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And Inquests Into a Wildfire and the Deaths of Five Firefighters at Linton on 2 December 1998

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And Inquests Into a Wildfire and the Deaths of Five Firefighters at Linton on 2 December 1998 R eport of the Investigation and Inquests into a Wildfire and the Deaths of Five Firefighters at Linton on 2 December 1998 STATE CORONER’S OFFICE, VICTORIA Preface Introduction The Coronial Inquest hearings into the December 1998 Linton fire and the tragic deaths of five Geelong West volunteer firefighters (Messrs. Stuart Davidson, Garry Vredeveldt, Christopher Evans, Jason Thomas and Matthew Armstrong) took 106 hearing days and produced in excess of 11,500 pages of transcript. Over 28,000 pages of exhibit and other documents were produced during the running of the Inquests. There were over 1500 pages of submissions and replies by the legal representatives for the interested parties. The Coronial Investigation into how the deaths occurred and the fire was managed raised many questions that required detailed examination. A coronial inquest hearing forms part of this overall investigation process. A significant number of issues canvassed at the Inquest hearings and raised in the documentation produced during the Investigation were critical to the safe management of the fire and for the future safety of firefighters. Apart from the entrapment that took the lives of the Geelong West Crew, a number of other incidents occurred earlier in the management of the fire, which placed the lives of many other firefighters at serious risk. Ultimately, the failures of training, supervision, communication, enforcement of operational and safety systems lay behind the deaths of the volunteer firefighters and the serious risks to the lives of many other firefighters in the wildfire that has come to be known as “Linton.” The Coronial Investigation was undertaken in order to determine how the deaths and fire occurred, who contributed to the deaths and fire and what could be done to prevent such occurrences in the future. Counsel instructed by solicitors represented a number of the interested parties who appeared at the Inquests. During the running of the Inquests it was indicated to all parties that detailed written submissions and, if necessary, written replies would be required at the completion of the evidence. In addition, at the end of the written submission procedure, time was set-aside for oral submissions. In general, the written submissions by counsel for the various parties were of a high standard, raising many differing perspectives which were helpful in guiding me through the maze of complex facts and inter-woven issues. Their work is appreciated. The process for the Inquests was designed to be inclusive, involving all of the parties enabling them, as far, as was practical and appropriate, to contribute to the investigation and development of the issues. The processes have been more comprehensively set out in Chapters 2, 3 and 4. It is also noted that Counsel Assisting were approached on a regular basis outside court by Counsel for each of the parties to raise additional matters such as administration, witnesses required, new issues, requests for Counsel Assisting to cover additional issues or ask questions of witnesses, etc. Where appropriate these requests were addressed during the running or followed up by Counsel Assisting. The continued support of the Office of the Director of Public Prosecutions and its resources over the time of the investigation and the Inquests is also greatly appreciated. Without that constant and high level of support this work could not have been achieved. The Report was prepared with the drafting assistance of Messrs. Tom Gyorffy (Crown Prosecutor) Garry Livermore (Barrister) and Glenn Childs (Legal Executive from the Office iii of Public Prosecutions). The task was enormous, and without their tireless professional dedication the Report would not have been completed by this time. I wish to express my great appreciation to each of them for their hard work. Ultimately, the conclusions and recommendations are my own. It is to be hoped that this work helps lead to improvements in safety for all of Victoria’s dedicated and community minded volunteer and full-time firefighters. About this Report This Report on the deaths and fire is divided into 23 Chapters, and where possible, each Chapter is designed to be as self-contained as practicable. At the end of the document are a series of Appendices, which are listed in the Contents at the beginning of Report. The Appendices contain various plans and maps, recommendations from a number of the parties who made submissions during the Inquests and the recommendations of the Firefighting Agencies’ joint “Operations Review of the Linton Fire/Midlands Fire.” Also a summary list of the Coroner’s recommendations is contained in Appendix A1. A Glossary of various terms used in the evidentiary material and the Report is to be found in Appendix 8. It should be noted that reference in the footnotes to “B” or “T” followed by a number respectively equates to the relevant page in the Brief of Evidence or the Transcript of the evidence at the Inquests. All