The West Gate Bridge Collapse

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Gregson & Humphrys / 31 July 2019
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The West Gate Bridge Collapse:
How Disaster Happens
UTS CRICOS PROVIDER CODE 00099F
Sarah Gregson, University of New South Wales &
Elizabeth Humphrys, University of Technology Sydney
Draft version of forthcoming book chapter. Not to be reproduced or
distributed without permission.
Gregson S & Humphrys E (2020, forthcoming) ‘The West Gate Collapse:
How Disaster Happens’, In Peter Sheldon, Sarah Gregson, Russell
Lansbury & Karin Sanders (eds), The Regulation and Management of
Workplace Health and Safety: Historical and Emerging Trends, Routledge:
London.

Gregson & Humphrys / 31 July 2019
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Abstract
On 15 October 1970 in Melbourne, Australia, a span of the West Gate Bridge fell
during construction, killing 35 employees. The subsequent Royal Commission Report
into the causes of the collapse cited a number of problems with the erection of the
steel structure, including poor engineering practices, design flaws, and fragmented
management oversight. The report also suggested that industrial action had
contributed to the disaster by unduly lengthening the construction period. In the
concluding words of the commissioners, ‘the unions and men must bear their share of
responsibility for the tragedy that ensued’. Surprisingly, the case study provided by the
West Gate Bridge collapse has been little studied outside the engineering discipline;
we argue that it raises important considerations for scholars of work organisation and
safety today. Using Quinlan’s (2014) ‘ten pathways’ analysis, this chapter examines
the contributory factors that led to the West Gate Bridge disaster, including the
contested place of health and safety inspection and union influence at this work site.
Introduction
In October 1970, a section of the West Gate Bridge collapsed during construction and
35 employees were killed. It remains Australia’s worst industrial disaster outside of
mining. The tragedy received significant media coverage at the time, a Royal
Commission examined ‘the circumstances surrounding and the cause or causes direct
and indirect’ of the collapse, and there has been significant analysis of the bridge’s
engineering flaws (Biezma and Schanack, 2007; Charrett, 2008; Coles and Gourley,
2003; NCE Editorial, 2010). However, the political, social, industrial relations (IR), and
occupational health and safety (OHS) implications of the collapse warrant further
scholarly analysis. Moreover, the Royal Commission findings have never been
subjected to critical sociological assessment. Decades after they were handed down,
they remain the accepted wisdom (Royal Commission Report [hereafter RCR], 1971).
While the RCR did identify a range of factors that contributed to the tragedy, we argue
that responsibility was dispersed too widely. This diluted criticism of the employers with
the most significant duty of care, and neglected the question of regulatory failure. By
revisiting the Royal Commission findings, we hope to shed light on the collapse’s
contemporary lessons — including the dangers of organisational fragmentation on
building sites and the significance of worker voice in OHS discussions. As Hayes
(2011: 23) suggests, studies of decision-making in hazardous industries demonstrate
the utility of continued reminders about past tragedies for accident prevention. Further,
they invoke the dangers inherent in corporate fragmentation, organisational pressures
and cost-cutting, all issues of profound ongoing relevance.
In this chapter, we use Michael Quinlan’s ‘ten pathways’ framework
1
to subject what we
know about the West Gate Bridge disaster to greater scrutiny (Quinlan, 2014). The
pathways Quinlan identifies provide a rigorous scaffold for scrutinising industrial death
and injury, developed through a systematic examination of mining disasters between
1992 and 2010 across Australia, Britain, Canada, New Zealand and the United States
1
Quinlin’s ten pathways are: (1) engineering, design and maintenance flaws; (2) failure to heed warning
signs; (3) flaws in risk assessment; (4) flaws in management systems; (5) flaws in system auditing; (6)
economic or reward pressures compromising safety; (7) failures in regulatory oversight; (8) worker or
supervisor concerns that were ignored; (9) poor worker or management communication and trust; and,
(10) flaws in emergency and rescue procedures.

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(Quinlan, 2014: 31-33). He identifies ten pattern causes of workplace disaster that
repeatedly recur and, by highlighting the notion that ‘errors’ cannot be fully equated
with ‘failures’ and ‘flaws’ in work systems, his study is a necessary corrective to
investigations that search for individual scapegoats and ‘unforeseeable’ triggers of
tragedy. We, too, focus on the political, organisational and economic pressures that led
to the West Gate collapse as illustrations of common warning signs that emerge in non-
mining contexts as well. In addition, we emphasise the importance of unbiased
investigations of workplace accidents for the proper apprehension of all contributory
factors. As a product of their time, the Royal Commission Report interpretations are
well overdue for reassessment.
The collapse
By the 1960s, the idea of a road link across the Yarra River in Melbourne had gained
momentum as a much-needed infrastructure project for the city’s development
(Hitchings, 1979: 6-12). Unable to finance the project, the Victorian State government
formed the Lower Yarra Crossing Authority [hereafter the LYCA or Authority],
comprising a consortium of businessmen who had been lobbying for improved road
transport links between their Western-based establishments and other parts of the city
(Royal Commission Transcript [hereafter RCT], 1: 14-17).
2
With all the imprimatur of a
government department, if not a corresponding sense of public service, the Authority
was vested with sufficient powers to attract finance, issue contracts, supervise
construction, acquire land, and operate a toll bridge upon completion (Charrett, 2009).
