Internal Review of Operations During the 2015–16 Bushfire Season

Internal review of operations during the 2015–16 bushfire season

“A lesson learned isn’t a lesson until it brings about change” Dr Christine Owen Contents Internal review of operations during the 2015–16 bushfire season ...... 1

1 Executive summary ...... 4

1.1 The 2015–16 bushfire season in Tasmania ...... 4

1.2 Bushfire management in Tasmania ...... 4

1.3 About this review ...... 5

1.4 About the recommendations ...... 6

1.5 Summary of recommendations ...... 7

2 Purpose and scope of review ...... 13

2.1 Purpose ...... 13

2.2 Scope ...... 13

3 The 2015–16 bushfire season in Tasmania ...... 15

3.1 Extreme weather, a record number of fires and an unprecedented response ...... 15

3.2 The firefighting deployment ...... 16

3.3 Timeline of campaign fires ...... 16

4 Review method ...... 17

4.1 Project approach ...... 17

4.2 Data collection ...... 18

4.3 Data analysis ...... 19

5 Acknowledgments ...... 21

6 Recommendations and context ...... 22

6.1 Preparedness ...... 23

6.2 Review of state incident management and arrangements ...... 26

6.3 Capacity and capability ...... 28

6.4 Planning and Incident Action Plans ...... 32

6.5 Resourcing and resource-tracking ...... 34

6.6 Communication ...... 36

6.7 Air operations ...... 37

6.8 Safety ...... 40

6.9 Interoperability ...... 42

6.10 Local knowledge ...... 44

6.11 Communication systems and information technology...... 45

6.12 Finance ...... 47

Tasmania Fire Service Page 2 Review of operations during the 2015–16 bushfires 7 Conclusion ...... 48

Tasmania Fire Service Page 3 Review of operations during the 2015–16 bushfires 1 Executive summary

1.1 The 2015–16 bushfire season in Tasmania

The bushfire season in Tasmania between October 2015 and March 2016 elicited a response and commitment that was unprecedented in Tasmanian history. It involved a wide range of emergency management personnel from within Tasmania, other Australian jurisdictions and overseas. This event was unique, in part, because of the number of fires occurring in remote and inaccessible areas requiring fire suppression.

1.2 Bushfire management in Tasmania

The agencies most closely involved in bushfire management in Tasmania are Tasmania Fire Service (TFS), Forestry Tasmania (FT) and the Parks and Wildlife Service (PWS). Each of these agencies is represented on the Tasmanian Government’s Multi-Agency Coordination Group (MAC). An Inter-Agency Fire Management Protocol is reviewed each year that is effectively the operating agreement between the three agencies. The protocol underpins the cooperation that exists between the agencies to ensure the suppression and management of bushfire in Tasmania is safe, efficient and cost-effective. Through this arrangement the agencies collaborate in relation to training, identifying and mitigating risk, planned burning operations and suppressing bushfires.

Since the 2013 Tasmanian Bushfires Inquiry Report and its subsequent recommendations, these organisations have continued to develop their combined bushfire response capability at both the response and incident management levels.

This year, for the first time, the Tasmanian Government’s ‘Tasmanian Interoperability Register’ was activated. This ensured state servants from several government agencies were available to provide surge capacity in support roles, resulting in a whole-of- government response. Agencies included in the register are:

• Department of Health and Human Services • Tasmanian Health Service • Department of State Growth, Department of Justice • Department of Police, Fire and Emergency Management (DPFEM) • Department of Premier and Cabinet • Department of Primary Industries, Parks, Water and Environment • Department of Treasury and Finance • Forestry Tasmania (FT) • Department of Education • TasTAFE.

Tasmania Fire Service Page 4 Review of operations during the 2015–16 bushfires 1.3 About this review

At the end of the 2015–16 bushfire season, TFS, FT and PWS initiated an internal operational review into the season to ensure ongoing continuous improvement in emergency management, particularly the subsequent operational response to fires affecting Tasmanian communities, community and environmental assets, and Tasmania’s longer-term economy.

A review team was established that included members from TFS, FT, PWS and the University of Tasmania to manage this internal operations review (the Review).

The objective of the Review was to ensure that operational lessons learned during the 2015–16 Tasmanian bushfire season were identified, captured and communicated to Tasmania’s emergency management partners and relevant stakeholders by July 2016. The Review involved:

• a survey developed and analysed by Dr Christine Owen that provided all personnel who were involved in the bushfire campaign an opportunity to provide feedback. Christine has extensive experience in research and has worked with the University of Tasmania, the Bushfire and Natural Hazards Co-operative Research Centre and the Australasian Fire and Emergency Services Authorities Council (AFAC) • debriefs with Incident Management Teams throughout Tasmania • debriefs with State Fire Operations Centre personnel • debriefs with personnel from New South Wales, Victoria and Queensland • debriefs with specific functional and support areas • agency-specific debriefs conducted by FT and PWS in all three regions. The information gained has been analysed and collated in the body of this report, and recommendations for action have been identified for the attention of the MAC and TFS Executive Leadership Team.

Feedback through the Review has provided valuable insight into the experiences of individuals who were involved in the operational response during this past bushfire season. These insights can help identify the lessons to be learned so we can continue to improve. It should be noted that participants also provided feedback on how we have continued to improve in recent years and identified areas that worked well. Relevant agencies should continue to remind their personnel about the value of their ongoing and outstanding contribution to their organisations and the Tasmanian community.

It was recognised that many of the issues that arose this bushfire season could be attributed to the unprecedented scale of the event and the enormity of the response. The focus of the Review has been to proactively research and analyse the lessons that can be learned from collective experience in readiness for any similar events that could occur in the future. As a result, this report focuses on improvements, although the many areas that worked well are also acknowledged.

Tasmania Fire Service Page 5 Review of operations during the 2015–16 bushfires 1.4 About the recommendations

Overall the Internal Operational Review aligns closely with several recommendations made within the AFAC Independent Operational Review1.

The Review acknowledges the many aspects that went well and need to be sustained. Much of the focus of the recommendations primarily relate to areas of improvement. While some of these can be easily actioned, others will require resources to be allocated and may require a project to be initiated.

The review team has not prioritised the recommendations, and acknowledges that this is a separate exercise to be undertaken by the MAC. Particular action that requires consideration prior to the 2016-17 bushfire season has been noted ‘as a matter of priority’.

1 AFAC Independent Operational Review: a review of the management of the Tasmanian fires of January 2016 (April 2016) Tasmania Fire Service Page 6 Review of operations during the 2015–16 bushfires 1.5 Summary of recommendations

Note: For the purpose of this Review, Tasmanian fire and emergency services and land management agencies will be referred to as ‘responsible agencies’.

Recommendation For context see…

1. That responsible agencies: Section 6.1 Preparedness • review current preparedness policies and procedures to identify minimum functional staffing levels for all response and incident management roles. Areas in need of particular attention include Staging Areas and Air Base Management where rapid establishment is critical • ensure updated policies and procedures are widely promulgated to confirm that personnel across all agencies are aware of, and have ready access to, current operational procedures and preparedness for the coming bushfire season • review the content of pre-season briefings so that the content is appropriate to the needs of each target audience. This requires targeting operational content to the needs of response personnel to clarify intent • refine a multi-agency State Fire Action Plan to address preparedness and support needs, including trigger points for interstate/international surge capacity • include in preparedness the need for communications and information technology expertise to be available as part of the surge capacity • investigate existing individual agency preparedness ‘kits’ and identify gaps where pre-prepared multi-agency kits would be advantageous (e.g. establishing Staging Areas) • evaluate the degree to which the existing design of Incident Management Teams working within regional Incident Control Centres as well as the State Fire Operations Centre are suitable to meet operational demands • identify roles and/or functions where Business Executive Services (BES) of DPFEM could provide incident management support arrangements at all levels.

2. That as a matter of priority, responsible agencies review Section 6.2: state fire incident management processes and arrangements Review of state including: incident management and • the roles and functions within and between state and arrangements regional fire operations, particularly the role of Regional Fire Operations Centres in Level 3 incidents • the reporting relationships between state, regional and Level 3 Incident Management Teams (IMTs) • investigate the viability of a multi-agency statewide duty roster

Tasmania Fire Service Page 7 Review of operations during the 2015–16 bushfires Recommendation For context see…  the reporting relationships between state, regional and Level 3 Incident Management Teams (IMTs)  investigate the viability of a multi-agency statewide duty roster  the appropriateness of IMT managing fire complexes and, if needed, identifying the resourcing requirements for this to be a suitable approach to management  arrangements for establishing Staging Areas, including their resourcing requirements, maintenance and demobilisation  standardising procedures and systems to ensure consistency across regions and agencies, including terminology used  developing ‘trigger points' for intra/interstate resource deployments, including standardised inductions, briefings and shift rotations  developing ‘trigger points’ for the establishment of split and/or 24-hour IMT shifts  developing procedures for escalation, de-escalation and demobilisation of all levels of incident management.

