Remembering West Gate

On the 14th March, I attended a play called West Gate^[1].  The play is an evocative account of the failure of the West Gate Bridge which occurred on the 15th October 1970 and continues to be the largest infrastructure disaster in Australian history.

The focus of the play is those who died in the tragedy.  The playwright^[2] has stated that his aim was to give voice to the men who worked and died on the bridge:

“…that there was no response, it was quite devastating, …no justice, no recourse … there seemed to be a silence within the culture and the men’s death was not investigated …and the engineers just went on….. One of the engineers, which riled me, won prizes for their work … and they took West Gate off their work histories.”

He goes on to say the play is an opportunity for the blue collar story to be told.  Yes, it can be presented as a kind of class struggle saga but there should also be greater understanding of why this disaster occurred.  The honouring of the 35 men who died is important but if we don’t remember why the failure occurred something similar can happen again.

The play brought back a memory.  When the bridge fell, I was sitting in a lecture theatre on the third floor of the Civil Engineering building at Melbourne University. I was in third year and just a few weeks away from taking a three-month work experience assignment with John Holland, the main contractor for the bridge construction.  I had been assigned to work on the West Gate Bridge.  Timing sometimes has a significant impact on your life.

After the play, I felt a need to go back in time.  I have a copy of the Royal Commission Report^[3] (the Report) into the failure of the bridge.  It had long gathered dust on a bookshelf.  I read it and reread it and then again.

Some background and the lead up to the failure

During the 1950s and 1960s Melbourne grew to be the business and industrial centre of Australia.  A long conceived crossing of the lower reaches of the Yarra River became an imperative to better connect the eastern, largely residential suburbs, with the western industrial heartland.  The lack of this crossing was a major constraint on economic growth.  In 1965, a Lower Yarra Crossing Authority (the Authority), initially a private entity, was empowered by the Victorian Government to build what was to be the West Gate Bridge.

In 1966, the Authority appointed consulting engineers Freeman Fox and Partners (FF&P) of the United Kingdom and Maunsell and Partners (Maunsell) of both the United Kingdom and Australia to prepare detailed designs and specifications for three contracts – foundations, concrete works and steel works.

In early 1967, tenders were called for the construction of the bridge and after a selection process and award of the three contracts, work began on the bridge in mid-1968.

The steel works contract (Contract S) involved fabrication and erection of a five-span cable-stayed steel trapezoidal box girder bridge.  This would be the centre piece of the entire crossing.  The five spans extending across 850 metres of water and mud flats would sit on six concrete piers nearly sixty metres above the Yarra River.

By late-1969, the first span (14-15) had been fabricated in two half-spans.  These two half-spans were lifted separately up to rest on the concrete piers.  There, the two half-spans were joined ‘in the air’.  The matching up and joining of the half-spans proved challenging.   On the 15th October 1970, the second span (10-11) had almost been completed to a similar stage when it collapsed and fell to the ground killing 31 workers, four engineers and injuring many others.  It left many grieving families including 24 wives and 88 children.

The collapse of span 10-11 was the greatest construction failure in Australia’s history both in terms of loss of life and broader social and economic impacts.  Yet, with the passage of fifty-six years, it had become a distant memory and for many it was an unknown. West Gate, the play is a reminder of this terrible event.

The Royal Commission

The Victorian government appointed the three-man Royal Commission chaired by Justice Edward Barber of the Victorian Supreme Court. The other two commissioners were Frank Bull, Professor of Civil Engineering Adelaide University and Hubert Shirley-Smith, consulting engineer, Fellow of Imperial College, London and was in 1969, President of the International Association for Bridge and Structural Engineering.

The Commissioners delivered the Report to the Victorian Parliament on 14 July 1971, just eight months after the collapse.

The Report is in ten parts and covers in great detail the events leading up to the collapse, the design of steel box girder spans, various reports and tests, the performance of the key participants, industrial relations and responsibilities.  The Report is exhaustive (and exhausting!) in its precision and the detailed descriptions of key events, the technical challenges and difficulties, the actions and possible motives of individuals and organisations and the communication and lack of it between the key parties.

High hopes at the beginning

At the beginning, it would have seemed that the building of the West Gate Bridge would go well.  The Authority had selected FF&P and Maunsell as the bridge designers and supervising engineers.  FF&P was a world leader in steel box girder bridge design and Maunsell, also with an international reputation, was headquartered in Melbourne.

The two main contractors, World Services and Construction (WSC) for the fabrication and erection of the steel spans and John Holland (JHC) for the concrete elements of the bridge were both capable and credentialed contractors. JHC was also Melbourne based.   Finally the General Manager of the Lower Yarra Crossing Authority was an experienced engineer and bridge builder.

What went wrong? The answer is plenty.  The multitude of errors, poor decision making and mismanagement makes this story complicated to tell and to say who was responsible for what happened.  Everything – design, tendering, evaluation and selection, early works, labour relations and oversight – was to prove problematic.

A new kind of bridge

The post war period was the halcyon era for constructing steel box girder bridges. They were all the rage – there were five being built in Europe around the same time as the West Gate Bridge construction commenced.

The steel box girder concept was considered to have a number of advantages with the capacity to span long distances being the principal one.  It combined lightness with strength and hence had economic advantages over other bridge designs.