The LYCA appointed two firms of consulting engineers to oversee the project —
Melbourne-based Maunsell and Partners [hereafter Maunsells] and London-based
Freeman Fox and Partners [hereafter Freeman Fox] — both leading design and
construction companies. Maunsells undertook the administrative work and Freeman
Fox’s role was to design the bridge and oversee technical matters. A number of
contractors were engaged to complete elements of the overall construction; the most
significant being John Holland Constructions [hereafter Hollands] for concreting work
and World Services for steel work. Construction began on both sides of the river in
early 1968, and the foundations were completed in September 1969 without significant
problems. By the end of 1969, however, World Services had fallen well behind
schedule on the western side and its contract was terminated by the LYCA. Hollands
assumed responsibility for their work, although its personnel had little experience in
steel erection. World Services agreed to provide technical advice to Hollands to
address this gap (RCT, 1: 24). Blame for delays was contested; while key LYCA,
Maunsells, World Services and Freeman Fox personnel maintained industrial action
was the culprit, some evidence suggested that World Services was using labour
problems as an excuse (RCT, 9: 2268). West Gate workers were highly organised into
seven unions.
3
Through regular site meetings, industrial action was initiated over
matters like pay, conditions, union rights and employer disciplinary strategies — for
example, downing tools until a sacked workmate was reinstated. On several occasions,
2
All references to the Royal Commission Transcripts provide the volume number followed by the page
number (e.g. Volume 1 page 11 is ‘RCT, 1: 11’)
3
These were the Amalgamated Engineering Union, the Australasian Society of Engineers, the
Boilermakers and Blacksmiths Society of Australia, the Builders Labourers’ Federation, the Building
Workers Industrial Union, the Federated Engine Drivers and Firemen’s Association, and the Federated
Iron Workers Association of Australia.

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workers took industrial action about workplace safety, and some delegates tried to form
a safety committee, but Hollands management was reluctant to participate.
In June 1970, a Freeman Fox-designed box girder bridge in Milford Haven in Wales
collapsed while under construction, killing four workers. The unions sought assurances
that the West Gate structure was safe and Freeman Fox resident engineer, Jack
Hindshaw, addressed a combined union meeting. He rested his reputation on the
bridge’s safety and, on hearing this, the workers voted to return to work. Joining the
two sides of the bridge, however, did not go smoothly. Workers had been manoeuvring
half girders into place on the western side, frustrated by a significant difference in
camber. Engineers decided to place seven eight-tonnes concrete blocks (kentledge) on
one girder to pressure it into place, but instead caused a bulge in the bridge structure.
Early on 15th October 1970, west side engineer David Ward ordered the removal of
thirty bolts in an attempt to flatten the bulge. At 11.50am, the structure could no longer
bear the stress — witnesses said the steel turned blue, bolts snapped like gunfire, and
the entire span between piers 10-11 collapsed (Coles and Gourley, 2003: 7-8). Thirty-
three men perished in the fall, 18 were hospitalised, and two of those men later died.
Twenty-eight women were made widows and 88 children lost their father.
Two investigative processes were initiated. Firstly, State Coroner Harry Pascoe
attended the scene quickly and formed a committee of inquiry. The committee
consisted of engineering and scientific experts, drawn from construction firms,
academia and government. Secondly, Mr Justice Barber from the Victorian Supreme
Court was appointed to head a Royal Commission, alongside two other Commissioners
— Frank Bull, an Adelaide professor of civil engineering, and Sir Hubert Shirley-Smith,
a British bridge expert who had been a witness on the Milford Haven inquiry. With state
police, the Coroner collected surviving documentation and interviewed witnesses,
searching for contributory factors. The Committee’s evidence and technical report
proved vital for the Royal Commission, but the Coroner waited for the Royal
Commission findings before adopting them in his own report (RCR, 1971: 10; Pascoe,
1973).
The Commissioners attributed blame to ‘the acts and omissions of those entrusted with
building a bridge of a new and highly sophisticated design’ (RCR, 1971: 97). They said
it was:
…mistakes, miscalculations, errors of judgment, failure of communication
and sheer inefficiency. In greater or lesser degree, the Authority itself, the
designers, the contractors, even the labour engaged in the work, must all
take some part of the blame. Error begat error, and the events which led to
the disaster moved with the inevitability of a Greek tragedy (RCR, 1971: 97).
Because the engineers were clearly concerned about the implications of the Milford
Haven collapse, the Commissioners characterised their assurances that the West Gate
structure was safe as ‘improper’ and a disingenuous ‘breach of their duty’, used to
‘pacify and ally the suspicions of the labour unions and their members, on the matter of
working safety’ (RCR, 1971: 101). The project was inadequately supervised and
decisions were based on incorrect stress calculations (RCR, 1971: 102). At Freeman
Fox, the Commissioners levelled the heaviest criticism, listing haphazard
communications, inadequate oversight, and poor decision-making as critical. ‘For all
the above reasons’, they concluded, ‘we are compelled to conclude that Freeman Fox
bear a heavy burden of responsibility for the failure of the bridge’ (RCR, 1971: 104-5).