3. That responsible agencies review the adequacy of the Section 6.3: State’s capacity and capability during emergency bushfire Capacity and incidents, including: capability  finalising a statewide capacity and capability register and subsequent framework that includes areas targeted for future development  conducting a gap analysis against minimum functional requirements, as well as a skills audit across all agencies including the volunteer (TFS and SES) workforce, to identify opportunities to increase capability to address gaps  revising strategies to increase the State’s remote area firefighting capacity, including the potential development of the volunteer workforce  Parks and Wildlife Service, as the land manager and agency responsible for the reserve system that represents the largest portion of ‘remote area’, will coordinate the further development of Tasmania’s remote area firefighting capability and capacity in collaboration with partner agencies  identifying opportunities for cross regional and/or jurisdictional development, including an increase in exercise regimes  reviewing current mentoring processes to ensure opportunities are identified and formalised

Tasmania Fire Service Page 8 Review of operations during the 2015–16 bushfires Recommendation For context see…  recommending to AFAC that AFAC develop guidelines to ensure a nationally consistent approach be adopted in relation to terminology, training and fitness requirements for remote area firefighting  providing additional exercising in areas of incident management, including the principles relating to management by objectives  auditing individual agency operational pocket books or aide-memoires and developing multi-agency toolkits for Tasmanian-specific contexts. This may include adapting AFAC aide-memoires or those of other agencies  reviewing the tree felling accreditation and competency maintenance requirements of each agency to provide a comparison and understanding of the variations in skill level and competency requirements  reviewing the processes agencies have in place to confidentially report on discrimination or harassment are working. This may include an investigation into any potential blockages (cultural or otherwise) to affected persons speaking up.

4. That as a matter of priority responsible agencies review Section 6.4: the current process and systems for the development of Planning and Incident Action Plans (IAPs) including options for Incident Action dissemination with the aim of introducing a more streamlined Plans IAP that is both fit for purpose and meets compliance obligations. This includes:  investigating options to ensure that current information is provided in compliance with quality assurance systems and fit for purpose at all levels from the fireground to the SFOC  all agency partners adopting one IAP template to be implemented across all agencies and regions  investigating the levels of resourcing required within the Planning Function to ensure that IAPs can be prepared in time and that appropriate span of control is maintained  investigating options and trigger points for the implementation of 24-hour or split-shift Incident Management Teams (IMTs) or Functions to ensure the production of appropriate and timely IAPs  investigating why communication and information flow between the Operations and Planning Sections continue to break down, so that these critical coordination points can be reviewed and included in subsequent exercising to improve integration.

Tasmania Fire Service Page 9 Review of operations during the 2015–16 bushfires Recommendation For context see…

5. That responsible agencies review the current procedures Section 6.5: and systems for all procurement, resource allocation, tasking Resourcing and and tracking, including: resource tracking  reviewing the process and systems to support resource requests, especially triggers for expediting inter/intrastate requests  reviewing data collection and recording to log and track resources to (a) remove workload duplication (b) develop a consistent approach across regions and agencies as a matter of priority  reviewing the use of ‘T Cards’ as a resource-tracking tool on the fireground.

6. That, as a matter of priority, responsible agencies Section 6.6: investigate options for improving overall communication Communication between all levels of incident management, including from the fireground to Incident Management Teams (IMTs). This may also include the subsequent relationships/links between operations and strategic planning within IMTs. 7. That responsible agencies review the current management Section 6.7: of air operations within the Tasmanian framework, including: Air operations  identifying options for increasing capacity and capability, including the development of the TFS and SES volunteer workforce in support roles, and ensuring a nationally consistent approach is adopted in relation to the development of skills and qualifications in these roles  increasing the knowledge of aircraft capabilities and limitations to inform operational decision-making as well as to inform government, stakeholders and the community  reviewing the process and subsequent authorisation of aircraft for strategic and tactical deployment and to ensure aircraft use is a ‘best fit for purpose’  reviewing the process and subsequent authorisation for fire chemical use, including operational awareness of fire chemicals  developing processes and systems that support the evaluation of the effectiveness of aerial firefighting  reviewing existing ground-to-air communication practices, to ensure wherever possible air operations has a dedicated communications channel  reviewing procedures for the deployment and operation of aircraft at the state and regional level – including a review of the current dedicated air-desk procedures, flight following and engagement of ‘call when needed’ aircraft

Tasmania Fire Service Page 10 Review of operations during the 2015–16 bushfires Recommendation For context see…  reviewing the reporting structure and lines of communication for aircraft management to ensure tasking of aircraft is appropriate, efficient and safe.

8. That responsible agencies review a range of practices Section 6.8: associated with safety, including: Safety  reviewing and reinforcing the safety roles at the strategic and tactical level in Tasmanian responses  reviewing and/or developing processes and systems to identify and mitigate hazardous trees, including working within hazardous and tall timber environments  investigating accidents/near misses and communicating outcomes in a timely manner  developing standardised documentation and procedures that allow for the timely reporting, recording and investigation of accident/near misses  reviewing and/or developing procedures that support incident management personnel in the event of accidents/injures and/or fatalities  considering procedures and ‘trigger points’ for the deployment of medical support to Staging Areas.

9. That responsible agencies continue to promote and develop Section 6.9: current interoperability arrangements, including: Interoperability  reviewing the functions and authority level of MAC and the Inter Agency Training Committee (IATC)  reviewing the integration and coordination of emergency training between the IATC member agencies  increasing whole-of-government participation, particularly the current interoperability arrangements and ensuring opportunities are provided for ongoing training and exercise participation.

10. That responsible agencies: Section 6.10: Local knowledge  continue to improve the process for ensuring that local knowledge is accessed at all levels of incident management  ensure that local knowledge is included in any future inter/intra-state fireground operations and Incident Management Teams  develop a protocol outlining what ‘accessing local knowledge’ entails to clarify expectations of local personnel.

Tasmania Fire Service Page 11 Review of operations during the 2015–16 bushfires 11. That responsible agencies and the Business Executive Section 6.11: Services division of DPFEM review current procedures Communication and/or arrangements for communications and information systems and technology (IT) support during emergencies, including: information technology  developing procedures to ensure incident communication plans include technical input and meet the operational requirements of the complex/incident  identifying options for streamlining IT systems and multi-agency compatibility requirements  reviewing and/or developing procedures and systems that further support the increased use of social media during emergency incidents – including public information and operational information  identifying and implementing IT solutions to improve the dissemination of incident information, including Incident Action Plans and any relevant operational information.

12. That responsible agencies and the Business Executive See 6.1.2: Services (BES) division of DPFEM identify and develop Finance options for improving the processes required to provide up- to-date incident expenditure, collection and inputting of relevant data and ongoing financial cost estimate analysis, including:  identifying options for providing personnel with the financial skills required to assist at relevant levels of incident management  reviewing the financial procedures and systems associated with all aspects of air operations, including the National Aerial Firefighting Centre and ‘call when needed’  reviewing and/or developing interagency financial procedures that ensure, wherever possible, processes are streamlined during multi-agency incidents  identifying options and approvals for payment allowances and overtime within TFS and the process/documentation in general  developing surge capacity within BES during periods of increased workload and any required incident management support.

Tasmania Fire Service Page 12 Review of operations during the 2015–16 bushfires 2 Purpose and scope of review

2.1 Purpose

This Internal review of operations during the 2015–16 bushfire season (the Review) was initiated by Tasmania Fire Service (TFS), Parks and Wildlife Service (PWS) and Forestry Tasmania (FT) and as part of an ongoing program to ensure continuous improvement of operational response during bushfires.

The objective of this Review is to ensure that operational experiences during the bushfire season of 2015–16 are identified so that lessons from them may be learned. To this end the TFS Chief Officer supported this Review with the intent of:

• debriefing those engaged in the bushfire season • gaining from their insights • communicating the findings to all emergency management partners and relevant stakeholders. This Review builds on the work that has already been done in Tasmania since the bushfires of 2013 and the report from the 2013 Tasmanian Bushfire Inquiry. To date, realising those recommendations has seen widespread organisational improvement that has included (but is not limited to): refined command and control structures; updated and informed operational procedures; the integration of local knowledge; and further development of operational doctrine.