However, the steel box girders were complicated structures – they were continuous over many supports, were divided by internal webs into multiple cells with the thin steel plate protected against compression and hence buckling by an array of stiffeners. These stiffeners ran in both transverse and longitudinal directions and were bolted or welded to the steel plate.

At the time, the understanding of the structural characteristics of the steel box girder bridge was embryonic.   The Commissioners were mindful that ‘some aspects of the stress analysis of the structures (the steel box girders) remain so far unresolved’ but they also made clear that the ‘pushing of boundaries’ associated with building them was a pursuit expected of the engineering profession.

This is how they expressed this trade off between opportunity and uncertainty:

“Engineers engaged on the design of major bridges cannot stand still.  It is part of their duty, not only to their clients but to the community as a whole, to advance, to develop new concepts of design, to adopt new methods of calculation such as the computer and to encourage the production and use of improved material, such as high tensile steels and pre-stressed concrete.

These advances have led to ever-increasing spans of bridges, to lighter and more economical structures, and novel methods of design to assist in combating the forces of nature.  FF&P have undoubtedly been in the lead in the design of great bridges, as witness the entirely new conceptions in their design of the Severn bridge – achievements which won them the distinction, against international competition, of being selected to design the long span  Bosphorus Bridge to connect to Europe and Asia.

It is however necessary to emphasize that when leading designers are working as pioneers only just within the bounds of the engineer’s knowledge, some slight misjudgement, or failure to appreciate every aspect of a new problem may prove disastrous and bring tragic and fatal results.  Under these conditions, it is more than ever essential to employ really adequate margins of safety and to ensure that they are not eroded by various unexpected and accidental factors, including of course, imponderables and human fallibility.”

In this way the Commissioners set the ground rules for what they would have expected to happen in the evolution of the West Gate Bridge.  Unfortunately it didn’t work out this way.

It is noteworthy that three other steel box girder bridges collapsed around the time of the West Gate Bridge failure.  In November 1969, at the Fourth Danube Bridge at Vienna, Austria an over 400 metre box girder span failed, in June 1970 at Milford Haven, UK a cantilevered box girder span of 60 metres suddenly buckled and collapsed and in November 1971 at Koblenz on the Rhine in West Germany another cantilevered box girder span collapses.  A review of the Milford Haven collapse (another FF&P designs) was meant to inform the building of the West Gate Bridge but was not complete until after West Gate failed.

The steps toward disaster

I have chosen to tell the story of the West Gate Bridge failure chronologically beginning with the appointment of the bridge designer/consulting team, then the design, the erection process, then the path towards collapse.

1.    The consulting engineers – FF&P with Maunsell

In mid-1967, the Authority entered into an agreement with Maunsell and FF&P to prepare plans and cost estimates for the bridge.  This relationship between Maunsell and FF&P was not a healthy one.  The Report tells us that it was one of ‘disharmony and distrust’

Whilst the Authority asked for it, Maunsell, as the local partner in the consortium, did not want senior FF&P representation in Melbourne.  FF&P, for its part, were secretive about its design and ‘meagre’ in their reporting to both the Authority and Maunsell.  The Commissioners reported that the senior Maunsell partner based in Melbourne was duplicitous – he chose ‘to hunt with the Authority and run with FF&P’.

This disharmony and distrust constrained the free flow of information and the possibility of optimum solutions to the problems that would be encountered.

2.    The design

About one third of the Report is devoted to the design of the steel box girders.  The treatment of the design elements and associated calculations is exhaustive and covers design criteria, general features, structural complications, the stiffening requirements, the splicing of box units, design procedure, safety factors, loading, treatment of calculations by both FF&P and WSC, points of failure – specifically buckling, review and a number of more detailed matters.  However, I will spare you this detail.  The key learnings of what not to do are all contained in the Commissioner’s conclusions:

“We assert that the basic cause of the tragedy at West Gate was the design inadequacies which led to the safety margins being much too low and certainly lower than the specified values.

We find that FF&P approached the design of West Gate Bridge in a disorganised and unsystematic manner and without any real guidance being given to the engineers doing the work by senior men such as Roberts and Brown^[4].

The calculations contain a great many errors of arithmetic and of engineering principle and these have gone unchallenged until this Commission.

It is doubtful if FF&P had any effective internal checking system.  They certainly failed to give any adequate check to WSC’s calculations although apparently prepared to approve them.

We find that FF&P made assumptions^[5] about the behaviour of box girders which extended beyond the range of engineering knowledge. …..  In many cases the FF&P assumptions would appear to be unjustified and liable to cause serious over-stressing of the parts affected.

We cannot agree with the senior FF&P witnesses that the design, as it now is, is unquestionably sound and we stress the importance of having a thorough and truly independent check made before work is recommenced.”

That the senior FF&P engineers did not provide ‘any real guidance’ is at the heart of the faulty design.  It needs to be recognised that, in 1970, FF&P was a celebrated bridge designer.  The poor design wasn’t due to FF&P’s lack of capability but rather that the firm’s senior partners failed in their duty to properly oversee the work in both the design and construction phases. During the Commission’s hearings, the FF&P founder Sir Ralph Freeman, Dr Oleg Kerensky, Sir Gilbert Roberts and Dr William Brown all gave evidence.  These eminent engineers maintained the design was sound.  In doing so none of them impressed the Commissioners.

