was preventable and recommended sweeping changes to amusement park regulation.
Outside court, Eugene's mother Tammy White cried as she remembered her "cheeky and outgoing" youngest son.
"He was so loved," she said.
"I fought for an inquest because I knew that Eugene's death was preventable, and today the coroner agreed with me.
"The coroner has recommended change for the entire amusement industry ... I hope they all take it on, so this doesn't happen to another family."
Her lawyer Barrie Woollacott said he hoped WorkSafe Victoria listened to the coroner's recommendations, adding that the inquest was told it did the "barest minimum" of what it had to do.
"Amusement park operators will always do the bare minimum, it seems," he said.
"So the regulatory authority needs to be stronger, needs to be tougher and needs to be more demanding."
The Cha Cha was Eugene's favourite ride and he lined up about 5.20pm on April 17, when the last ride was called.
At 132cm, he was tall for his age and able to ride without an adult.
He was seated next to a smaller and younger child and placed on the outside seat, meant for adults and bigger children, and slid into his friend as the ride began.
As both children were small, the U-shaped rod used to restrain them did not work and Eugene slipped from underneath the lap bar.
He was ejected from the carriage, fell and hit his head before landing on the ground.
He was taken hospital, but could not be saved and died when his life support was turned off on April 21.
Wittingslow Amusements was prosecuted by WorkSafe for health and safety breaches but the charges were withdrawn in 2020.
When an 11-day inquest was held last year, ride owner Michael Wittingslow refused to give evidence.
Coroner Sarah Gebert found the restraints that were supposed to hold Eugene in his seat were not compliant with Australian standards.
"Without doubt, members of the public would hold an expectation or reasonable assumption that there is a system in place to ensure the safety of amusement rides in Victoria," she said.
"Yet, this investigation revealed that the Cha Cha was able to operate without restraints which were compliant with Australian standards over many years."
She found a German man who was operating the ride that day was not sufficiently trained or supervised, and that Mr Wittingslow did not know if he was trained.
She recommended a review to improve training standards and accreditation of ride operators and attendants, including looking at whether there should be minimum standards for training.
Victoria should reinstate a requirement to register amusement structures and operators, she said.
Ms Gebert said the Cha Cha, which was built in 1961, was not checked as stringently as newer rides.
She recommended new ride designs be registered and WorkSafe be given powers to refuse or cancel an application for design registration if it believes the design posed a risk or was unsafe.
Additionally, the national audit tool used by WorkSafe to inspect rides should be enhanced for the safety of all rides.
She expressed concern that a 2015 Queensland safety alert, requiring ride owners to have ride restraints assessed by an engineer, was not adopted by WorkSafe before Eugene's death.
"This appears to be a missed opportunity to re-enforce rider safety for Cha Cha type rides," Ms Gebert said.
The body created an information sheet in 2018, recommending measures to mitigate risks on rides like the Cha Cha.
A WorkSafe spokesman said it will consider the coroner's findings over the coming weeks and was providing support to Eugene's family.