However, the bushfires that occurred in Tasmania between October 2015 and March 2016 (the subject of this Review) required an operational response not previously seen in this State. In addition to the assistance provided by all levels of Government in Tasmania, a range of international, interstate and local firefighting resources were deployed.

As a result it was found that there was a need for a comprehensive review of the past bushfire season in order to identify learnings for the future.

2.2 Scope

The scope of this Review related to the Tasmania Government’s operational capability during the 2015–16 bushfire season in Tasmania (from October to March).

2.2.1 Within scope It includes a review of tactical, strategic and state-level incident management and response to large-scale complex incidents, providing an opportunity for TFS and partner agencies to measure improvements into the future.

Following the 2015–16 campaign, TFS commissioned an Independent Operational Review through the Australasian Fire and Emergency Services Authority Council (AFAC)2, however, this review focused mainly on the campaign fires that occurred from January. The intent of the AFAC Review was to understand the significant aspects of that event that worked well and should be built on, and to highlight any issues that can be improved upon. This Review (the internal review) acknowledges the findings of the AFAC report and in several areas supports and makes reference to the recommendations contained within it.

2 AFAC Independent Operational Review: A review of the management of the Tasmanian fires of January 2016

Tasmania Fire Service Page 13 Review of operations during the 2015–16 bushfires 2.2.2 Outside scope It excludes:

• face-to-face debriefs with local and/or district brigades. Based on the difficulties and sheer number of people involved there was an expectation that any required face-to- face debriefs would be conducted at the local level, allowing observations and insights to be captured within regions and the online survey. • the Commonwealth Senate Inquiry into the response and lessons learned from the recent bushfires affecting the Tasmanian Wilderness World Heritage Area (TWWHA) • TFS fatigue management issues that are currently being externally reviewed. However, the Review did identify several issues relating specifically to personal and group fatigue • the effectiveness of the responsible agencies public information and subsequent community engagement.

Tasmania Fire Service Page 14 Review of operations during the 2015–16 bushfires 3 The 2015–16 bushfire season in Tasmania

3.1 Extreme weather, a record number of fires and an unprecedented response

The bushfire season in Tasmania between October 2015 and March 2016 elicited a response and commitment that was unprecedented across all jurisdictions in Tasmania’s recent history, and included involvement from a wide range of emergency management personnel from within Tasmania, other Australian jurisdictions and overseas.

Before the 2015–16 bushfire season, TFS, PWS and FT held annual pre-bushfire season briefings with multi-agency personnel across all regions, including presentations to all TFS volunteer districts, career staff and non-operational staff. In addition, FT and PWS also delivered their annual pre-bushfire season refreshers to all employees involved in fire management activities.

As a result of an established El Nino event and a strong Indian Ocean Dipole, Tasmania experienced the driest spring on record during 2015. Rainfall over the September, October and November period was below average in most areas, with the exception of the North East Coast where there was significant rainfall in early November 20153.

During the December, January and February summer period there were record statewide mean temperatures, with rainfall over this period recorded as below average for most parts of the State. The West Coast received ‘markedly less rain than usual’ and the lowest on record for the period September–February4.

Total Fire Ban days (TFB) were declared across TFS regions during October 2015, December and January 2016, with a statewide TFB declared for four continuous days from 23–26 January 2016.

Tasmania’s bushfire season started early October 2015 and indicators suggested a busier than ‘normal’ bushfire summer period. Prior to 13 January 2016, Tasmania experienced around 1,060 vegetation fires, approximately 35 of those fires required an ongoing operation response beyond 48hours.

On 13 January, a dry lightning storm crossed the State in the late afternoon igniting over 80 fires on reserved land, including the Tasmanian Wilderness World Heritage Area (TWWHA), Permanent Timber Production Zone land and private land. Fires continued to be reported as they were detected by spotter flights over the following days. Reports indicate that on 14 January there were 28 known fires on reserved land. More fires were detected over the following week—and by 24 January approximately 48 fires had been reported on reserved land as a result of the 13 January lighting strikes.

Following the lightning event on 13 January, another series of lightning strikes caused fires on 27 January and 14 February 2016. Overall, TFS and partner agencies, FT and PWS, responded to a total of 2,247 incidents—556 of these were vegetation fires.

Due to the high number of fires, the State Fire Controller (SFC) established a State Intelligence Unit tasked with providing risk management and fire behaviour advice to the SFC, Government and to Incident Management Teams based in TFS regions. This unit used National Emergency Risk Assessment Guidelines to consider both the consequence and likelihood of each fire.

3 Meteorological Conditions Relevant to the January 2016 Tasmanian Bushfires, Bureau of Meteorology, 2016 4 Meteorological Conditions Relevant to the January 2016 Tasmanian Bushfires, Bureau of Meteorology, 2016

Tasmania Fire Service Page 15 Review of operations during the 2015–16 bushfires As at 21 March, all fires were contained and were being patrolled. A total of 124,248 hectares had been mapped as affected. While the fires were predominantly on public lands, the TFS led the response in conjunction with PWS and FT.

3.2 The firefighting deployment

Approximately 1,100 employees and volunteers from TFS and the State Emergency Service (SES), 220 PWS, 140 FT personnel and 70 FT firefighting contractors were deployed during the 2015–16 firefighting campaign. The vast majority of these personnel undertook multiple rotations, meaning there were thousands of deployment rotations by Tasmanians.

For the first time, the Tasmanian Interoperability Register was activated. This made available many state servants to provide operational support, resulting in a truly whole-of- government response.

In addition, an Interstate and International Liaison Unit (IILU) was established in Tasmania from 23 January 2016 to coordinate ongoing resource requests and subsequent deployment to Tasmania. It was the first time nationally that IILU arrangements of this type had been established and deployed.

There were over 2,000 interstate and international personnel rotations involving over 1,000 personnel from Victoria, New South Wales, Australian Capital Territory, Queensland, South Australia and New Zealand. This was supported by 152 interstate vehicles and two base camps deployed from Victoria and New South Wales.

Interstate and international personnel were engaged in all facets of operational activity, including substantial remote area firefighting. In addition, approximately 600 contractors were engaged in firefighting and logistical support activities. There were also several thousand vehicle and aircraft movements over the campaign.

3.3 Timeline of campaign fires

Pre-October 2015 Preparedness and pre-emptive arrangements in place from the beginning of the bushfire season 13 January 2016 Initial lightning event (standard response and initial priorities identified) 19 January 2016 Chief Officer discussions in relation to interstate support 23 January 2016 Interstate/international deployments arrived in Tasmania 24 January 2016 Interstate and International Liaison Unit (IILU) established in Tasmania 28 January 2016 Second lightning event 14 February 2016 Third lightning event 14 February 2016 Mole Creek base camp established 16 February 2016 Stanley base camp established 10 March 2016 Interstate/international assistance ceased

Tasmania Fire Service Page 16 Review of operations during the 2015–16 bushfires 4 Review method

4.1 Project approach

4.1.1 Review team To meet the Review objective, a review team was established.

Team member Organisation Role

Gavin Freeman Deputy Chief Officer Project sponsor

Greg Butters A/Regional Chief, Office of the Chief Project manager–reporting Officer, TFS to the Deputy Chief Officer

Dr Christine Director, The Learning Organisation Research leader Owen

Dean Sheehan Manager, Fire Management, Forestry Team member Tasmania

Adele Wright Fire Management Officer (Policy), PWS Team member

Debra Pope Executive Officer, Internal Team member Communications, TFS

Kristy Baker Executive Support Officer, TFS Team member

Jane Melross Principal Consultant, The Write Report writer Solution

4.1.2 Review team meetings The review team met several times between April and July 2016 to:

• identify all response, emergency management partners and stakeholder groups, and implement systems and structures to facilitate maximum participation and feedback • develop a process and support systems to capture feedback, including the development of an online survey • develop survey questions, manage the piloting of these and propose adjustments needed based on feedback • develop agenda and target areas for face-to-face debriefs • identify reporting mechanisms • review data and identify recommendations based on themes that became apparent through the surveys and debrief • develop a report (this Review) on findings and recommendations • develop a communications plan to communicate the findings of the Review.

