The document summarizes lessons learned from the 1970 collapse of the West Gate Bridge in Melbourne, which killed 35 workers. There were numerous failures across engineering, design, risk assessment, management systems, and regulatory oversight that contributed to the disaster. A Royal Commission and Coronial Inquest found flaws but also blamed unions for delays, though they had raised safety concerns that were ignored by managers. The document examines how responsibility was diluted and analyzes the disaster through various lenses to understand the systemic failures that led to the tragedy.

1. The West Gate Bridge collapse:
Lessons for Workplace Safety
Elizabeth Humphrys
School of Communication
UTS
Sarah Gregson
School of Management
UNSW
1

2. Many pathways cross… • engineering, design and maintenance flaws
• failure to heed warning signs
• flaws in risk assessment
• flaws in management systems
• flaws in auditing
• economic/reward pressures
• failures in regulatory oversight
• worker or supervisor concerns ignored
• poor workplace communication and trust
• deficiencies in emergency and rescue
procedures
This presentation will appear in forthcoming book:
The Regulation and Management of Workplace
Health and Safety, published by Routledge.
Examining the West Gate bridge
disaster through analytical framework
provided by:
Michael Quinlan, Ten Pathways to
Death and Disaster: Learning from Fatal
Incidents in Mines and Other High
Hazard Workplaces, Federation Press,
Annandale, 2014.
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3. Introduction
• 11.50am on 15 October 1970, a span of the West Gate bridge in Melbourne
collapsed during construction
• 35 employees killed
• Errors, failures and flaws
• Mistakes cannot be viewed in isolation (Reason, 2008)
• Royal Commission and Coronial Inquest into disaster set up in the aftermath
• Commission report reveals a litany of errors, failures and flaws
• Transcripts shed light on findings in final report
• Commissioners’ biases undermined conclusions they drew
• Can unions cause disasters or is it always management’s duty of care?
• Necessary to accurately assess pathways to prevent future disaster
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4. Broader literature of links
between poor OHS outcomes
and:
• Precarity
• Sub contracting
• Workplace OHS organisation,
worker voice
• Then and now
• Importance of 50th anniversary
in 2020
4

5. flaws in management
systems, regulatory
oversight
• Bolte (conservative) government –
West Gate as emblem of modernity,
progress
• Set up Lower Yarra Crossing
Authority
• Two consulting engineers:
• Maunsell and Partners,
Melbourne
• Freeman Fox and Partners, based
in London
• Several contractors for
different aspects of the job
• World Services
• Holland Constructions
• Fractured responsibilities, buck
passing, enmities and poor
communication between
engineers of different
contractors
• Effect of ‘speed up’ pressures
• Failures of oversight
• LYCA seconded a consulting
engineer from Country
Roads Board
• Inhouse ‘inspectors’
5

6. flaws in engineering, design, maintenance, risk
assessment
Bridge design controversial, design flaws
properly addressed only post-collapse
• First contractor – World Services – was
experienced in steel construction required
for West Gate
• Contract terminated because of time delays
and replacement, John Holland, did not have
this experience
• Freeman Fox engineers was supposed to
closely oversee their work, but did not
• Role clarity, leadership, information,
communication were all insufficient
• Engineer David Ward ordered bolt removal
without sufficient consultation, information
Engineering mistakes by supervising engineers
• Calculations seriously in error, giving a ‘totally
inadequate analysis of the situation’,
contractors had no ‘real idea of the stresses
imposed’.
• Commissioners stated, ‘permission for the
operations that led to the collapse was entirely
the responsibility of the supervising engineers,
who could, and should, have vetoed any work
they considered unsafe’ (RCR:18).
• Mr James, Maunsells engineer, attested the
structure should be safe at all times … in his
diary he wrote, “you could not go to the Union
and say, “You must work on Sunday or
Saturday afternoon or whatever” because the
structure was unsafe” (RCT:1442).
6

7. flaws in management
systems
Strong union representation on site
• Worker concerns initially about day to day
issues, rather than a large-scale calamity
• Growing sense of unease
• safety concerns about making the two sides of
the bridge meet
• workers push for a safety meeting/committee
because ‘it looks bad’.
• Attempts to form safety committee met with
employer opposition - ‘the firm [John Holland]
was not for it at all.‘
7