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The Commissioners also labelled unionised workers’ actions as ‘industrial sabotage’,
concluding that delays caused by industrial strife, absenteeism, and inclement weather
had weakened the bridge’s structure. Their predispositions were clear:
The action of the trade unions and the men and [Hollands’] failure properly to
control the labour retarded the work and undoubtedly contributed to the
weakness of the span at the relevant time and so to the ultimate collapse. It is
widely accepted that the essential requirements for good labour relations are
mutual trust, confidence and respect as between management, trade unions
and men. Once this relationship is established, all concerned will work as a
team and first-class production can be achieved. Without it, little if any progress
can be made. By their actions in compelling [Hollands] to engage men in whom
they had no confidence and to run the job in a manner not of [Hollands’]
choosing, the trade unions and men must accept their share of responsibility for
the tragedy that ensued (RCR, 1971: 96).
The Commissioners’ conclusions suggest that, had the workers obeyed management’s
orders, the bridge would have been completed safely. Using Quinlan’s ten pathways
analysis in combination with the same testimony available to the Commissioners, we
question whether this is a credible conclusion to draw from the available evidence.
Analysing disasters and safety
A political economy approach to OHS identifies that disasters, and safety incidents
more generally, occur within broader capitalist structures. Quinlan adopts a three-
pronged political economy approach in which the social relations of capitalism:
1) affect the ‘form and scope (including work safety, labour and social protection
legislation) of safety’
2) influence ‘enforcement by the regulator or inspectorate, judiciary, coronial and
other investigative bodies’
3) shape ‘levels of influence businesses, unions and other interest groups can
exert on governments’ (Quinlan, 2014: 24).
This approach challenges unitarist OHS approaches that assume employers,
employees and governments have shared safety concerns, can safely self-regulate,
and will adopt participative practices that promote safe outcomes (Robens Committee,
1972).
Capitalist social relations include ‘the distribution of wealth and power within societies,
and dominant social policy paradigms that privilege markets and profit, production or
economic growth over safety’ (Quinlan, 2014: 24). In this chapter, we too show how
workplace conflict over safety is commonly obscured or misconstrued to downplay
worker concerns. In Australia, this is borne out, for example, in the traditional
separation of IR and OHS legislative regimes. Any blurring of regulatory boundaries
between IR and OHS regimes is often resisted by employer groups who insinuate that
unions use OHS concerns to further other industrial claims (Gregson et al, 2015).
Unsurprisingly, this separation has largely benefited employers, given legislative
provisions and enforcement mechanisms have never been sufficient to overpower
management prioritising production schedules and, in that environment, workplace
action against unsafe conditions has been sporadic (Creighton and Rozen, 2017: 20-
22). We argue that a political economy approach offers a compelling contextualisation
of the West Gate disaster and the Royal Commission investigation and findings.

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Recent scholarly attention to workplace disaster has challenged limited notions that
most cataclysmic events occur by chance, accidental human error, or some
combination of both, and can be characterised as ‘largely unavoidable byproduct[s] of
capitalist production’ (Bittle and Lippel, 2013: 2). Our arguments are based on a
paradigm that workplace disasters are ‘caused’ and that, while individual actions and
decisions may play a role, contextual factors offer more profound insights. Accurately
analysing the causes of disaster is fundamental to pursuit of amended regulation, more
targeted oversight and, ultimately, reduction in or prevention of future workplace injury
and death. All too often, political action takes place only after large workplace tragedies
have occurred and where corrective steps are constrained by financial considerations
(Berger, 1999). Indeed, the West Gate disaster highlights the longevity of this class-
based struggle to avoid the financial costs of workplace safety paid by employers,
insurers, and the state. In the immediate aftermath of a disaster, the failure to attribute
blame to those most responsible assists these parties to escape appropriate
reparations and punishment. Moreover, as Johnstone’s (2003) work has highlighted,
prosecutions and penalties are rarely sufficiently cautionary to provide reliable
incentives for safe practices.
Many researchers have pointed to managerial tendencies to ‘push the envelope’ by
restricting resources available for workplace and public safety (see, for example, Taylor
and Connelly, 2009). While the managerial strategies, ideologies and academic
fashions around the employment relationship may change over time, the productive
pressures at the heart of capitalism create continuities. A range of ubiquitous factors
create the preconditions for compromised safety outcomes: incentive payments that
reward work intensification and ‘speed ups’ (Hopkins, 2010; Gregson et al, 2015); cost-
cutting agendas that lead to ‘fissured workplaces’ (Weil, 2014; Johnstone and Stewart,
2015); weaknesses in managerial oversight and assessment (Hopkins, 2006); blurring
of organisational boundaries and responsibilities (Woolfson, 2004); regulatory
‘degradation’ (Gunningham, 2012; Tombs and Whyte, 2012); and attacks on worker
voice (Robinson and Smallman, 2013). Since the Robens Report (1972) was handed
down, it has been uncontroversial to say that worker involvement in OHS is integral to
safe outcomes. While workers can use their workplace knowledge to monitor and, at
times, refuse dangerous work, meaningful worker involvement is rarely effective if
workplace structures and cultures do not facilitate constructive responses to workers’
concerns (Hopkins, 2006). Nor are knowledge and power equally distributed in any
workplace (Bohle and Quinlan, 2000: 265). On a construction site, where many
engineering decisions are made autonomously, something akin to the ‘medical
dominance’ enjoyed by doctors (Willis, 1983; 2006) is vested in university-qualified site
leaders. Even with a high level of workplace organisation, the ability of building workers
to question authority is limited by disparities of expertise.