Tasmania Fire Service Page 17 Review of operations during the 2015–16 bushfires 4.2 Data collection

4.2.1 Methods All personnel who assisted with the firefighting response were invited to provide feedback about their experiences in this review. Feedback was collected in three ways:

1. Survey A survey (online and hard copy), developed and analysed by Dr Christine Owen, provided all personnel who were involved in the bushfire campaign an opportunity to provide feedback. Christine has extensive experience in research and has worked with the University of Tasmania, the Bushfire and Natural Hazards Co-operative Research Centre and the Australasian Fire and Emergency Services Authorities Council (AFAC).

The survey was distributed through TFS, PWS and FT networks. To ensure that the feedback was inclusive, the survey was also mailed out in hard copy to all TFS volunteers and distributed to contacts in interstate and international agencies for distribution. Response rates and demographics are included below. A preliminary report of the findings was prepared to feed into the second phase of data collection (debriefs with functional groups and one-on-one interviews).

2. Debriefs with functional groups Face-to-face debriefs with functional groups were held in each region of Tasmania to gain insights from those involved in Incident Management Teams. In addition, PWS and FT held their own debriefs.

To follow up on feedback from interstate and specialist stakeholders, TFS also held face-to-face debriefs in New South Wales, Queensland and Victoria and debriefs with specific areas of DPFEM who supported the operational response.

In addition, FT conducted a specific debrief targeted at their female firefighting and incident management staff; the review team would encourage the responsible agencies to consider a multi-agency format in any future debrief process. This would assist with progressing several of the recommendations within this report.

4.2.2 Level of participation

Feedback method Conducted when Participation Survey Online 15 April–30 May 857 responses Hard copy 15 April–15 June 249 responses Total survey responses: 1,106 responses Face-to- • IMT – North West Thursday 19 May 36 attendees face debriefs • IMT – North Friday 20 May 25 attendees • IMT – South Tuesday 20 May 31 attendees • IMT – Queensland Wednesday 1 June 25 attendees • IMT – NSW Thursday 2 June 13 attendees • IMT – Victoria Friday 3 June 23 attendees • SFOC/RFOC Monday 20 June 30 attendees

Tasmania Fire Service Page 18 Review of operations during the 2015–16 bushfires Feedback method Conducted when Participation • FT debrief (North West ) Friday 13 May 23 attendees • FT debrief (North East) Tuesday 17 May 23 attendees • FT debrief (South ) Wednesday 18 May 45 attendees • PWS debrief (South) Monday 16 May 18 attendees • PWS debrief (North) Tuesday 17 May 20 attendees • PWS debrief (North West) Wednesday 18 May 12 attendees • TFS Admin (North West) Monday 30 May 5 attendees • RATs Tuesday 6 June 12 attendees • Air operations Tuesday 14 June 14 attendees • Engineering Services Tuesday 14 June 8 attendees • FireComm Tuesday 14 June 16 attendees • Finance Wednesday 15 7 attendees June • Safety Thursday 16 June 7 attendees • FT Female staff Thursday 16 June 12 attendees • IT and Communications Friday 24 June 9 attendees • Incident Controllers/RFCs June 2016 (various) 9 attendees Total face-to-face debriefs 423 attendees

4.3 Data analysis

4.3.1 Data approach A phased approach was undertaken to the Review, where a survey was first used as a means of reaching out to as many people as possible. This was important, given that there would not be the opportunity to interview or engage everyone in face-to-face debriefs given the sheer numbers of people involved. Despite this limitation, it was important to try to capture as many insights as possible from the many people involved.

The structure of the survey focussed on aspects important in incident management. People completing the survey were asked to think about:

• their overall experience and to provide answers to their perceptions of reporting and briefings • receipt of and assessment of the quality of incident action plans • whether relevant safety strategies had been adopted • experiences of communication and information flow as well as teamwork and coordination.

Tasmania Fire Service Page 19 Review of operations during the 2015–16 bushfires In addition the survey canvassed perceptions of the effectiveness of air attack and elements that might limit people from being able to effectively do their job. A number of qualitative comments were also sought, including:

• what aspects were done well • what could be done better • what lessons would be important to learn for the future. Preliminary findings were extracted after two weeks from the Tasmanian sample and used to inform the next phase, the face-to-face debriefs of Incident Management Teams as well as other specialist groups and interstate/international agencies.

In terms of the face-to-face debriefs, each followed a systematic agenda. Verbal comments were captured at the meetings and transcribed into a database that has also been collated into the themes that now form the structure of this report.

The themes synthesised and discussed here were identified in both the survey and face- to-face debrief comments.

Tasmania Fire Service Page 20 Review of operations during the 2015–16 bushfires 5 Acknowledgments

The review team would like to acknowledge the considerable goodwill and participation in the Review from people who were part of the operational response and contributed to the survey, as well as those who participated in the face-to-face debriefs.

The review team would also like to acknowledge all the valuable assistance provided by personnel who did not have the opportunity to participate in the campaign response but who continued to maintain operational preparedness in areas where bushfires would ‘normally’ have been expected and may have impacted on communities should any fires and/or emergencies occurred.

Tasmania Fire Service Page 21 Review of operations during the 2015–16 bushfires 6 Recommendations and context

A note about the recommendations This section highlights each recommendation, summarising its context and how it was identified. Where possible it provides a reference directly to where the comments were made.

Important notes about these recommendations are:

• Overall the Review closely aligns to several recommendations made in the AFAC Independent Operational Review5. • The recommendations in this Review have been kept as broad as possible and follow the themes identified by the review team. • While the review team has not prioritised the recommendations, and acknowledges that this is a separate exercise to be undertaken and coordinated by the MAC, particular action that requires consideration before the 2016–17 bushfire season has been noted ‘as a matter of priority’. • The detail on a way forward will require further analysis, and it is recommended that all data in this Review should be used as a reference to help prioritise and resource subsequent action. • The majority of recommendations are at the multi-agency level, therefore further consultation will be required to ensure recommendations are prioritised and appropriate resources allocated. • It is anticipated that many recommendations will require a formal project to be initiated along with the allocation of resourcing and funding. • These recommendations should be prioritised based on sound risk management principles. • It is acknowledged that several recommendations contained within this Review have links and benefits to other recommendations. Therefore, it is important that this report be considered holistically rather than focussing specifically on individual recommendations. Where possible, recommendations have been cross-referenced to others that are related. • In addition, the review team notes that there are opportunities for case studies to be identified, developed and communicated to exemplify the lessons that can be learned and detail the insights from specific incidents, for example a smoke inhalation incident at Couta Rocks and an interstate vehicle-rollover.

5 AFAC Independent Operational Review: a review of the management of the Tasmanian fires of January 2016 (April 2016)

Tasmania Fire Service Page 22 Review of operations during the 2015–16 bushfires 6.1 Preparedness

Context 6.1.1 The survey results and face-to-face debriefs acknowledged improvements by the agencies in relation to the 2015-16 bushfire season preparedness. These included:

• a targeted summer bushfire campaign emphasising bushfire safety and aimed at reducing community risk • pre-season bushfire conferences for all TFS districts and non-operational staff, emergency management partners and land management agencies • pre-season bushfire refresher field days held by FT and PWS • implementation of the multi-agency tenure-blind fuel reduction burning program which resulted in 40 burns being completed • the multi-agency exercise held in October 2015 to ensure interoperability and communication processes were tested before the bushfire season’s onset. The exercise also tested Rapid Impact Assessment capability, Incident Management Team composition, WebEOC as a command and control tool, and operational structures • TFS signing, in December 2015, the AFAC ‘Interstate / International Interoperability Agreement’, which then allowed for access to surge capacity from across the nation. 6.1.2 The following comments were reported in debriefs, indicating the elements it would be important to sustain. It was evident in debriefs that the people who were involved in the campaign believed their efforts were worthwhile, and a number of people commented on the difference in preparedness this bushfire season compared with previously. Comments in the survey included:

I feel very proud to be a member of the Tasmania Fire Service, I feel the incidents were managed very well, the strategy was right and it was well executed. In general, considering the complexity of the fire season. It was all done well. Just a few things need fine tuning. Initial resourcing has improved. It was great to see the TFS throwing many units hard and fast at these fires. When a new fire broke out, the strike teams were pre-prepared, and multiple local brigades were paged at the same time - thus ensuring a large turn-out of units quickly. Great work!! Recent upgrade of trucks has been excellent. Reflecting in the scale of these fires no lives lost / very little structures you have to say WELL DONE. 6.1.3 However, feedback from the online survey as well as the face-to-face debriefs indicate that a range of preparedness strategies need to be improved. These include ensuring all agency personnel have an up-to-date understanding of operational procedures and preparedness plans. It is proposed that operational content at bushfire pre-season briefings be increased and briefings are targeted for specific audiences. In addition, that personnel on the Tasmanian Interoperability Register be included in pre-season briefings as well as exercises.