8. failure to heed warning signs/ workers concerns ignored
• June 1970 Milford Haven collapse –
four men killed
• Unions raised more formal concerns
about safety
• Site engineer, Jack Hindshaw,
assured workers West Gate safe
• Lot of faith in engineer expertise -
Tommy Watson told us ‘The
engineers were gods.’
• September, 1970 - stormy meeting held
between Hindshaw (FF) and Wilson
(LYCA).
• Wilson attacked FF as inefficient, and
expressed doubts about safety of the
bridge.
• Hindshaw showed him over the bridge
to assure him that the stiffening work
was being done effectively.
• Engineer joke to ‘throw a bag over the
buckle’ so that Wilson would not see it.
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9. economic and reward pressures
compromising safety
• Budget blowing out
• WSC underbid for the job – next bid up
was $750,000 more
• WSC was in a lot of financial trouble
(RCR:79).
• ‘The company was losing money, and
looked like losing a great deal more’
(RCR:80).
• Communication terrible from Freeman
Fox.
• This was supported by all the other
parties.
• LYCA pressure to finish
9

10. Royal Commission
• Bias evident in the taking of evidence –
commissioners, counsel led witnesses
without challenge
• Commissioners/legal reps asked leading
questions about industrial disruption on the
site
• Unions not represented at the Royal
Commission
• VTHC sent detailed CV of commissioner, Sir
Hubert Shirley-Smith – strong links with FF
10

11. Coroners’ report
City Coroner Harry Pascoe:
‘I was surprised at the lack of co-ordination and the lack of support in
the higher echelons.” Pascoe says. “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. I couldn’t
help but protest about it. Everybody was trying to give the impression
of efficiency and happiness at doing the job. They were all trying to
keep a stiff upper lip.” Weekend Australian, 1990:11.
11

12. Royal Commission findings
• Did find Freeman Fox principally
responsible for disaster
• ‘proper procedures’ not followed which
led to ‘inexcusable’. engineering
outcomes (RCR:19).
• Spread the blame to include unions –
industrial delays caused collapse
• Preposterous notion that workers knew
their industrial action was weakening the
bridge’s structure but kept working
‘The action of the trade
unions and the men and
JHC’s 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….By their actions in
compelling JHC to engage
men in whom they had no
confidence and to run the
job in a manner not of JHC’s
choosing, the trade unions
and men must accept their
share of responsibility for
the tragedy that ensued’
(RCR:96). 12

13. • VTHC secretary, Ken Stone, expressed
astonishment at the findings
• Management always responsible for safety
• Acknowledged disputes and time lost
• Said majority of disputes were over safety
The Age, 4 August 1971.
• List of industrial
stoppages 13 April - 14
August 1970 (RCR:121)
• Of 21 disputes, majority
were:
• ‘provision of first-aid
man at pier 15
• disputes over work
while raining
• unclean toilets
• opposition to night
shift
• stop work meetings
about demarcations
and overtime that
had WHS elements
13

14. Findings were used
against union delegates
and organisation
Industrial officer notes in VTHC
records:
• Management refused to re-
engage 10 ‘troublemakers’
• Site manager claimed to
have read the findings
• Said safety relied on having
no industrial action on site
• ‘We cannot put the bridge
together safely with the
previous [industrial] history
and everybody must agree
with it.’
Matter settled with agreed
terms - workers to:
• Be on probation 6 months
• Be on time
• Do overtime when asked
• Not be absent without
getting supervisor approval
• Work diligently
• Instant dismissal for breach
of above
• Union unable to challenge
dismissals
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Danger of
drawing
mistaken
conclusions?

15. Conclusions
• West Gate workers raised concerns about safety
that were ignored by managers
• Misplaced confidence that nothing would go
wrong among engineers
• Royal Commissions may be poor vehicles for
unbiased assessment
• Long history of anti-union agendas
• Dilution of responsibility
• Problematic notions of ‘joint responsibility’
• ‘Ten pathways’ framework permits detailed
analysis of a complex disaster like the West Gate.
• Framework ‘complete’ for a non-mining workplace
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