Quinlan’s ‘ten pathways’ highlight pattern causes of disaster that emerge repeatedly in
post-disaster investigations. Although these pathways have not been tested outside the
mining context, Quinlan (2014: 143) argues that a familiar ‘pervasive pattern of flaws
across diverse industries’ is present in other researchers’ work. Our research on the
West Gate collapse also demonstrates the clear applicability of this framework. While
the engineering problems have been well documented — an unusual erection method,
inadequate stress calculations and allowances, and problematic decision-making — we
argue that the organisational and management failures highlighted by the ‘pathways’
can more fully address why the design and construction problems went undetected, or
were ignored and allowed to fester. While the actions and omissions of engineering
personnel that precipitated the disaster suggest that some engineers failed to detect
danger, an approach that focuses on individual fault — like the Coroner’s assessment
of whether victims caused their own deaths — can obscure wider contextual factors.

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In this study, we also scrutinise the level of independence of the commissioners on the
West Gate inquiry, the potential for bias, and whether their findings aligned with
witnesses’ testimony, in order to assess the historical and contemporary value of the
findings. In particular, we question whether workers can ever be responsible for a
disaster of such magnitude. We conclude that, apart from allaying public anger about
official inaction, it is difficult to see what purpose the Royal Commission served in the
absence of criminal charges against those responsible.
Ten Pathways to the West Gate disaster
To facilitate our analysis, we grouped the ten pathways into four key themes, thereby
reducing overlap and assisting concision and analytical clarity. For example, in the
West Gate case, project management failures were also failures of communication and
failures to act on warnings signs. In grouping the pathways in this manner, we can
more clearly delineate failures within the construction project’s complex route to
disaster. Our themes are:
Design and project management failures — (1) engineering, design and
maintenance flaws; (3) flaws in risk assessment; (4) flaws in management systems;
(5) flaws in system auditing.
Communication failures and failures to act — (2) failure to heed warning signs; (8)
worker or supervisor concerns that were ignored; (9) poor worker or management
communication and trust.
Failure of government and incident response — (7) failures in regulatory oversight;
(10) flaws in emergency and rescue procedures.
Economic pressures — (6) Economic or reward pressures compromising safety.
Design and project management failures
The West Gate disaster involved clear evidence of engineering and design flaws,
including related flaws in risk assessment, management systems, and auditing. Coles
and Gourley (2003: 15-16) delineated six direct causes of the disaster related to
design, erection methods, and management oversight. These causes were: the
decision to remove bolts to address the buckle; the use of kentledge; inappropriate
steelwork erection procedures; inadequate and inaccurate attention to structural
stresses; and unsatisfactory design of component parts. The Coroner concluded that
Freeman Fox’s failure ‘to give proper and careful evaluations to design’ and the neglect
of safe erection procedures were key, especially when the design ‘required greater
than usual care to be exercised’ (Pascoe, 1973: 3). Commissioner Shirley-Smith asked
Sir Gilbert Roberts, the bridge designer, ‘Do you agree that engineers have, in the past,
learnt more by their failures and disasters than successes…?’ On the contrary, Roberts
begrudged the ‘atmosphere of caution’ and ‘unnecessary’ safety measures taken after
the Milford Haven collapse. Sir Hubert reminded him that men’s lives depended on safe
construction practices but Roberts reiterated that excessive caution ‘sets back the
practice’ (RCT, 6: 2151-2).
Management systems on the West Gate project were extremely fragmented by
corporate schisms, distance, lack of role clarity, and unworkable chains of command.
Nor were the responsibilities of, and the relationships between, the parties clear (RCR,
1971: 98; Charrett, 2008; 2009). When Hollands accepted the erection work, an
unusual contractual arrangement was made — given the advanced stage of the work

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and the company’s inexperience with steel bridge work, Hollands’ contract with the
LYCA abrogated any responsibility it would normally assume for future construction
problems. Although not supportive of the contracting changes, Freeman Fox undertook
to provide calculations and extra supervisory personnel to complete the project and, as
the acknowledged experts, World Services agreed to provide on-the-ground support to
Hollands. Maunsells London clarified the arrangement between the parties in a letter to
the LYCA in July 1970:
The present arrangement with Hollands, for better or worse, is what amounts to a
labour-supply contract without contractual responsibility for the erection
procedure. The responsibility for deciding how to complete any gaps in the
erection scheme, and indeed for all technical decision [sic] of consequence, now
falls upon the Joint Engineers acting on behalf of the Authority (RCT, 1: 255/2).
This arrangement troubled Freeman Fox resident engineer, Jack Hindshaw, who felt
placed in an invidious position — nominally in charge of the project, Hollands staff had
better relations with World Services personnel and often ignored his instructions.