Tasmania Fire Service Page 23 Review of operations during the 2015–16 bushfires 6.1.4 There is also an opportunity to enhance multi-agency planning by refining individual agency fire action plans and combining these into one multi-agency preparedness plan at the state level. There are currently different approaches taken within individual agencies to planning: some agencies develop a state-level plan and others have regional plans. A combined multi-agency State Fire Action Plan (SFAP) could identify, for example, pre-planning arrangements, state/regional response arrangements, logistical arrangements and reference to relevant agency operational doctrine. The completion of an SFAP should also include how such response arrangements will embed local knowledge and overall incident management communication.

6.1.5 Any future increase in interstate/international and intrastate deployments would be enhanced if preparedness for these were included in the multi-agency State Fire Action Plan (SFAP) mentioned above.

6.1.6 Some agencies have several ‘kits’ available that currently assist with preparedness and subsequent initial response, for example, Sector Commander. The Review proposes that an audit be conducted of individual agency kits to pool resources as well as to identify areas where there are gaps, so that kits can be developed for areas of need. Additional kits would further enhance agencies’ initial response, particularly in establishing Staging Areas and Air Base Management. Rapid establishment of these functions is seen as critical to fireground safety and communication.

6.1.7 The Review also identified a need to improve pre-season skills maintenance for all response and incident management roles. This was particularly evident for people engaged as firefighters in Remote Area Teams (RATs), where firefighters suggested the specialist skills required planned and ongoing training for skills maintenance, including aircraft operations (See also 6.3.7, 6.3.8, 6.3.9 and Recommendation 3).

6.1.8 There was a lot of discussion in debriefs about the challenges of working in facilities that were not able to cope with the scale of incident management and the consequent loss of situational awareness between IMT functional units due to building design. The agencies should identify and develop options for resourcing appropriate incident control facilities at all levels, including a complete review of current Incident Management Teams operating within Regional Incident Control Centres (ICC) and SFOC designs. This should be completed as a matter of priority. However, it should be acknowledged that any options identified for purpose-built ‘fit-for-purpose’ emergency management facilities will require longer-term planning.

Recommendation 1

That responsible agencies: • review current preparedness policies and procedures to identify minimum functional staffing levels for all response and incident management roles. Areas in need of particular attention include Staging Areas and Air Base Management where rapid establishment is critical • ensure updated policies and procedures are widely promulgated to confirm that personnel across all agencies are aware of, and have ready access to, current operational procedures and preparedness for the coming bushfire season • review the content of pre-season briefings so that the content is appropriate to the needs of each target audience. This requires targeting operational content to the needs of response personnel to clarify intent

Tasmania Fire Service Page 24 Review of operations during the 2015–16 bushfires • refine the multi-agency State Fire Action Plan to address preparedness and support needs, including trigger points for interstate/international surge capacity • include in preparedness the need for communications and information technology expertise to be available as part of the surge capacity • investigate existing individual agency preparedness kits and identify gaps where pre-prepared multi-agency kits would be advantageous (e.g. establishing Staging Areas) • evaluate the degree to which the existing design of regional Incident Control Centres as well as the State Fire Operations Centre are suitable to meet operational demands • identify roles and/or functions where Business Executive Services (BES) of DPFEM could provide incident management support at all levels.

Tasmania Fire Service Page 25 Review of operations during the 2015–16 bushfires 6.2 Review of state incident management and arrangements

Context 6.2.1 The following comments were reported in debriefs indicating elements that would be important to sustain. Feedback in the survey highlighted the effective use the campaign made of Australasian Inter-service Incident Management System (AIIMS).

The AIIMS structure was an effective tool used to manage the incidents. This facilitated the use of interstate assistance which was seamless in the integration into local teams.

In addition, support from the state level to the local level was appreciated. Comments included:

Gavin's visibility, transparency, and leadership throughout the season is to be highly commended; the working relationships between agencies, states and countries was impressive to see and be a part of, and the learning opportunities I had with interstate colleagues were invaluable I think SFOC is really well done, just need to sort the rest of the incident management structure (state). Our liaison is much improved and stakeholder engagement was well done. We didn't have any serious injuries, that is a major achievement

6.2.2 The feedback provided through debriefs also identified a number of areas that need to be improved. Debriefs identified confusion about the respective roles and functions of the state, regional (SFOC/RFOC) and local Level 3 IMTs and how they interconnect resulting in ambiguity of responsibilities. There is a need to evaluate the current incident management arrangements and framework to ensure the best fit in relation to future incidents of this complexity and scale. A review of current arrangements and subsequent recommendations should be finalised as a matter of priority. 6.2.3 Furthermore, the current practice of IMTs managing a ‘complex’ of incidents needs to be reviewed for its appropriateness. If considered a suitable strategy, it must be applied consistently across regions. In addition, the feedback at debriefs revealed inconsistencies in the establishment and functions of Staging Areas. These too need to be consistent across regions. The development of a State Fire Action Plan should provide the guidance if it includes the development of clear multi-agency operational procedures, resource requirements for complex incidents, suitable Incident Control Centres and Staging Area facilities and, wherever possible, the use of common terminology aligned to the AIIMS glossary. Staging Area management and appropriate resourcing is seen as critical if the agencies continue the ‘complex’ model.

6.2.4 To ensure consistency in resourcing and communication, the agencies would benefit from the development of a Tasmanian ‘trigger points’ support tool that assists with the decision-making process for intra/interstate deployments. While this improvement will help with escalation, there is also a need to review procedures associated with de-escalation and demobilisation of all levels of incident management.

Tasmania Fire Service Page 26 Review of operations during the 2015–16 bushfires 6.2.5 Feedback from the debriefings indicated that at times personnel received limited induction and/or briefings from incoming and/or outgoing fire crews as well as for incident management personnel. In addition, personnel involved in the state briefings commented that they were too long. A standardised procedure for inductions, briefings and handovers needs to be developed to help improve situational awareness and communication across all levels of incident management. In addition, when intra or interstate teams arrive, there needs to be someone within the IMT who can provide briefings and liaison, removing the load from existing Incident Management personnel.

6.2.6 Comments from debriefs and individual personnel indicate the possible need for improving the responsible agencies’ current procedures relating to state bushfire overview. Each agency has personnel undertaking similar roles and functions over the bushfire season, specifically monitoring bushfire activity and coordinating response. A multi-agency approach to a ‘State Duty Officer’ should be investigated and options considered on how efficiencies could be improved.

Recommendation 2

That as a matter of priority, responsible agencies review state fire incident management processes and arrangements including: • the roles and functions within and between state and regional fire operations, particularly the role of Regional Fire Operations Centres in Level 3 incidents • the reporting relationships between state, regional and Level 3 Incident Management Teams (IMTs) • investigate the viability of a multi-agency statewide duty roster • the appropriateness of IMT managing fire complexes and, if needed, identifying the resourcing requirements for this to be a suitable approach to management • arrangements for establishing Staging Areas, including their resourcing requirements, maintenance and demobilisation • standardising procedures and systems to ensure consistency across regions and agencies, including terminology used • developing ‘trigger points' for intra/interstate resource deployments, including standardised inductions, briefings and shift rotations • developing ‘trigger points’ for the establishment of split and/or 24-hour IMT shifts • developing procedures for escalation, de-escalation and demobilisation of all levels of incident management.

Tasmania Fire Service Page 27 Review of operations during the 2015–16 bushfires 6.3 Capacity and capability

Context 6.3.1 Any jurisdiction in Australasia would have found a campaign of this nature and duration challenging. The assistance received by interstate and international personnel was well received, and the level of effort and goodwill needs to be acknowledged. The ways in which people worked together and extended limited capacity were well done. The following are some of the comments identified in the survey: In a challenging year, a real effort was made to split scarce resources, and to attempt to minimise fatigue in crews. Fantastic support from interstate experienced staff and volunteers. The IMT was a friendly, helpful environment in which I felt comfortable and accepted. I could ask questions and get good answers and learnings. I was well looked after and respected by a great, professional and competent bunch of people. I enjoyed my time there very much.