In the hearings both Roberts and Brown were presented by Kerensky as overseeing the design – Roberts up to the end of 1969 and Brown from the beginning of 1970.  However the Commissioners doubted whether either was actually in charge of the design process.  The Commissioners also questioned the capability of both men.  In the case of Roberts they stated:

“There can be no doubt that, in the past, Roberts established his outstanding ability as a designer of large bridges.  At the time when West Gate Bridge was being designed, Roberts was nearly 70 years old, and, as his evidence shows, more than a little detached from modern structural theory and computer technology, both of which are desirable for a proper understanding of the stress analysis of a cable-stayed box girder bridge.”

They go on to suggest that:

“By claiming to be the designer of the bridge Roberts may have conveyed to the Authority and the contractors that the all-important work of stress analysis was in his, supposedly, capable and experienced hands.  We feel that Roberts made an error of judgement in allowing himself to be put in this position of ‘designer’ when he was no longer controlling the process of design.”

Roberts did, however, state that he had entrusted the actual design to Brown.  This didn’t impress the Commissioners either:

“We feel that Roberts’ trust in Brown’s ability to guide and direct the work in an effective manner so as to result in a safe and efficient structure, was misplaced.”

Brown, in his evidence, effectively admitted to a lack of oversight of the design team:

“Brown  admitted that the way in which the West Gate design had been handled was somewhat less effective than would be normal.  He, himself, at the time, was involved in several other major projects for big bridges.”

3.    The steel box girder fabrication and erection contract (Contract S)

The Report states that there was lack of progress on Contract S ‘from the very beginning of work on the project’.  WSC was beset by industrial problems arising out of two unions being in a demarcation dispute over well-paying construction jobs.  They were also delayed because FF&P would not provide details of their design for the trapezoidal box girders and also did not review WSC’s structural calculations for the span erection stresses.  WSC were also considered poorly organised.

The critical problem in the eyes of the Commissioners was the relationship between WSC and FF&P.  This relationship should have been close but it was close to non-existent.  It was critical that WSC fully comprehended not only the design drawings but their basis as per the assumptions on loading and the calculation of stress.  WSC needed to understand the FF&P design logic because the structure needed to be capable of taking both the stresses of erection and permanent placement.  Equally important was that FF&P should check WSC estimates of the erection stresses.  FF&P failed to do this.  The Commissioners blamed FF&P for this state of affairs;

“Beneficial co-operation between WSC and FF&P thus broke down at an early stage so far as calculations were concerned.  The evidence shows that FF&P were principally to blame for this unhappy state; in addition to refusing to hand over a copy of their calculations they rarely replied to correspondence asking for technical information.”

4.    The span erection nightmare

Spans 14-15 (East) and 10-11 (West) are the two outer spans of the main bridge and were the first to be assembled and erected – 14-15 first, and then 10-11.

Each of these spans was initially assembled and joined on the ground in controlled conditions.  This assembly was firstly as half-spans made up of eight box girder ‘units’ joined together by bolts.  The half-spans (north and south) were lifted to the top of the columns and there joined ‘in the air’.

The Commissioners considered that this method of assembly and erection had ‘a number of serious disadvantages’.  Firstly, there was difficulty in ensuring tight control over the assembly of the half-boxes on the ground to ensure the two half-spans would line up and join in their suspended positions on the columns.  Further to this, because the half-spans were asymmetrical, when they were being lifted they experienced lateral bending (horizontal bowing) and this caused compression instability leading to severe buckling of panels and stiffeners of some half-boxes.

The net result of these two difficulties was that when the two half-spans were lined up they did not match up well.  There was significant misalignment of the cambers in the top plate and there was the buckling that is referred to above.

In commenting on the approach used, the Commissioners made three main points – this method of erection had never been attempted before anywhere; as soon as the buckling problem became evident, the half-span should have been returned to the ground ‘so that the buckles could be removed and an adequate system of bracing and stiffening fitted’; and, finally, why the ‘obvious’ lack of effective bracing was not addressed.

The Commissioners commented that they could not understand why these problems were not anticipated by WSC and why FF&P did not detect these problems in their checking of the erection proposals.  They concluded that both  FF&P and WSC had judged the situation badly in continuing to lift the half-spans to the top of the columns.  In their view neither FF&P nor WSC had ‘any real idea of the stresses imposed’.

In the case of span 14-15 the buckling and mis-alignments were dealt with using a combination of lifting (jacking) of one half-span relative to the other and removal of some bolts to allow a release of the pressure on the buckled plate diaphragms.  As highlighted by the Commissioners, this ‘joining up’ process involved no consideration of the structural failure consequences:

“Although it apparently achieved its object, this operation (the joining) was a regrettable necessity.  The act of releasing plates while under stress means inevitably that some other parts of the section must carry the load.  The relaxed plates can never return to the same strain condition that they would have had if they were not disturbed.  The consequential redistribution of internal stress which was not envisaged when making the design calculations, would almost certainly cause some reduction in the real safety margin on the span.”