To worsen matters, evidence from Cecil Wilson, LYCA general manager, indicated that
the Authority, and indeed all parties, had lost confidence in Freeman Fox’s role as
consulting engineers and sought external ‘special advisers’ on technical matters ‘in
order to ensure that our consultants are doing the right thing’ ((Hitchings, 1979: 20;
RCT, 1: 283). Queries from the Authority, Hindshaw, Holland and World Services to
Freeman Fox in London went unanswered for months. Of the relationships between
Melbourne and London, the Commission chairman noted ‘too many things seem to
happen with nobody being specifically responsible…which partner is responsible for
this or that’ (RCT, 7: 2462). For this reason, he said, ‘One has a good deal of sympathy
for Hindshaw out here in Australia not really knowing where he stands, asking for
guidance and, as far as I can see, not getting it in writing’ (RCT, 7: 2466-7).
The Commissioners argued that the LYCA placed too much emphasis on completion
delay without proper risk assessment and pondered whether completion timeframes
imposed on the parties had been too tight. They described an ‘atmosphere of urgency’
that led to ‘ill-considered decisions’, ‘mistakes’, and ‘hasty actions’ (RCR, 1971: 98).
The Commissioners criticised all the other parties, but concluded that ‘justice to them
requires us to state unequivocally that the great part of the blame must be attributed to
[Freeman Fox]’ (RCR, 1971: 105). Even while negotiations between the LYCA and
Hollands were taking place, the Commissioners found that ‘the Authority had already
entertained serious doubts as to the safety of the bridge design, and particularly as to
adequacy of the structure during the process of erection’, but did not relax its
completion pressures (RCR, 1971: 98). After the Milford Haven collapse, the Authority
ordered an independent audit of the design and employed Maunsells in London for the
work. An interim report received in September 1970 raised concerns about the
structural stresses and a stop work order was sent, suggesting further stiffening works
were required (RCT, 4: 1378-9). Freeman Fox engineer, David Ward, attested to being
aware of the order but said work did not stop on the west side (RCT, 4: 1173).
Management decisions to prioritise completion over safety showed disregard for the
risks they took with workers’ lives.
Communication failures and failures to act
Although Maunsells and Freeman Fox were global players in large construction
projects, communication between the London-based head offices and the Australian
building site was often slow and superficial and failures to heed warning signs occurred

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at many junctures. As the above example suggests, the poor management of the
project included devastating instances of communication failures between contracted
parties and the LYCA prior to the collapse, and a failure to ensure appropriate
oversight of contractual work by the engineering consultants. In addition, there were
occasions when worker or supervisor concerns were ignored, so that construction
could continue. Coroner Harry Pascoe identified both management processes and
communication issues on site:
I was surprised at the lack of co-ordination and the lack of support in the higher
echelons. … They all had secrets. They wouldn’t get together and talk about
how to do something, or feared they would give away their ideas and somebody
else would cash in on it. … Everybody was trying to give the impression of
efficiency and happiness at doing the job (Egan, 1990: 10).
Freeman Fox design engineer Peter Crossley clearly recognised that the structure was
under great stress but had insufficient capacity to do accurate calculations himself, or
to make his superiors aware of the seriousness of the situation. The Coroner and the
Commission both noted that Hindshaw was unenthusiastic about the use of kentledge
to address the western side buckle, but did not use his position power to follow another
course of action — an illustration of worsening communication problems between
consultants and contractors.
When workers heard that the Milford Haven Bridge had collapsed, the unions made
formal OHS inquiries and a meeting of management and workers was held.
Hindshaw’s assurances that the bridge was safe convinced a 2/3 majority vote of
workers to return to work. Tommy Watson and Pat Preston, both West Gate survivors
and union leaders, confirmed the considerable influence Hindshaw’s assurances, as an
experienced engineer, had on workers (Panel of West Gate workers, 23 November
2018). This was not, however, evidence of good communication and trust about OHS.
On the contrary, there was what Berger (1999) termed ‘a mumbling environment’
where workers tried to raise concerns with management, got inadequate or denialist
responses, and went back to work for lack of an alternative. In addition, the Coroner
noted that Maunsells and Freeman Fox cooperated ‘in allaying the suspicions of labour
unions and their members on matters of safety by expressions of assurances which
were made without any proper foundation’ (Pascoe, 1973: 4). Indeed, in a revealing
telex from the Melbourne-based joint consulting engineers to Freeman Fox in London,
Mr Fernie wrote, ‘Please consider alternatives for stiffening splices eg the concrete
implications of proposals very severe on labour, authority’ (RCT, 8: 2797). Fernie
admitted that, having reassured the workers of the structure’s safety, commencing a
stiffening program would have been ‘embarrassing’. For their part, West Gate workers
did a lot more than ‘mumble’ about safety issues on the bridge, but evasion and buck-
passing were management’s response. In the wake of the Milford Haven collapse,
Maunsells engineer Howard James said the engineers were playing ‘a very dangerous
game’ to reassure workers when there were doubts about the ‘screwy’ erection
methods. ‘[Y]ou could not go to the Union and say, “You must work on Sunday or
Saturday afternoon or whatever” because the structure was unsafe”’ (RCT, 4: 1442).
He told the Commission that a structure should be safe at all times during construction
and production pressures were no excuse for ignoring safety concerns.