6.3.2 However, given the likelihood that Tasmania will face these conditions again and, based on feedback from debriefs, it is important to identify opportunities to enhance multi-agency Level 3 coordination and response with particular reference to incident management capacity and capability. A campaign of this nature soon exhausts the availability of capable personnel. In addition, feedback at debriefs identified challenges associated with existing agency personnel registers that were not up to date in terms of currency of roles, and that accessing suitable personnel for tasks was difficult because multi-skilled personnel had been engaged in another area of skill. Following on from the recommendations in Section 6.1—Preparedness, once minimum numbers of functional roles are established, a multi-agency gap analysis between existing personnel available and functional requirements needs to be undertaken.

This multi-agency gap analysis identifying primary functional or unit roles should be undertaken as a matter of priority to enable the completion of a statewide capacity and capability statement and database that identifies functional areas requiring further pathway development.

6.3.3 In identifying capability, it is also important that a skills audit of the State’s volunteer workforce be conducted. It is also an opportunity to canvas those volunteers who may have an interest in further development opportunities. Survey feedback from volunteers suggested they felt their potential skill base was not maximised and that volunteer development opportunities need to be aligned with interstate agencies. The following comments from the survey illustrate the perspectives of many of the volunteers who took the time to complete the survey.

One local [name of] brigade were asked to attend but not expected by those in charge when they arrived. The volunteers said they felt like the kid at school who is last picked for the footy team when no one knew what to do with them. When your brigade is requested, you volunteer time, turn up for briefing and drive around all day because the hierarchy can't make their mind up where they want you it doesn't do much for morale. It is understood that these were complex incidents but this mustn't happen.

Tasmania Fire Service Page 28 Review of operations during the 2015–16 bushfires 6.3.4 Based on responses there are opportunities to develop volunteer personnel in areas other than traditional first response roles, including air operations, Staging Area management and IMT roles. In addition, a number of female personnel commented that they believe they could make a more substantial contribution if given the opportunity. The Review recommends that a strategy to increase capability include options for diversifying incident response personnel. This should include an investigation of any perceived and/or existing barriers to developing capability so that these may be overcome.

6.3.5 Capacity to be engaged and to make a full contribution to one’s organisation is also predicated on acceptance of diversity and opportunities for all people to be able to contribute to their full potential. The survey collected information on whether people had either witnessed or experienced discrimination. The comments show that some personnel feel that they or others have been subject to abuse including sexism, racism and differences in attitudes towards volunteers. It is important that every opportunity is taken to affirm the professional codes of conduct of the agencies as well as for agencies to ensure they have in place the appropriate means by which such experiences or concerns can be confidentially reported and followed up.

6.3.6 The location and remoteness of many fires during 2015–16 has attracted considerable discussion on existing and future firefighting capabilities required for remote area firefighting. While Tasmania maintains a capability, the majority of interstate and international requests during the 2015–16 campaign were for personnel able to fight fires in remote locations, including winching operations from aircraft.

6.3.7 It should be noted that, while the interstate deployments were very helpful, there were difficulties associated with inconsistent skill levels, including fitness, within these deployments.

6.3.8 While outside the scope of this Review, the review team suggest that responsible agencies recommend to AFAC that jurisdictions assist in developing guidelines to ensure a nationally consistent approach is adopted in relation to terminology, training and fitness requirements for remote area firefighting. This would help reduce the confusion experienced by the agencies, at all levels of incident management, and external stakeholders.

6.3.9 It is recognised that PWS has the responsibility for fire management on reserved land that includes most of the remote areas in Tasmania, however Tasmanian agencies should jointly consider options for increasing the state’s capacity and capability in this specialised area of firefighting, including the various ‘levels’ associated with remote area firefighters.

6.3.10 While a number of agencies have accredited tree fellers, it was identified that there were varying levels of skill and competency requirements for tree felling accreditation across Tasmanian and interstate agencies. At times this created issues when assigned tree felling could not be undertaken to the level required, resulting in more suitably skilled tree fellers needing to be re-deployed or taken away from their current role in order to complete the task to ensure a safe working environment. This is also acknowledged in 6.8.5—Safety and is seen as a significant risk to the responsible agencies.

Tasmania Fire Service Page 29 Review of operations during the 2015–16 bushfires 6.3.11 Operational training has contributed significantly in the development of personnel. Feedback from the online survey indicated that personnel – particularly those on the fireground – felt that their training served them well. However, the Review also received considerable feedback about improvements that were needed in training. From the feedback provided, it is difficult to point to any one area; responses ranged from a need to review the mentoring process; personnel undertaking roles without any formal qualification or development; limited opportunities for pre-season and or skills maintenance in general; and people undertaking roles where they were perceived as not having the skills and knowledge required. A review of training and skills maintenance should be undertaken as a matter of priority and it needs to identify any blockages relating to multi-agency operational development. This should be considered in conjunction with 6.3.2 as well as proposed skills maintenance for roles such as RATs – see 6.1.7.

6.3.12 The Review received considerable comment about challenges associated with setting what were perceived as unachievable incident management objectives, which also then had consequences for subsequent strategies that were developed and implemented. To effectively manage bushfires and other large emergency incidents, the agencies operate using the nationally recognised AIIMS. The principles that underpin AIIMS are Flexibility, Management by Objectives, Functional Management, Unity of Command and Span of Control. However, feedback suggested these principles were, at times, not appropriately applied and that exercising needs to be undertaken to help ensure incident management teams can consistently apply these principles. In addition, strategies of escalation need to be exercised at all incident management and operational levels to ensure that span of control is not exceeded, particularly in critical aspects of developing an IAP, and that functional units (e.g. Planning and Operations) exercise coordinating their activities to achieve integrated outcomes.

6.3.13 The development of a series of pocket books or aide-memoires for operational personnel, such as those that interstate agencies use, would also enhance capacity and capability. The review team recommend, as a matter of priority, conducting an audit of existing individual agency aide-memoires with a view to developing multi-agency versions for Tasmanian-specific contexts. These will assist with a number of the recommendations contained in this report.

6.3.14 Finally, communications and information technology expertise needs to be identified in the preparedness planning and that capacity be available as part of the surge requirements.

Recommendation 3

That responsible agencies review the adequacy of the State’s capacity and capability during emergency bushfire incidents, including: • finalising a statewide capacity and capability register and subsequent framework that includes areas targeted for future development • conducting a gap analysis against minimum functional requirements, as well as a skills audit across all agencies including the volunteer (TFS and SES) workforce, to identify opportunities to increase capability to address gaps • revising strategies to increase the State’s remote area firefighting capacity, including the potential development of the volunteer workforce • ensuring one agency has primary responsibility for further developing Tasmania’s remote area firefighting capability

Tasmania Fire Service Page 30 Review of operations during the 2015–16 bushfires • identifying opportunities for cross regional and/or jurisdictional development, including an increase in exercise regimes • reviewing current mentoring processes to ensure opportunities are identified and formalised • recommending to AFAC that AFAC develop guidelines to ensure a nationally consistent approach be adopted in relation to terminology, training and fitness requirements for remote area firefighting • providing additional exercising in areas of incident management, including the principles relating to management by objectives • auditing individual agency operational pocket books or aide-memoires and developing multi-agency toolkits for Tasmanian-specific contexts. This may include adapting AFAC aide-memoires or those of other agencies • reviewing the tree felling accreditation and competency maintenance requirements of each agency to provide a comparison and understanding of the variations in skill level and competency requirements • reviewing the processes agencies have in place to confidentially report on discrimination or harassment are working. This may include an investigation into any potential blockages (cultural or otherwise) to affected persons speaking up.

Tasmania Fire Service Page 31 Review of operations during the 2015–16 bushfires 6.4 Planning and Incident Action Plans

Context 6.4.1 While there are many aspects that need to be improved in planning, and in developing and disseminating Incident Action Plans (IAPs), it is also important to acknowledge the considerable effort in producing them and their penetration. In the online survey, of the 1,106 people who responded, most received an IAP (n=608 or 62.5%); for 143 people (14.7%) this was reported as not applicable. When filtered to include those people reporting that they were working in an operational role, this rose to 65.8% (n=456). In addition, comments in the survey acknowledged the effort IMTs in each region provided to ensure planning was effective. For example:

North West IMT did an excellent job of preparing their plans for the night when the wuthering heights fire took off and TFS had to evacuate the town. They provided telephone numbers of residents. When a dozer cut the phone lines I was able to call residents mobiles to check they received emergency warning and were safe on the beach. Lots of detail on their planning and was the most well prepared plan I have seen during the whole fire season.

