The apology came formally during an inquest in Goulburn which started on Wednesday, and personally via Mayor Bob Kirk and senior management on Friday.

It also came amid an emotional day of evidence on Friday in which council operations director Matt O’Rourke broke down during questioning.

Asked by his barrister, David Lloyd SC why he had attended the entire inquest, Mr O’Rourke replied:

“This awful thing happened on my watch. It’s something I’m not proud of but it’s something I want to address and by participating as fully as I can, I believe it will give me better context on the way I need to operate.”

The inquest, at which Deputy State Coroner Teresa O’Sullivan presided, explored the circumstances, manner and cause of 50-year-old James Hughes’ death on October 4, 2015 at Oallen Ford bridge.

The Canberra man was travelling to the south coast when his restored Ducati 900S2 motorbike hit a large pothole on the southbound lane of the bridge’s northern approach.

He then hit a guardrail and fell five metres over the bridge. He died of “multiple injuries,” an autopsy found.

The pothole was one metre wide, split in two areas and took up “most of the lane,” officer in charge of the investigation, Constable Jessica Walsh told the inquest. 

In final submissions on Friday, counsel assisting the Coroner, Timothy O’Donnell, said that based on evidence, Ms O’Sullivan would have “little difficulty finding that the condition of the northern approach to Oallen Ford bridge substantially contributed to the death of James Hughes.”

“It is evident...that the road’s surface should never have deteriorated to the extent that it did,” Mr O’Donnell said.

He detailed a Roads and Maritime Service investigation concluding that the council had not maintained the road safely or warned motorists about the condition. 

RMS investigator Greg Wright also found that the council did not record or promptly investigate complaints about the road’s condition by motorists Fred Kroesche on September 28, 2015 and Peter Dwyer on October 1, 2015.

Further, it had not acted upon advice from the council’s works supervisor and inspection officer, Chris Brassel, on September 22, 2015 that the bridge approaches should be “made safe” as soon as practicable.

Mr Wright also concluded that the council had not used an “appropriate method of repair” when potholes appeared within days and weeks of the road’s opening on September 11, following the new bridge’s construction.

“This isn’t a matter where one person is to blame or where one mistake was made,” Mr O’Donnell said.

“It is a number of errors, as has been demonstrated by Mr Wright and a number of witnesses in this inquest, and it’s the accumulation of these errors that ultimately failed Mr Hughes on October 4.”

​Hughes family solicitor Ian Bradfield said his clients recognised and appreciated the council’s concessions of systemic failings which led to Mr Hughes’ death.

“The Mayor and general manager (Warwick Bennett) expressed their condolences and apologies to the family over the luncheon break and they accept that as genuine,” he said.

But he branded the accident a “gross failing” by the council which had a “fundamental responsibility to ensure its roads were safe and for checks and balances to be in place.”

Mr Bradfield argued the council should have had a reasonable expectation Oallen Ford Road would be heavily used that long weekend. Further, it had evidence that trucks were exceeding the road’s 15 tonne limit, causing wear and tear to its surface through braking on the decline.

The inquest had heard audio of a council works meeting about the road on October 1. In it, then works coordinator (assets and design) David Ellison warned that the road was “f---king failing.”

Mr Bradfield described this as a “significant statement” that was not acted upon.

He argued there were “failings” in the road’s construction, internal reporting on its state, reviews of the thoroughfare following completion, and in public complaint handling.

“It is not the perfect storm...It is cumulative failure and error and it’s our submission you can’t put any other blush on it,” Mr Bradfield said.

“…We say you can protect the individual and protect the corporate structure but at the end of the day this is not a Swiss cheese failure but a systemic failure.

“It was a recipe for disaster and the disaster occurred. The result is that James Hughes is no longer here.”

Mr Hughes’ partner, Melissa Pearce wept as she listened. His elderly father, Colin and brothers Allan and Peter also looked on.

But barrister Mark Cahill said the council accepted there were failings. The Mayor, general manager and four directors had attended the inquest every day.