5.    The dismissal of WSC and replacement by JHC

After some consideration and time, the Authority dismissed WSC from undertaking the task of erecting and joining span 10-11.  In their place JHC was appointed to do the erection of span 10-11.  This new contract (Contract E) was one of no liability or more simply a labour management contract.  This resulted in an increased burden being placed on the FF&P resident site team.  This was a task, as will be highlighted later, they were not up to and should not have been assigned.  The Commissioners saw all this as leading to ‘confusion that was disastrous’.

The Authority, mindful of JHC’s lack of experience in steel erection, also provided in the new contract for WSC engineers to assist JHC.  JHC, for reasons unknown, chose not to avail itself of this expert assistance.  The Commissioners concluded that JHC ‘became over-confident’ in their own capabilities and hence ceased to seek or follow the advice of WSC senior personnel

6.    The erection and joining of span 10-11^[6]

Much of the ‘story’ of the erection of span 10-11 is presented in Part 2 of the report which is ominously titled, The Collapse.  Hence, in reading it there are no illusions of a happy ending.

Of the many errors of the erection process, the Commissioners put particular store on the switch from WSC to JHC.  From this point on it was a case of the blind leading the blind.  JHC with very limited steel erection experience was being directed by the inexperienced FF&P site supervision team.  Further to this the Authority was playing a largely ‘hands off’ role except to threaten contract cancellation if there were further delays.

The other concern raised by the Commissioners was one of complacency arising out of ‘the apparent successful elimination of the buckles which occurred on the east site (i.e. span 14-15)’.  Again in the Commissioners words:

“…having successfully dealt with the buckle on the east side, the engineers were reasonably confident of their ability to handle the buckle on the west side; a confidence that was fatally misplaced.”

The problems of misalignment experienced with span 14-15 were repeated in the erection of span 10-11.  The vertical difference in camber edges was as great as 114 mm (4.5 inches) and there was buckling of the spliced panels joining units 4 and 5 (mid-point of the span).

JHC proposed the use of kentledge (large concrete blocks) to reduce this camber difference.  The Report speculated on how the FF&P site staff reacted to the proposal.  Apparently FF&P in London were not informed of this idea and might not even have been interested according to evidence given by a senior partner.  The Commissioners determined that the FF&P resident engineer Jack Hindshaw ‘made a serious error of judgement in not referring the question of the use of kentledge to London for advice on its effect on the stresses’.  They concluded:

“In our opinion the matter of kentledge from start to finish was badly handled and reflects little credit on either the resident engineer and his staff or on the contractor’s site staff on the west side.”

Eighty tonnes of kentledge was placed on the deck resulting in a large buckle in one of the upper plates at the join between the fourth and fifth box units.  This was the mid-point of the span.  The Commissioner concluded that the placing of the kentledge caused there to be partial failure in the span and that, at this time, the ‘margin of safety against complete collapse must have been small’.

However, for the site engineers there was no such awareness.  Their focus was on removal of the buckle at the north span splice between units 4 and 5.  The idea of removing bolts in the transverse inner top deck panel to relieve the buckle had been discussed amongst the resident engineer’s team and the JHC site team but there was no clarity on when this would happen.  One possibility considered was to wait until the two half-spans were joined and additional units were added at column 11 with the effect of removing the stresses in the mid-span units.

However, this didn’t happen and on 14th October, David Ward, the FF&P site engineer for span 10-11 gave a written instruction to Bill Treacy of JHC for the removal of the bolts.  At 8:30 am on 15th October 1970, under Ward’s direction, the removal of the bolts began – in all some thirty-seven of them were removed.

7.    The collapse

As set out in the report, what happened next was a spreading of the buckle to a wider area and further buckling failure.  Then ‘a gentle settlement’ occurred in the half-span.  It took another 50 minutes for the whole span to collapse because as the Report explains:

“Plastic creep in the steel and possibly the effect of thermal changes all contributed to the slow diffusion of yielding, first in the north half-span and subsequently across the full width of the south half-span to bring about total collapse.”

A more graphic and dramatic description of what happened in these last few minutes before collapse is found in a book also titled West Gate^[7]:

“There was no more movement, so they continued.  It wasn’t until 30 bolts on one side of the centre splice and seven on the other had been removed that they noticed the bulge begin to flatten.

Suddenly the gradual flattening changed dramatically.  A vicious and inexplicable buckle appeared and began to spread throughout the whole length of the two spans (actually the two half-spans).  Then the northern half seemed to settle gently.  Everyone knew that there was something dreadfully wrong.  What they didn’t know was that the full weight of the northern span was being held up solely by its southern counterpart.

Men were summoned to speed up the re-bolting work.  Set procedures were forgotten as they tried frantically to get the bolts back in place.  At 11 am Ward tried to contact Hindshaw to tell him to get over to the west side as quickly as possible.  The phone on the east side rang.  Crossley^[8] picked it up.  He went out to find Hindshaw.

By the time Hindshaw and Crossley had crossed the river and got to the top of the west side span, re-bolting was well under way, and the buckle appeared to be disappearing.  But the whole mass of steel had moved.  Hindshaw knew instantly what he was looking at.  He was horrified.