On the morning of the collapse, engineer William Tracey expressed disquiet about the
removal of bolts. The Coroner (1973: 5) noted that ‘his doubts were apparently so
grave that he insisted on written instructions from David Ward, the section engineer
who had assumed responsibility for their removal’. No serious blame was attributed to
Tracey, as he had little previous experience in steel erection and simply fell in line ‘with

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what amounted to a direct order from the engineers in a field which was within their
province’ (Pascoe, 1973: 5). The workers who removed the bolts were concerned
about these directions. Edwin Halsall testified that he half-joked to tradesman, Barney
Butters, “Don’t take any more bolts out, Barney, it’s going to fall down” (RCT, 3: 871).
Mr Halsall said Butters did not reply, but “put his hand up and pointed towards Mr
Miller” (RCT, 3: 882). Halsall confirmed that workers must always defer to the
engineers on matters requiring expertise (RCT, 3: 887A). Des Gibson told the
Commission of a conversation between Miller and Butters, where Butters told Miller the
bolt removal would be better done in the cool of the evening (RCT, 3: 908); instead it
was done in the middle of the day.
Despite the West Gate unionists’ industrial militancy, workplace organisation around
OHS was at a nascent stage. Worker/management communication was poor, and
attempts by the unions to develop safety systems were ignored or undermined. A
Hollands employee, Thomas Greenwood, gave evidence that attempts to set up a
safety committee had not received management support. Greenwood said, ‘They were
of the opinion that once a Safety Officer got on the job, all he would do all day would be
to walk up and down and look for faults’ (RCT, 3: 763). That said, in order to
demonstrate the disruptive militancy of the unions, the Commissioners included a list of
industrial stoppages that took place 13 April-14 August 1970 in their final report. The
list was revelatory, but perhaps not in the way intended. Of 21 disputes, the majority
were about OHS — provision of first-aid personnel, working in the rain, unclean toilets,
opposition to night shift, and demarcation and overtime disputes that had OHS
elements (RCR, 1971: 121). Overall, the extent of industrial disputation on site
indicated there was little trust between the parties. To the extent that workers did trust
engineers’ expertise, it was tragically misplaced.
Failure of regulatory and incident response
The apparent dearth of external regulatory oversight on the West Gate project did not
receive sufficient attention during the RC investigation. The Country Roads Board of
Victoria (CRB) was the government authority responsible for construction and
maintenance, standard setting, and inspection of main roads in this period. Plans and
procedures for projects were submitted to it for approval, but the inquiry revealed little
evidence of an onsite presence at the West Gate (RCT, 7: 2548). Bridge designer, Sir
Gilbert Roberts, was asked by Commissioners whether a standard or code applied to
bridge design and Roberts replied that such regulations were ‘not necessary’.
Dismissing the importance of national standards, he said, ‘a designer must have his
own code of conduct’ and ‘design rules’ (RCT, 6: 1928). Solicitor-General Murray
asked Dr Brown, a Freeman Fox partner, ‘Are we to take it that Freeman Fox
considered that from time to time even though the design is generally in accordance
with [a regulatory code] they can depart from it?’ Brown replied, ‘Yes, if we felt it was in
the interest of our client to do so’ (RCT, 6: 2250).
The pseudo-governmental status of the LYCA was problematic; its operations were
largely self-regulated and former expert public servants and academic engineers were
engaged as an in-house inspectorate (RCT, 1: 281-2). Cecil Wilson had been
employed by the Country Roads Board before becoming LYCA general manager
(Hitchings, 1979: 20). Formerly a senior metallurgist at the State Electricity
Commission, Ian Shugg became the Authority’s ‘independent’ specialist consultant on
metallurgical issues, such as the supply of steel and welding procedures (RCT, 2: 243).
The joint consulting engineers also hired ‘inspectors’ who oversaw various aspects of
the construction, such as welding and concreting. One of them, Ernest Enness, was
not an engineer and had no independent authority, reporting to Chris Simpson, the east

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11
side Freeman Fox engineer. On one occasion Enness told Hindshaw that if he had his
way, ‘I would make them take the whole of the diaphragms out and start again’. In
reply, Hindshaw reportedly said, ‘I do not think we need to be as drastic as that’ (RCT,
2: 456-7). Enness also testified that he opposed Ward’s decision to remove the bolts,
but did not raise objections. When asked whether it was not his place to advise
engineers, he agreed but now regretted his silence (RCT, 2: 459). Enness had a
material interest in not making enemies on site — he had already secured a position
with the LYCA as maintenance supervisor on the completed bridge (RCT, 2: 459).
Peter Mackian, a boilermaker, attested he saw the inspectors on a daily basis
‘patrolling around the job’. Asked if they ever commented on work quality, he said, ‘I do
not think they ever complained’. Nor had he ever been asked to redo work because an
inspector wanted a problem addressed (RCT, 3: 750). Although labelled ‘independent’,
the employer of these inspectors was also the customer on this project. In evidence,
Wilson professed he had held expert concerns about the bridge’s safety and had
expressed them to site engineers. His LYCA position, however, fatally compromised
any standard-setting role he may have adopted, particularly as he was always urging
speed. That said, when ‘jokes’ were made about covering up the bulge until it could be
fixed, it was Wilson that the engineers worried would find out. Boilermaker Max Adams
testified both Tracey and Ward had told him at different times to ‘throw a bag’ over the
bulge so that Wilson would not see it. Adams had not taken the suggestion seriously
and never saw the bulge covered (RCT, 3: 927). Rather, it had become something of a
‘shared joke’ among the engineers, he felt (RCT, 3: 932).