“They are here because they acknowledge there are lessons to be learnt. Indeed, they have already learnt them and substantial changes have been made,” he said.

“The council is open to continuing this reform process.”

Mr Cahill told Ms O’Sullivan it was the greatest of regrets that the changes did not occur with “sufficient alacrity to prevent the tragedy.”

But he argued the events should be placed in context. 

A pothole that appeared in the same area on September 15 had been reported and repaired the next day, Mr Cahill said. At a works meeting on September 17, management decided to extend the asphalt beyond the 20-metre stretches on either side of the bridge to make the road safe.

The asphalting was programmed to occur on October 1 or 2. But due to the contractor’s commitment to two Goulburn jobs, the work was delayed until mid-October.

The inquest heard that Mr O’Rourke was not aware of this and only found out after the accident.

“It is conceded that there were a series of failings that led to that repair not being done,” Mr Cahill said.

“But it is not in the way Mr Bradfield put it.”

He said several witnesses had expressed views with the benefit of hindsight that the road had deteriorated in an unexpected way. 

Mr Cahill argued that former works manager and engineer, Andrew Palmer and contract supervisor Chris Brassel had told the inquest the September 22 pothole repair was a sufficient response, subject to the asphalting taking place soon after.

But Mr Palmer had also earlier said he had concerns about the intended road surface as early as January, 2015 when bridge construction started.

He had a “difference of opinion” with Mr O’Rourke about the extent of asphalting either side of the bridge. Mr Palmer had argued it should extend further but Mr O’Rourke settled on 20 metres each side.

The pothole that Mr Hughes struck occurred on a bitumen section further up the hill. Witnesses said gravel was apparent in the pothole.

Mr Cahill outlined several council procedural changes implemented since the fatality. These included an overhaul of the customer request management system; stricter internal reporting and road monitoring; higher grade duties, ensuring someone was acting in roles during leave; and depot consolidation to improve communication.

The inquest had heard that the department was “under-resourced” due to several staff members’ leave. Some of this was approved by Mr O’Rourke but he did not have authority to approve others. It had contributed to a communication breakdown about road monitoring after the September 22 pothole.

Mr O’Rourke earlier told the inquest that under the changes, staff would glean far more information about potholes at the first point of contact. 

A large pothole, defined as 30cm by industry standards, would be judged “urgent” with staff assigned to attend within an hour and render the area safe. 

“Under the previous (customer request) system a pothole was categorised as medium risk and we recognise that was inadequate,” Mr O’Rourke said.

“By going to urgent it puts it on a whole new plane.”

Mr O’Donnell welcomed these changes, extra resourcing and training and improved communication measures.

“If communication was better between workers, perhaps different actions may have been taken,” he said.

In his closing submission, David Lloyd SC said his client, Mr O’Rourke, had been an “impressive” witness.  

“He was careful and thoughtful in what he said. He made concessions about his personal failure from the first,” Mr Lloyd told the inquest.

“He was in a senior position and he acknowledged council failures at a number of levels.”

Mr Lloyd argued Mr Palmer’s earlier evidence that he had told Mr O’Rourke on September 22, 2015 that the road’s condition should be monitored and shown him photos of a second pothole in an email from Chris Brassel on the same day, should be rejected.

He said Mr O’Rourke had testified the conversation “never happened” and if he had seen the photos, he would have hastened the asphalting.

Mr Lloyd said there was objective evidence, supported by Mr Brassel, that Mr O’Rourke’s version was correct. Further, Mr Palmer had omitted the September 22 email in his initial statement to police.

Outside the inquest, Ms Pearce said she accepted and appreciated the council’s apology and the efforts to improve procedures.

“It’s been really hard,” she told Fairfax Media.

”Everything’s been hard – (especially) to sit through the evidence and hear what happened.

“It’s good to have the inquest out of the way, but at 6 o’clock tonight I still won’t have James.

“Nothing will bring him back but I believe people have learnt from it and things will change.”

Ms O’Sullivan will hand down her findings at Glebe Coroners Court on February 21. 

This story first appeared on the Goulburn Post.