But, whether it was his nature, the lack of communication that had built up between him and the men, or a desire not to transmit to them the frightening possibility he had become aware of, there was no sign of panic in his voice as he urged the men to hurry.  He remained outwardly composed for almost 20 minutes.  And he was still calm when he walked to the phone and contacted World Services’ senior representative on the site, Gerit Hardenberg, and asked him to come over.

Then shortly before 11:50 am, as if musing to himself, Hindshaw asked Hardenberg: “Shall I get the bods off?”.”

The 10-11 span collapsed at precisely 11:50 AM on 15th October 1970 to kill the thirty-five men who were either working on the 10-11 span or having their lunches in the huts directly underneath.

The Commissioners’ verdict

The Commissioners found that:

“To attribute the failure of the bridge to this single action of removing bolts (from the 4-5 joint) would be entirely misleading.  In our opinion, the sources of the failure lie much further back; they arise from two main causes:

Primarily the designers of this major bridge, FF&P failed altogether to give a proper and careful regard to the process of structural design.  They failed also to give a proper check to the safety of the erection proposals put forward by the original contractors, WSC.  In consequence, the margins of safety of the erection proposals put forward by the original contractors, WSC.  In consequence, the margins of safety for the bridge were inadequate during erection ; they would also have been inadequate in the service condition had the bridge been completed.

A secondary cause leading to the disaster was the unusual method proposed by WSC for erection of spans 10-11 and 14-15.  This erection method, if it was to be successful, required more than usual care on the part of the contractor and a consequential responsibility on the consultants to ensure that such care was indeed exercised.  Neither contractor, WSC nor later JHC appears to have appreciated this need for great care, while the consultants, FF&P, failed in their duty to prevent the contractor from using procedures liable to be dangerous.”

FF&P senior engineers did not adequately support either their design team or their site staff. The Commissioners couldn’t be clearer on this point of failure:

“Apart from matters of design, the most serious fault of FF&P so far as concerns the actual supervision of the work was a two-fold failure.  Having failed to provide a senior engineer capable of fundamental professional decisions, the London partners left the relatively junior engineers on site without sufficient communication.

Over and over again the site staff were without proper instructions.  This we find was a serious dereliction of the engineers (FF&P) duty to their client.”

No gold stars

Other than FF&P, the Commissioners present a litany of flaws and the problems related to the performance of all the other players.  In the words of the Commissioners:

“In greater or less 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.”

What did the Commissioners more precisely mean?

The Authority

The Authority began its task of building ‘a structure of world standard’ by selecting a world class duo of consulting engineers to design the bridge and oversee its construction.  However in the words of the Commissioners, ‘the bright beginning faded to a pitiful result.’

The Commissioners considered oversight of the project was inconsistent and contributed to the poor decisions that were made by the consultants.  Firstly, the Authority did not exercise its right to inspection enough and did not insist on more comprehensive reporting to it, particularly of problems.  The Authority General Manager Cecil Wilson had particular responsibility for this failure:

“Our criticism is that Wilson did not do more in the way of inspecting the project, as the Authority was entitled to do under the terms of its contract with the consulting engineers, especially when it began to show signs of trouble.  It is doubtful that he ever visited the west side at any relevant time. He certainly did not between the raising of the two halves of span 10-11 and the collapse.  After JHC took over the assembly and erection of the steel boxes, Wilson in his own interests should have kept a close observation on the work.  Had he done so and made some forthright comments to the engineers the serious situation which eventuated might have been avoided.”

This leads us to the Authority’s oversight of the WSC contract (contract S) and their replacement by JHC (contract E).  The Commissioners felt the Authority acted too slowly in finding a way to have the WSC program advanced and in replacing WSC with JHC to erect the span 10-11, they took insufficient account of the latter’s inexperience in the erection of steel structures.  Contract E allowed JHC to evade (at least in a legal sense) their responsibility for the actions they took.  It also placed greater responsibility on FF&P and particularly their site staff who were ill-equipped to deal with it.

The Commissioners also felt that Wilson, ‘may have been difficult’ in his relations with the consultants.  Whilst they were ‘sympathetic’ with Wilson in what he had to deal with it wasn’t a wholehearted endorsement:

“It is impossible not to sympathize with Wilson, even if he sometimes displayed ill-temper and perhaps some intemperance of language, which was the result of frustration, at times amounting to despair.  He was in a most unenviable position with responsibility for a great  and complex project which almost from the first encountered difficulties.  Some degree of acerbity was well justified.  Both the FF&P and JHC engineers on the site appear to have regarded Wilson as something of a “bogey man”, particularly Hindshaw, who claimed Wilson had “torn strips off him” on one occasion, and plainly feared a repetition.”

The Commissioners considered that the Authority’s concern about progress was poorly demonstrated and led to counter-productive outcomes:

“Nevertheless the determination to keep the work moving at all costs was so extreme as to engender an atmosphere in which speed was the all-important consideration. In a number of instances the burning desire for speed resulted in quick ill-considered decisions which brought about trouble, difficulty and delay, whereas time spent in careful thought, and the adoption of what appeared to be the slower method of procedure would have, in the long run, meant an earlier and happier result.  We are satisfied that this climate of urgency and pressure tended to lower morale, and in fact directly caused some of the more serious errors of judgement upon which we have had occasion to comment.”