In stark contrast, we found no public criticism of the state’s rescue response to the
West Gate tragedy — indeed, it appeared that flaws in emergency and rescue
procedures might be the only pathway to disaster that was inapplicable in the West
Gate case. Emergency services responded quickly and there was fervent cooperation
between rescue workers, survivors of the collapse, and social welfare personnel who
provided sustenance at the scene (Wilson, 1970). In newspaper stories, several
survivors were praised for their dedication and heroism (Anon, 1970b). The Coroner
agreed, stating that ‘all that was humanly possible to save and mitigate the suffering of
the injured, was undoubtedly done’ (Pascoe, 1973).
4
However, there is evidence that
what is now call post-traumatic stress disorder was prevalent among survivors,
including those who participated in rescue operations. Tommy Watson, a survivor,
described two sources of psychological distress he both experienced and witnessed.
Firstly, all the workers were laid off a few days after the collapse, fragmenting social
support, especially for the single men. From his perspective, ‘There was no
counselling, there was no support. Nobody ever came and seen me…400 people
walking around like zombies … and there was no support’ (Tommy Watson interview,
2018). Secondly, Mr Watson argued that because rescue workers were unfamiliar with
building equipment, uninjured survivors stayed on site to recover bodies of dead
workmates (West Gate panel, 2018). He was convinced that this increased the trauma
experienced by survivors.
Economic pressures
Economic or reward pressures compromising safety played a key role in shaping
management decisions. Coles and Gourley (2003: 5) argued that adherence to project
4
The Inquest Deposition Files at the Public Records Office of Victoria (PROV, VPRS 24/3, Unit 120)
contain an untitled, undated and hand annotated typescript of what we are confident is a prepared speech
for Coroner Harry Pascoe, to deliver his findings of the Coronial Inquest into the West Gate. In the
typescript Pascoe quotes from the Royal Commission Report, delivers his findings as to cause of death of
each of the 35 men, and makes remarks on various elements of the disaster.

Gregson & Humphrys / 31 July 2019
12
timeframes was critical for the LYCA, due to high interest on borrowings. As a highly
visible symbol of government performance, the LYCA was determined that ‘detailed
designs must be rapidly prepared’ so that the tender process could be expedited
(Coles and Gourley, 2003: 5). In evidence, Gerit Hardenberg, a senior civil engineer
with World Services, attested that the company was always aware that falling behind
the schedule was problematic, not least because there were significant financial
penalty clauses in their contract for failure to meet deadlines. ‘We had constant
pressure from Mr Birkett [LYCA] primarily to hasten on’, Hardenberg said. ‘He was
quite naturally, from his point of view, pushing us, because of the delay’ (RCT, 2: 549).
One criticism of World Services delays was that management skimped on employing
sufficient staff, especially supervisory staff, to complete the job efficiently, a failure also
blamed for the high level of industrial action. The Commission received documents
demonstrating that the World Services tender for the project was a massive $750,000
lower than the next cheapest bid (RCT, 1: 255-3), suggesting it underestimated the
budget required (RCT, 7: 2508-9). In turn, World Services management said the delays
could be attributed almost entirely to union-led disruptions. In one engineer’s diary, it
was noted, ‘Schroeder said it was all the fault of the labour. Apart from that they would
have been right up to date’ (RCT, 7: 2551). While most managers thought this was one
factor among others, one gave evidence that productivity would have improved if there
had been more site engineers employed to give detailed instructions and schedules to
work teams so that there was less need for questions (RCT, 8: 2817). In response, the
Chairman quipped sympathetically ‘Satan finds some mischief still for idle hands’ (RCT,
8: 2820).
Labour shortages continued to stalk the project after Hollands took over the erection
work and several Commission witnesses argued that the company was not active
enough in recruitment to keep the job on schedule (RCT, 8: 2852-3). Employers were
also reluctant to hire 22 union militants left behind by World Services. Joint Consulting
Engineer, Howard James said “Well, the principal difficulty here was that it was no
good advertising for men at this time because we knew there were a number of
unsatisfactory men on the market and we did not want to gather them in.” Hollands’
strategy was to wait and pick up ‘good men’ from World Services when their fabrication
contract ran down (RCT, 8: 2852-3). Eventually, union pressure to engage the men
won the day but the Commissioners were unimpressed by this exercise of union power
(RCT, 5: 1595).
As we delineated at the outset, a political economy approach to industrial disasters is
crucial, as it is attentive to how the social relations of capitalism shape business
practice and OHS. Economic pressures on the West Gate project illuminate clearly how
concerns about timeliness in production and efficiency and delay on site are not
neutral, but moulded by a dominant ideology that privileges profit and the pace of
production over safety.
The Royal Commission
The West Gate Bridge Royal Commission began hearings on 28 October 1970 and its
report was made public on 8 August 1971. It heard evidence from 52 witnesses and
considered 319 exhibits (RCR, 1971: Appendix A and B). Although such inquiries have
an aura of judicial independence, they are, as Prasser (2006: 31-32) put it, ‘creatures
of executive government’. It is governments that establish royal commissions, decide
terms of reference, allocate the duration of the inquiry, appoint commissioners and
determine what resources will be put at their disposal. Moreover, as argued earlier,

Gregson & Humphrys / 31 July 2019
13
such inquiries do not exist outside the social relations of class society and the structural
interests that are embedded in governmental and legal processes.