of the Submissions and Replies of the parties have been added to the Brief and are to be found between B 9000 and 10561. Chapter 1 is an introduction to the Victorian Coroner’s jurisdiction and covers the statutory framework applicable to the jurisdiction (Coroners Act 1985) and the law to be considered by the Coroner when exercising the function of investigating deaths and fires. Relevant occupational health and safety issues are considered in Chapter 20 for the purpose of explaining the background of how the concept of “contribution” is determined. The statutory findings on identity of the deceased, cause of death and fire, how the fire and deaths occurred and the identity of the person (or persons) contributing to the death and fire are contained in Chapter 22. Chapter 21 sets out some of the work the firefighting agencies and the Bureau of Meteorology have undertaken on firefighter safety both before and after Linton. The Coroner’s comments and recommendations are to be found in Chapter 23. There are 55 Recommendations, which canvas a number of issues from the application of occupational health and safety principles and practice to the suppression of wildfire, to research and development. Chapter 5 gives a general overview of the fire. Other examples of the way the Chapters are constructed include Chapter 14, which deals with the entrapment of the five Geelong West volunteer firefighters, and Chapter 19 which covers the issue of the wind change information, the role of the firefighting agencies and the Bureau of Meteorology. Chapter 7 deals in detail with the fire and its cause. Details of the structure of the agencies, training, firefighting procedures and methods, etc. are to found in Chapter 6. The other chapters cover the various incidents during the fire, the role of the Incident Management Team in Ballarat, Forward Operations Point at Linton, the Staging Area and Communications. The Report, Brief and Exhibits are on CD-ROM. Copies of the Report and the CD-ROM are available from the State Coroner’s Office, Southbank. It is noted that Appendix A6 to the Report contains an index to the brief for the CD. Graeme Johnstone State Coroner 11 January 2002 Assisted by Messrs Tom Gyorffy and Garry Livermore who were instructed by Mr Glenn Childs from the Office of the Director of Public Prosecutions iv Acknowledgments The Coroner relies on a range of individuals and agencies to undertake an investigation. The investigation into the Linton fire and deaths of the five volunteer firefighters was both complex and lengthy. As can be seen by the acknowledgments the list of agencies and individuals contributing to the process has been extensive. The investigation was undertaken with the assistance of a range of government agencies - the Victoria Police Arson Squad, Victorian Forensic Science Centre, the Victorian Workcover Authority and the Victorian Institute of Forensic Medicine. The police officers involved were Detective Senior Sergeant Colin Cortous, Investigation Supervisor, Detective Sergeant Brad Daly, Investigation Leader and Detective Senior Constable Robert Court, Investigator. Also other members of the Arson Squad assisted from time to time. Dr. Olga Korytsky from the Victorian Forensic Science Centre undertook the scientific fire investigation. Mr. Dennis Noonan from the Workcover Authority provided an expert report on occupational health and safety issues. Dr. Michael Burke, Forensic Pathologist from the Institute of Forensic Medicine, provided the forensic details on cause of death. Investigations of this type inevitably require the assistance of a range of experts. Mr. Noonan has already been mentioned. The investigation also relied on fire experts (Messrs. David Packham and Phil Cheney, Drs. Neil Burrows and Kevin Tolhurst). Dr. Michael Reader from Monash University gave expert opinion on weather. The Victorian Government Reporting Service provided the running transcript for the Court and to counsel for the parties. The Court Transcript Officers were – Mrs. Shirley Shaw, Ms. Janice McDonnell, Mrs. Karen Salviato, Mrs. Lynne Warren, Ms. Vivienne Broadhurst, Ms. Janet Ceff and Mrs. Liz Colgrave. The CAT Reporters were - Ms. Tracey Graham, Mrs. Kim Fiorentino and Mrs. Diane Byass. Technical, Supervisory and other reporting support was provided by – Mr. Frank Hamelink, Mr. David Hoy, Ms. Chris McKee, Mr. Graham Davidge, Mrs. Denise Mackie and Mr. Ian Neilson-Male. Lastly, Ms. Sue Elliot provided typing assistance for the final report. During the running of the Inquests the CFA provided a number of additional reports and statements. It also undertook testing of firefighting safety equipment and provided demonstrations for the Court. DNRE also provided additional reports and material from overseas. Mr. Geoff Evans from the CFA and Ms. Catherine Dunlop, its instructing solicitor, obviously undertook a large role to help ensure the provision of material and organising the testing and demonstrations. Ms. Allison Smith, solicitor, also assisted with organising the transcript of communications. Mr. Peter O’Riley from DNRE and its instructing solicitor William Southey performed similar functions on behalf of that organisation.
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