In summary, the Authority was an inconsistent participant in the project with a mixture of excessive and insufficient attention.  Critically, it created an atmosphere where the last one to be informed about problems would be the Authority and specifically the General Manager Wilson.  A poorly informed and engaged Authority meant an Authority with little influence over what was happening except to create as the Commissioners expressed it ‘a constant feeling of pressure that became oppressively evident’.

Maunsell

Maunsell,as the designers of the concrete elements of the bridge, were not directly involved in the design or erection of the steel box girder spans.  However, under their joint agreement with FF&P with the Authority they had certain responsibility to ensure the Authority was fully and correctly informed of what was happening.  As already stated Maunsell was an odd bedfellow with FF&P.  The two consulting firms were strong rivals and the senior partner responsible for the project, Edward Birkett was declared as duplicitous by the Commissioners.  Maunsell discouraged FF&P from having a senior and suitably experienced engineer on site even though the Authority had requested it.

In September 1970, Maunsell sought to reassure JHC of the adequacy of the FF&D design in that certain panels had been strengthened to increase safety margins and hence, ‘we are therefore able to give a categoric assurance ….. the bridge design is fully adequate ….’  The Commissioners considered these reassurances were unjustified and they conclude:

“This we can only categorise as improper, and in breach of their duty to the Authority, the contractor, and the workmen engaged on the project.”

JHC

As the contractor for the bridge foundations (Contract F) and piers (Contract C), JHC had performed well. It had made good progress and its work was of high quality.  The Commissioners also found nothing wrong with JHC’s willingness to accept ‘the challenge’ of undertaking the erection of span 10-11 in spite of their lack of expertise in steel erection.  The support of FF&P and WSC to JHC was to fill the gaps.

However, the Commissioners did find fault in JHC’s response to the offered assistance:

“We take the view that as the work progressed, the JHC management became over-confident.  They ceased to seek or follow advice from Hardenberg (WSC) and dispensed with the services of Spee and Schot (also WSC).  Hindshaw’s words – ‘they knew it all’, appeared to sum up, not unfairly, the JHC attitude.”

As it is described in the Report, the JHC arrogance was ‘a missed opportunity’ that ‘led to errors that could have been avoided …’.

The Commissioners view of JHC site staff was low – they ‘proved to be inadequate’.  They were ‘inexperienced and lacked the capacity to control the work, in particular, the difficult labour situation, or even to find the answers to day-to-day problems.’  They refer to the use of  kentledge (a JHC site staff idea) as ‘the gravest of errors’.

The Report also refers to ‘constant bickering and argument’ between JHC and FF&P site staff.  It also states that JHC work organisation was ‘unsatisfactory’:

The bolting up of splices was unsystematic and inefficient.  The section engineers allowed the incorrectly fabricated diagonal braces to be installed.  They failed to ensure that all K-plates were installed and in some cases, removed them after they had been fixed.

The Commissioners also point out that JHC was responsible for the placing of ‘various huts’ beneath the gap between the two half-spans for 10-11.  They conclude this was a ‘breach of duty’.

However, crucially, the Commissioners place no blame on JHC for the removal of bolts from the 4-5 splice.

WSC

The Commissioners were of the view that WSC’s ‘performance on West Gate, in many respects, fell far short of ordinary competence.’  They highlight ‘the unusual erection method’ that could only be justified after ‘the greatest care and thought’ – this, they declare, was absent.

The Commissioners were of the view that WSC’s fabrication of the half-spans was inadequate in several ways – a failure to measure camber difference and minimise it, provide insufficient stiffening to the outer edges of the flange plates and not providing sufficient information on erection stresses and to give JHC a ‘false sense of security’ on the adequacy of the structure in particular circumstances.

However, as already stated WSC’s difficulties in receiving design information from FF&P and the latter’s inadequate oversight of the WSC erection proposals did exonerate the former to some extent.

The Commissioners also note that WSC were incapable of managing ‘the labour situation’.

They also believed:

“…that the organization, particularly as to lower-echelon supervision, was inadequate.  There were insufficient foremen and the organisation of the work was inefficient.”

The Unions

Poor industrial relations was a feature of the whole project.  This is the Commissioners view of it:

“Throughout the construction and erection of the steel spans there was an extraordinary amount of industrial trouble including strikes caused by demarcation disputes between unions and other reasons.  There were also numerous stop-work meetings and much absenteeism.”

These stoppages were a significant contribution to the slow progress on the project.

This began with WSC’s difficulties with demarcation disputes between the Metal Trades Union and the Builder Labourers Union and extended into the JHC erection contract.  In the four month period leading up to the collapse of span 10-11, there were thirty-three stoppages of a half and full day, that is twenty per cent of the entire period.

The Commissioners were critical of the safety provisions and particularly in regard to the placement of works (mess, stores, offices and toilet) sheds.  It is noted that the placement of these sheds directly under the 10-11 span, ‘contributed’ to the high death toll.

At the critical time leading up to the collapse of span 10-11 the question of safety overlapped with poor industrial relations.  This made it difficult for the Commissioners to separate out cause from consequence.

