Inquest into the Death of Brasier, Thomas

Contributing factors

• Defective construction of brick pillar in 1975 - missing steel tie-down rod and concrete fill
• Absence of the original architect's design drawings
• Lack of structural inspection or quality control during initial construction
• Failure of Rottnest Island Board to conduct comprehensive audit following 1981 roof failures
• 1996 refurbishment focused on cosmetic rather than structural issues
• 2006 refurbishment contract did not require inspection or assessment of masonry pier tie-downs
• Architectural specifications for 2006 work did not mandate checking structural integrity of existing piers
• Roofing subcontractor not qualified or contractually required to assess structural adequacy of supporting columns
• Loss of original architectural documentation making it impossible to verify compliance with design

Coroner's recommendations

1. Government consider making it a requirement for local governments responsible for issuing building permits under the Building Act 2011 (WA) to require the details of all tie down connections for residential buildings to be submitted on plans provided to local government as part of the approval process preceding the construction of a residential building
2. Government consider making it a requirement for local governments responsible for issuing building permits under the Building Act 2011 (WA) to undertake inspections during the construction of a residential building to ensure roof tie downs are adequately constructed, placed and fitted
3. Government act to ensure that copies of all architectural drawings commissioned by a government body be archived with one government organisation so that in future they will be available to those in need of referring to them