Three aspects of the West Gate Royal Commission concern us here. Firstly, the unions
wanted expanded terms of reference. Kenneth Marks QC, a Maurice Blackburn lawyer
acting for the Victorian Trades Hall Council (VTHC) and the seven unions involved in
the West Gate site, argued that the Commission’s present mandate might limit the
investigation to questions about ‘what happened’, excluding broader questions of
safety precautions (RCT, 1: 2-4). Marks asked the Commission to examine OHS
protocols on site, whether any laws were broken, and whether current regulations and
laws were sufficient to prevent future loss of life. After some consideration, Justice
Barber rejected the expanded terms of reference. Further, although the terms of
reference were extended ‘to inquire into and report upon whether any aspect of the
design of the steel span between piers 10 and 11 is inadequate or undesirable’ (RCR,
1971: 106), important matters of local regulatory standards, a key pathway for Quinlan,
were not examined.
Secondly, we note that the unions did not formally participate in the Royal Commission
beyond the first sitting day (RCT, 1: 11). Approaches on behalf of the VTHC were
made to the State Government about covering representation costs incurred by the
unions, estimated to involve $10,000 in legal fees (Dean and Teague, 1970). In the
Victorian parliament, conservative premier, Sir Henry Bolte, advised that he had
refused the VTHC request, maintaining that “the Royal Commission will perform its
function and represent the public, which includes the trade union movement” (Hansard,
1970: 2051; Anon, 1970c). When a Labor member pointed out that other parties had
representation at the hearings, Mr Bolte argued that those parties had paid for their
legal teams, refusing to consider unequal corporate and union capacities to pay
(Hansard, 1970: 2051; Anon, 1970c). Because the unions were not represented,
unsubstantiated assertions about union activity on the site were allowed to enter the
record unchallenged.
Thirdly, we consider apprehensions of bias. On the Commission’s second sitting day,
Chairman Barber raised press comments about Sir Hubert Shirley-Smith, who had
enjoyed a close personal and professional association with several senior Freeman
Fox engineers. Barber maintained that Shirley-Smith’s credentials and impartiality were
beyond reproach, that he had not been employed by Freeman Fox since 1936, and
that he was named in the Act establishing the Commission and therefore could not be
dismissed. Via the office of Clyde Holding, then Labor Opposition leader, a long and
well-researched typescript regarding Shirley-Smith’s biography had found its way to the
VTHC (VTHC collection, UMA). The document outlined a life-long association between
Shirley-Smith and Sir Ralph Freeman, senior and junior, as well as Sir Gilbert Roberts,
the West Gate designer. Holding subsequently stated that if Labor colleagues had
known this information when Shirley-Smith was appointed, they would not have
supported his selection, clearly deeming it improper (Holding, 1970).
All royal commission reports are inevitably selective in some form or another. However,
the West Gate inquiry was limited in relation to: the terms of reference; the
Commissioners’ selective appreciation of some evidence; the corporate associations of
Commissioner Shirley-Smith; and, the inability of the unions to participate in the inquiry.
As a result, the persuasiveness and completeness of the findings are open to criticism;
certainly, the Royal Commission inquiry and findings cannot be presented as a neutral
account of a disaster.

Gregson & Humphrys / 31 July 2019
14
Conclusion
Only months before his appointment to the Royal Commission, Shirley-Smith wrote that
engineers must urgently address safety in construction, because of the human and
financial costs. In words that would later contradict the emphasis placed on union
conflict in the West Gate Royal Commission findings, he stated that ‘much more
working time is lost through accidents than through strikes’ (Williams, 1969). One
wonders if the damning evidence against his former colleagues at Freeman Fox
encouraged Sir Hubert to recant this position and to start ‘flinging mud’ wherever else it
would stick, including on the militant unions on the bridge who took several actions in
pursuit of improved health and safety.
While the Royal Commission investigation was thorough and made a range of
substantive conclusions, we argue that the Commissioners’ findings were imbued with
class prejudices that encouraged attribution of blame to workers and their unions.
Arguably, worker capacity to refuse work in a dangerous environment was the only
effective means that may have averted tragedy. Regrettably, however, while worker
organisation on the West Gate was highly evolved, OHS organisation was not. Workers
were, ultimately, unable to fully interrogate the warning signs provided by the Milford
Haven precedent, especially given the false assurances made by engineer Jack
Hindshaw prior to the collapse.
Far fewer commentators have read the Royal Commission transcripts than have relied
upon the final report, meaning that the biases contained in the Commissioners’
sometimes selective interpretations of witnesses’ testimony have gained an air of
orthodoxy through accessibility and repetition. We hope that this re-examination of the
Royal Commission transcript volumes highlights more complex pathways to disaster.
Moreover, as the 50th anniversary of the West Gate disaster approaches, the utility of
revisiting the causes of the collapse can be seen in contemporary reliance on
fragmented work organisation, and contracting and insecure work arrangements.
Importantly, the West Gate disaster provides a reminder that the causes of multiple
fatality disasters, while sometimes poorly recognised by managers, are predictable.
Quinlan’s methodology is here shown to be applicable outside mining, with a forensic
structure that can suggest prevention initiatives.
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