For the Commission proceedings the unions chose not participate.  Hence, the Commissioners noted that:

“In these circumstances we are conscious that on the matter of industrial relations we have only heard one side.  Nevertheless the uncontradicted evidence placed before us enables us to make some findings as to which we are entirely satisfied.”

The Report documents the extent of industrial disputation under both the WSC and JHC contracts.  They refer to strikes, stoppages, go-slows, disputes, absenteeism and very little work was done right up to the day of the collapse.  The Commissioners appraised the net effect of this as:

The six months of industrial sabotage on the job, however, had a crippling effect on the construction of span 10-11, from which it never recovered.

Of a specific and important nature was a refusal of men to use two gantries beneath span 10-11 until ladder access to them was improved.  This meant that the longitudinal splice in the bottom flange was, largely, unjoined.  Hence, the Commissioners concluded:

This considerably reduced the strength of the span and its resistance to failure compared with its strength if these upper and lower joints had both been completed.  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.”

After the Royal Commission

After the Royal Commission Report had been delivered to the Victorian Government, the Authority dismissed FF&P as designers of the bridge and sought assistance elsewhere.

In 1972, following a design review and provision of extra strengthening measures, the construction of the bridge resumed.  A new consortium of contractors which included both WSC and JHC was commissioned to finish the bridge.  The West Gate Bridge was finally opened for traffic in 1978 and has been operating ever since.

In Bill Hitchen’s West Gate, there is an account of why it took a whole seven years to finish the bridge.  There was further drama and intrigue, including on-going industrial disputation but fortunately far less tragedy.

In 2007, because traffic loads had increased considerably over the period since, a review and further strengthening of the bridge was undertaken.

Conclusions and reflections

The cause of the collapse

In the memories of many and the media telling of the story of the West Gate Bridge failure it comes down to the removal of those thirty-seven bolts.  This is the nature of our thinking.  Historians have a way of describing this.  They call it an immediate cause.  I suggest it would be better called a consequence of the actions that preceded it.  That is, if the bolt removal hadn’t happened, collapse due to another factor was highly likely because of the inherent low factors of safety of the box girder spans.  The spans were, in a sense, just holding on.

As the Commissioners pointed out, there were two fundamental reasons why span 10-11 collapsed.  The first reason was FF&P’s inadequate design that meant there was almost no factor of safety in strength of the structure to the loads that it was experiencing.  This, in turn, was due to a lack of oversight by senior FF&P engineers of the design process.  The second reason was a lack of duty by FF&P in their review and oversight roles of the span erections that were undertaken by WSC and JHC.

The Commissioners concluded that the leadership from all the parties involved – the Authority, FF&P, Maunsell, JHC, WSC and the Unions was deficient and if it had been of a higher quality, perhaps the West Gate Bridge would have survived its construction.

However, the Commissioners are very clear that, in spite of all these deficiencies it is FF&P, because of the negligence of its senior engineers, that was exclusively responsible for the bridge failure.  The Commissioners clear conclusion lifted the mist of confusion as to primary responsibility due to the multitude of poor communication, poor judgement and poor decisions by almost everyone involved.

Jack Hindshaw

The Commissioners made no findings against individuals although they did ponder their various inadequacies in the saga.  The most important of these individuals is Jack Hindshaw, the FF&P resident engineer.  Outside the findings of the Commission others including the Victorian coroner^[9] have chosen to attribute greater blame on Hindshaw.  Did he deserve this?

A resident engineer is the client’s representative responsible for work quality and program according to the contract specifications and other agreements with the contractors.  They are essentially the interface between the client and the builder.  This is the easy bit.  In practice, the resident engineer is often an employee of the designer and may be more a servant of the designer via employment and history.

According to the Report, Jack Hindshaw was an employee of FF&P but it would appear not a long-term one.  His work experience included five years with the Royal Engineers in India and Burma during World War II and afterwards nearly three decades mainly as a resident engineer in the UK working on concrete bridge construction and maintenance.

The Commissioners concluded Hindshaw had insufficient experience in steel bridge erection and that FF&P should have had, located in Melbourne, a senior engineer with relevant experience in steel structures.  Given that the Authority did not insist on this and FF&P’s partner Maunsell did not support it, this meant that Jack Hindshaw carried a responsibility burden far greater than reasonably he should have been expected to carry.

Furthermore, the reconstituted erection contract, as taken over by JHC, had meant FF&P were asked to take on greater but only loosely defined responsibilities.  These vaguely defined responsibilities passed directly to the site staff.  The Commissioners took a dim view of this:

“The failure clearly to define the roles of the FF&P staff and JHC engineers led to a confusion that was disastrous.”

The Report states that Hindshaw made a number of poor decisions – agreeing to the 80 tons of kentledge and the agreeing to removal of bolts without reference to senior FF&P engineers.  However, given he lacked firm guidance from London or from anyone in Melbourne and that he was the target of much of the Authority’s pressure to make progress, he may have felt he had no choice other than to agree to these actions.

Certainly this is how the Commissioners appreciated his predicament:

“He (Hindshaw) believed that JHC had been relieved of any responsibility and that the entire burden had been thrown on to him – a situation which would have been bad enough had he been armed with the complementary authority.  As it was he saw himself with all responsibility but no appropriate power to control the operation, which presented itself to him as quite an intolerable situation.  That Hindshaw’s position was difficult is perfectly true.”