6.4.2 The online survey, face-to-face debriefs and interviews, indicated a need to improve existing processes and systems for the development, quality assurance and dissemination of Incident Action Plans (IAPs). There were repeated comments made that IAPs have become too large and complex and that this makes them unfit for their original purpose, which was to provide incident objectives enabling response activities at the tactical level. There were repeated concerns, in the face-to-face debriefs especially, that the existing approach can leave the IAP with out-of-date, incorrect, irrelevant and/or incomplete information. A number of people reported that the lack of credibility of the IAP for frontline personnel has on occasion resulted in the practice of ignoring the directives in the IAP. This results in instances where fireground operations were not aligned with IMT objectives and strategies. This presents a significant risk to the agencies in terms of command, control and coordination and should be addressed as a matter of priority. 6.4.3 The review team acknowledge the concerns expressed at the SFOC debrief that the information contained in the IAP, while cumbersome, is important should a safety incident occur because this is when the additional information contained in the IAP will be needed. The SFOC debrief also noted the importance of a comprehensive IAP being able to provide evidence to any subsequent inquiry that front line personnel had received the required information. Nevertheless, the review team conclude that, given the importance of the IAP and the substantially different views on the value of its current format that a review of this document is warranted.

6.4.4 Multi-agency IAP templates need to be aligned and version-controlled to ensure only one multi-agency template is in use. The components within the IAP also needs to be reviewed so that incident management information and arrangements are targeted to particular levels to ensure both relevance and accessibility to all parties from the fireground to SFOC. These templates also need to be standardised across regions. Furthermore, alternatives to disseminating paper copies need to be explored and options developed that value-add and streamline current processes (in conjunction with 6.2.3).

Tasmania Fire Service Page 32 Review of operations during the 2015–16 bushfires 6.4.5 The current difficulties of not maintaining a 24-hour or split-shift Level 3 IMT/s due to a lack of capacity is also seen as contributing to the issues relating to IAPs and their accuracy. The recommendations included in other parts of this document, to identify trigger points for the establishment of split and/or 24-hour IMT or specific functional areas when resources are available, may assist in the timely development of IAPs (refer 6.3.12 and 6.5.6).

6.4.6 There was also considerable feedback, both in the survey as well as in the face- to-face debriefs suggesting that incident management teams may, at times, not be operating as an integrated unit; in particular, comments relating to communication disconnects between the functional units of Operations and Planning.

Recommendation 4

That as a matter of priority responsible agencies review the current process and systems for the development of Incident Action Plans (IAPs) including options for dissemination with the aim of introducing a more streamlined IAP that is both fit for purpose and meets compliance obligations. This includes: • investigating options to ensure that current information is provided in compliance with quality assurance systems and fit for purpose at all levels from the fireground to the SFOC • all agency partners adopting one IAP template to be implemented across all agencies and regions • investigating the levels of resourcing required within the Planning Function to ensure that IAPs can be prepared in time and that appropriate span of control is maintained • investigating options and trigger points for the implementation of 24-hour or split- shift Incident Management Teams (IMTs) or Functions to ensure the production of appropriate and timely IAPs • investigating why communication and information flow between the Operations and Planning Sections continue to break down, so that these critical coordination points can be reviewed and included in subsequent exercising to improve integration.

Tasmania Fire Service Page 33 Review of operations during the 2015–16 bushfires 6.5 Resourcing and resource-tracking

Context 6.5.1 It is important to acknowledge the challenges associated with resourcing and coordinating an effort of this scale. While it was not always the case, there were a number of comments made in the survey that indicate personnel felt their needs were being heard and addressed. The following include some positive comments identified in the survey that indicate practices important to sustain:

Calls on resources were heard and acted upon. Food/Meals were of a higher quality this fire season. Better rehydration options available also good vehicle preventative maintenance done daily. I thought interstate crews worked really well together under trying circumstances. The IC's were knowledgeable, professional, supportive and approachable. The IC never left until the last person (usually me) left the day. This support made all the difference. The food was great. Particularly pleased that we were able to donate excess food to the City Mission on one occasion - that arrangement should be formalised. Working on shift with interstate personnel was very interesting. The staging area managers worked there butts off and need more assistance on location at the incident witnessed firsthand.

6.5.2 The Review also identified a number of processes and systems being used across agencies and regions that need to be improved. These related to how requests were managed and how resources were allocated and tracked – personnel, heavy machinery, small equipment, aircraft etc. These were reported to have created inconsistencies across the state and is likely to have contributed to information discrepancies within the content of IAPs and to breakdowns in overall incident communication. More significant is the differences in practice for tracking personnel on the fireground; for example, T-cards removed despite there still being personnel who had not yet returned to the Staging Area. The following quotation is included from the survey data because of its significance: On the day of the [name of accident] my crews’ T card had been removed before we returned to the staging area due to a [agency] sector commander stating that we had left the fireground. We hadn't left the fireground. We were stuck at the [accident] with no phone reception and limited radio (we could have been in an accident ourselves in this area and no one would have known we were even missing).

6.5.3 ‘T Cards’ are currently the primary means of collecting resource information in relation to personnel and equipment logged onto the fireground at Level 3 incidents. Information includes the location of resources and relevant personal information i.e. dietary requirements etc. Responses indicate that T Card information was being collected, collated and recorded inconsistently across the state, including information summarised on whiteboards being photographed for sending to IMTs. T Cards are also used by agencies for different purposes and this will need to be considered and factored into any multi-agency resource tracking improvements. It is strongly recommended that, in conjunction with 6.2.3, the agencies ensure a consistent means of logging and recording resources on the fireground and that this be adopted statewide as a matter of priority.

Tasmania Fire Service Page 34 Review of operations during the 2015–16 bushfires 6.5.4 IRMS is currently the primary multi-agency database used for the collection, recording and reporting of incident information including resources, finance and equipment. Responses indicate that IRMS requires a comprehensive review in relation to the current data collection and reporting methods to ensure the system will continue to meet the needs of agencies, particularly at Level 3 incidents. In addition, it is recommended that the agencies investigate areas of workload duplication across agencies so that strategies can be put in place to reduce this, both during and post incidents.

6.5.5 Furthermore, responses indicate that IMTs had difficulties associated with tracking ‘small gear’ on both fire appliances and additional equipment allocated to the incident from regions and/or IMTs. This resulted in agencies not being able to track and/or account for some equipment and limited accountability. The recommendation suggests agencies identify options for resource allocation and accountabilities, over and above equipment carried on fire appliances, during and post incident.

6.5.6 Considerable comment was received about closing IMTs overnight (see 6.4.5) and the effect this had across agencies, particularly FireComm, given the scale of response. After-hour issues outside of incident management oversight were being redirected to FireComm, including resource tracking and accommodation arrangements. Strategies for managing after hours needs and trigger points for establishing either split shifts or 24 hours IMTs should be considered in conjunction with Recommendation 4, in order to address these issues.

Recommendation 5

That responsible agencies review the current procedures and systems for all procurement, resource allocation, tasking and tracking, including: • reviewing the process and systems to support resource requests, especially triggers for expediting inter/intrastate requests • reviewing data collection and recording processes to ensure appropriate logging and tracking of resources to (a) remove duplication of workload as well as duplication of workload requests (b) developing a consistent approach across regions and agencies as a matter of priority • reviewing the use of ‘T Cards’ as a resource-tracking tool on the fireground.

Tasmania Fire Service Page 35 Review of operations during the 2015–16 bushfires 6.6 Communication

Context 6.6.1 In this context ‘communication’ refers to the overall need for information-sharing and maintaining situational awareness at all levels of incident management.

6.6.2 Additionally the survey identified:

• most people (830 or 84.2%) answered ‘yes’ when asked if they knew to whom they were to report. This was consistent across the regions • most people (847 or 82.9%) answered ‘yes’ when asked if they received a briefing. When filtered to include just those people who reported working in an operational role, this rose to 88% (n=614). • people who were working at different levels all reported satisfaction with the quality of the briefings provided (responses range between 5.1 and 6.3 on average). However, there are significant differences reported in levels of satisfaction with the quality of the briefing between those on the fireground and those working at state level. 6.6.3 The Review identified varying degrees of satisfaction with briefings, inductions and handovers. This ranged from excellent to suggested areas for improvement where personnel did not receive any formalised briefing, induction and/or handover. This is seen as a potential safety risk to the agencies and standardised procedures and documentation needs to be develop as a matter of priority. 6.6.4 Communication from the fireground through to the state level is seen as pivotal in achieving command intent and subsequent operational objectives. The Review highlighted several areas where a breakdown in communication contributed to issues relating to the development of IAPs (See 6.4—Planning and Incident Action Plans) and overall situational awareness, particularly at the fireground to IMT level (see 6.2.5). The Review recommends that the agencies identify opportunities for communication to be improved and procedures developed that ensure potential for communication breakdowns are mitigated as much as possible, including the future use of WebEOC for its relevance and practicality.

