Bolger's comments on Cave Creek

@waynoski don't know about cave creek type platforms. NZFS build many bridges, including non standard for high use, on more pedestrian walkways. from my experience, the rules were, engineering staff were all ways consulted and advised on design etc. And inspected results. Not aware of any failures. I presume the cave creek platform was professionally designed. and that the collapse was a failure to follow the original design specs As I recall, DOC had been restructured, at helen Clarkes initiative. it created the same confusion about accountability and roles, as the last DOC restructure did. A subsequent review by Australian consultants rubbished the first restructure result, and introduced a very clear Line Management structure based on the military. Accountability was explicit, but that got changed t, eventually

"I presume the cave creek platform was professionally designed. and that the collapse was a failure to follow the original design specs" I don't think so. If it'd been built to the design then it'd probably not have collapsed as it did, but the first of the the established secondary causes was still a failure to provide qualified engineering input into design and approval of the project. It was determined not to have been designed or approved by an appropriately qualified engineer. There was also no geo-technical report when there should have been, and the Commission of Inquiry determined that the design documents weren't suitably specific. The platform itself was designed by a motor mechanic of 15 years, who'd joined Lands and Survey in 1986 and engaged in track maintenance and building walkways around Punakaiki. The COI determined he was highly regarded and committed to whichever task was required of him, but he didn't have any previous platform design or construction experience. All of this happened long before anything was built, and the mess just got worse. The project for the platform and surrounding tracks took place between Dec '92 and Apr '94, and the platform was never clearly identified as its own project with specific issues. Everything was well behind schedule, and in an effort to get it done (tracks, boardwalks, platform, stairs, everything else), a working bee called together roughly 20 DOC staff from the surrounding area. Most hadn't had anything to do with the project up until that time, and weren't suitably skilled for the job. If the situation was leaderless, maybe assisted by the high staff turnover they were having, then I could imagine how they felt they needed to get it done regardless. No plans were on site with the materials. Apparently nobody constructing the platform considered there might even be plans. Meanwhile the 7 metre section of steel, intended to connect the platform to concrete steps as a counterweight, was also missing, as was the bag of bolts on site. Without plans, nobody considered they were missing.

"the established secondary causes was still a failure to provide qualified engineering input into design and approval of the project. It was determined not to have been designed or approved by an appropriately qualified engineer. There was also no geo-technical report when there should have been, and the Commission of Inquiry determined that the design documents weren't suitably specific" @izogi Didn't realize that. Then it was a stuff up waiting to happen.

swiss cheese model of accident causation several factors line up to facilitate an accident happening https://en.wikipedia.org/wiki/Swiss_cheese_model

Here's my abbreviated and speculative version: Hole #1: Massive organisational restructure poorly planned, shambolically implemented Hole #2: Someone senior decided that skilled engineers were expensive and it would make the budget look better to sack them Hole #3: Regional silos not reporting adequately to Head Office, flows of information and lines of accountability inhibited Hole #4: Person designing the platform is capable, but unaware of their limitations and has no-one senior to peer-review their work with Hole #5: Project falls behind schedule, Multiple people get involved to get it back on track at the last minute and crucial plans, specifications and project management tools fall through the cracks Hole #6: "Working Bee" crew is thrown together get the job done, but they are not used to working as a team and no-one has real ownership or leadership on the day. Small but crucial items are overlooked and no-one is aware Hole #7: For a variety of reasons, the resulting structure is never inspected by an engineer before being put into service Hole #8: Prior reports of instability from other users are not acted on Hole #9: Large group of students arrive and several proceed to jump up and down on it After working four decades in heavy industry I could personally write up at least three other "Swiss Cheese" fatality accounts all with uncanny similarities. And as with each of them, the Cave Creek tragedy would never have occurred if any SINGLE one of these 'holes' had been closed. And crucially it is now widely understood the biggest and most lethal "holes" are the hidden ones that open up months or years before the accident. These are the 'hidden management' or 'systemic' faults that are endemic to the entire enterprise... and is WHY accountability at the most senior levels is the FIRST place you look to improve safety outcomes.

Yes it's effectively a list of secondary causes. It probably doesn't match those identified exactly in the report, but it's a similar principle. I'm not sure how reasonable it is to expect that #9 wouldn't occur. Even if it's a bad idea, how many platforms and structures exist out there which haven't, at some time, been overloaded with kids jumping up and down? The engineering recommendation that structures need to be designed to withstand any stress that could reasonably be expected to occur makes plenty of sense.