By making these decisions was Hindshaw culpable for the collapse of span 10-11?  In my view, the answer to this question is no.

Jack Hindshaw does not deserve the condemnations that continue to be thrown at him by those who do not see the challenges that confronted him.  Hindshaw went down with span 10-11 and did not survive to defend himself against these condemnations.

Moving on

In 1970, the population of Melbourne was 2.5 million, it is now approaching 5.5 million.  This is a simple indicator that a lot has changed in the fifty-six years since span 10-11 collapsed.  Back then there was a world leading consultant in steel box girder design who was flying high and perhaps thought it could give the West Gate Bridge minimal attention whilst it focussed on more spectacular bridges such as the Bosphorus Bridge.

Times have changed.  The most recent major piece of transport infrastructure to open in Melbourne is the Metro Tunnel.  The building of major infrastructure is done to a very different model today than during the 1970s.  The Metro Tunnel was built by a consortium called the Cross Yarra Partnership which consists of three large contractors – Lend Lease Engineering, John Holland and Bouygues Construction and a finance company, Capella Capital.  The contractual agreement for the Metro Tunnel was a Public-Private Partnership (PPP) where risk is shared to minimise cost.

In this new world, the designers are embedded in the consortium and designs are carried out in the tendering process.  It is a more collegiate process and arguably one where all the parties are more accountable.

In the case of the Metro Tunnel the design was carried out for the Cross Yarra Partnership by a joint venture partnership of consulting engineering firms, Arcadis, Arup and WSP.  These firms are all major international consultancy companies.  Of course, the consulting engineering world has changed as much if not more than the contracting world over these past fifty-six years.  Arcadis has 34,000 employees in more than 30 countries.

Interestingly, amongst its mergers and acquisitions history, I found that Freeman Fox and Partners was acquired by Arcadis in 1987.  So, in Melbourne’s latest major transport infrastructure project there are traces of two of the three major parties involved in the West Gate Bridge collapse – JHC and FF&P.

Innovation and social responsibility remain a balancing act

Earlier on in this documentation of a disaster, I quoted the Commissioners pondering the balancing act between pushing the boundaries between scientific and engineering knowledge and ensuring there is a reasonable level of safety provision in the design of the steel box girders.  They were of the view that FF&P in conjunction with the others did not apply a sufficient margin of safety to counter the uncertainties in stress analysis for steel box girders.  Brady, in his article (referenced earlier) refers to these uncertainties as ‘an endemic lack of understanding about bridges built from thin plates’.

It is interesting that now, in the third decade of the twenty-first millennium, we are pondering at a much grander scale, the impact of artificial intelligence on our society. Still, it is the same balancing act and there is the same need for responsibility that there was back in 1970 on one small bridge in far off Melbourne.

No team of champions

Communication and trust were the two things most missing in this assembly of the team of champions to build West Gate Bridge. What is it that they say about a champion team beating a team of champions?  This was very much the West Gate Bridge situation.  The Commissioners revealed, time and again, cases of discord and disunity in the building of this bridge:

“The various firms and companies assembled by the Authority for the West Gate Bridge enterprise were all of the highest reputation, well established and had demonstrated their ability by the successful undertaking of important projects.  The senior personnel of each party should have been accustomed to working in conjunction with other organisations and familiar with the problems inevitably arising in such circumstances.

It is all the more astonishing therefore, to find on this project the confusion, lack of co-operation and antagonism that developed not only between each of the parties and the Authority but between the parties themselves.

Some degree of dissension may well arise on a project of such magnitude, involving the need for co-operation among a number of people, but the discord at West Gate must have exceeded that of most projects.”

The Commissioners concluded that the primary cause of failure of the West Gate Bridge was FF&P’s inadequate design.  However if the communication and trust amongst the project participants had been higher, it is likely that FF&P would have been saved from its negligence.

This only highlights the complexities of what happened and how from a legal perspective, it would have been difficult to bring any of the participants to account for what went wrong.  This is presumably why no one party or individual was brought to account.  This may answer Dennis McIntosh’s expression of regret that I presented way back in the second paragraph.

Notes

^[1] Denis McIntosh, West Gate, directed by Iain Sinclair for Melbourne Theatre Company, 14 March 2026

^[2] Denis McIntosh, video – The Age, 5 March 2026

^[3] E Barber, F Bull, H Shirley-Smith, Report of Royal Commission into the Failure of the West Gate Bridge, Victorian Government, 14 July 1971

^[4] FF&P senior partners, Sir Gilbert Roberts and Dr William Brown

^[5] allowable stresses in panels, division of loads between webs, behaviour of bolted joints and the load shedding behaviour after an element becomes over-stressed.

^[6] An excellent ‘structural analysis’ perspective of the collapse is contained in: Sean Brady, West Gate Bridge Collapse – the story of the box girders.  The Structural Engineer, Oct 2016.

^[7] Bill Hitchings, West Gate, Outback Press, 1979

^[8] Peter Crossley, Site Engineer, FF&P

^[9] Bill Hitchings, West Gate, page 125.