6.6.5 In addition, several stakeholder groups suggested there would be benefits from being kept informed of resource deployments (for example, Engineering Services and TFS volunteer groups). Therefore, SFOC, RFOCs and IMTs should develop and/or maintain systems that support distributed situational awareness through information-sharing with all internal stakeholders, particularly in relation to resource deployments and ongoing operational requirements.

Recommendation 6

That, as a matter of priority, responsible agencies investigate options for improving overall communication between all levels of incident management, including from the fireground to Incident Management Teams (IMTs). This may also include the subsequent relationships/links between operations and strategic planning within IMTs.

Tasmania Fire Service Page 36 Review of operations during the 2015–16 bushfires 6.7 Air operations

Context 6.7.1 Over the past three bushfire seasons, Tasmania has had five National Aerial Firefighting Centre (NAFC) contracted aircraft available. Two additional fixed-wing firebombing aircraft were contracted over 2015–16. A ‘call when needed’ system is also maintained with predominately local aircraft companies.

6.7.2 Air operations played a significant role during 2015–16. The location and remoteness of fires dictated methods of response, including remote area crew insertion, as a number of fires were not accessible by any other means. In addition to the traditional rotary and smaller fixed-wing aircraft response, three Large Air Tankers (LAT) and one Very Large Air Tanker (VLAT) were available based out of Avalon, Victoria. At times 47 firefighting aircraft were operating in Tasmania.

6.7.3 The following comments were reported in debriefs, indicating the elements it would be important to sustain: During my 5 day shift, witnessed the State Air Ops team transition from a reactive situation to a more proactive and structured system approach in managing air operations. Use of aerial appliances very valuable tool this year – their experience was excellent.

6.7.4 The efforts of those involved in air operations is acknowledged. Also identified in the Review was the complexity involved in managing and coordinating an effort this large, and a number of aspects of the air operations that could be improved. The agencies’ air operations would be enhanced from an increase in capacity and capability (see also 6.1.7 and 6.3.4).

6.7.5 Feedback through debriefs also identified a number of safety concerns with air operations. These include personnel undertaking air operations roles without nationally recognised qualifications; times when there were insufficient resources available to safely coordinate the number of aircraft operating; and congested lines of air-ground communication because of other users on the same frequency. It is acknowledged that the increased number of aircraft had an impact on longer- term capacity; however, the agencies must identify options and develop a strategic plan that provides a clear future direction for Tasmania’s air operations capabilities (this links to and could be undertaken with 6.3—Capacity and capability.

6.7.6 The agencies have had limited exposure to certain types of aircraft and their individual capabilities and limitations, particularly VLAT, LAT, aircraft that use Forward Looking Infra-Red cameras (FLIR) and generally firefighting aircraft not seen in Tasmania previously. Feedback from debriefs suggests that this resulted in some aircraft being inappropriately deployed, and on occasion undertaking tasks that were not ‘fit for purpose’. This reduced aircraft efficiency and effectiveness in some instances. The agencies should identify options and implement strategies that increase overall awareness of aircraft and their operational capabilities, in conjunction with 6.12.3.

Tasmania Fire Service Page 37 Review of operations during the 2015–16 bushfires 6.7.7 In addition, to ensure aircraft effectiveness can be measured, procedures and systems should be developed that support an evaluation of daily aircraft operations. This would assist with aircraft being tasked for best ‘fit for purpose’ and ensure aircraft are being used in the most efficient and cost-effective way possible.

6.7.8 The use of fire chemicals in firebombing operations is becoming more frequent in Tasmania, and they were used during the 2014–15 and 2015–16 bushfire seasons. This has resulted in the use of fire chemicals that some fireground personnel may not have experienced before. Responses have indicated a need to increase operational personnel awareness of fire chemicals, particularly from firebombing aircraft, and any associated hazards on the fireground. In the event that agencies consider ongoing aircraft fire chemical use, options to increase fireground awareness should be identified and progressively implemented before and after the 2016–17 bushfire season.

6.7.9 Furthermore, comments received indicated frustrations with the approval process required for chemical use, particularly in the Tasmanian Wilderness World Heritage Area (TWWHA). The TWWHA is acknowledged as one of the last true wilderness regions on earth and encompasses a greater range of natural and cultural values than any other region on earth. As such, all care must be exercised with any suppression activity undertaken. The agencies need to identify and develop options for streamlining the authorisation process if fire chemicals are to be considered as an option in this type of environment.

6.7.10 The capacity for aircraft and air operations to communicate is critical, particularly considering the hazardous environment aircraft operate and the requirement for flight following and additional factors associated with controlled airspace. Wherever possible, the coordination between ground and air operations is predominantly through radio communication requiring dedicated radio channels. However, based on the number of resources and complexities, operations had difficulty maintaining contact with aircraft at all times. Options for ensuring dedicated air operations radio channels for complex and/or increased resourcing of these types of incidents should be developed as a matter of priority. 6.7.11 Air operations have become increasingly more regulated as well as more complex. An increase in the number and type of aircraft operated nationally and nationally consistent qualifications has contributed to the complexities. This area of operations requires far greater oversight in relation to increasing Tasmania’s overall capacity and capability; for example, oversight of current contractual and ‘call when needed’ arrangements and statewide coordination of air operations during Level 3 incidents. Feedback from debriefs indicates that a review of current state and regional air operations arrangements is required, which would aim to identify options and make recommendations as a matter of priority to enable a robust Tasmanian air operations structure for the future.

6.7.12 With the increase in aircraft numbers and the establishment of a dedicated airbase, there was confusion at times for IMTs and the fireground about the structure and reporting lines for aircraft management. At times, aircraft were removed from the fireground without the prior knowledge of fireground personnel, or arrived on site as well as arriving over the fireground for air attack without prior notice. At times it was felt by the fireground that aircraft could have provided greater effect if communication regarding deployment and location of water drops involved Sector Commanders on the fireground. In addition, some were concerned about safety for both air traffic as well as for those on the fireground who may inadvertently have been “bombed”.

Tasmania Fire Service Page 38 Review of operations during the 2015–16 bushfires Recommendation 7

That responsible agencies review the current management of air operations within the Tasmanian framework, including: • identifying options for increasing capacity and capability, including the development of the TFS and SES volunteer workforce in support roles, and ensuring a nationally consistent approach is adopted in relation to the development of skills and qualifications in these roles • increasing the knowledge of aircraft capabilities and limitations to inform operational decision-making as well as to inform government, stakeholders and the community • reviewing the process and subsequent authorisation of aircraft for strategic and tactical deployment and to ensure aircraft use is a ‘best fit for purpose’ • reviewing the process and subsequent authorisation for fire chemical use, including operational awareness of fire chemicals • developing processes and systems that support the evaluation of the effectiveness of aerial firefighting • reviewing existing ground-to-air communication practices, to ensure wherever possible air operations has a dedicated communications channel • reviewing procedures for the deployment and operation of aircraft at the state and regional level – including a review of the current dedicated air-desk procedures, flight following and engagement of ‘call when needed’ aircraft • reviewing the reporting structure and lines of communication for aircraft management to ensure tasking of aircraft is appropriate, efficient and safe.

Tasmania Fire Service Page 39 Review of operations during the 2015–16 bushfires 6.8 Safety

Context 6.8.1 The subject of fatigue management within TFS is being considered as part of an independent review, so fatigue management has not been discussed in depth. However, fatigue was a consistent theme and safety concern throughout the Review, particularly during face-to-face debriefs. There may be an opportunity for the agencies to review individual agency policy and consider options for a shared fatigue management policy during incident management.

6.8.2 While there were a number of safety issues identified, as well as near misses and accidents that raise issues that need to addressed, it is important to acknowledge that the majority of people who provided feedback on safety during the campaign said they felt safe. Furthermore, 80.2% of people who completed the online survey reported they were aware of the formal processes available to address potential safety issues. These results indicate that safety processes are well embedded across all levels of incident management.

6.8.3 Safety Advisors provided an important function at all levels of incident management, providing critical information and advice relating to a range of safety policy and accident/near miss trends. The Review has highlighted a need to clearly review and reinforce safety roles at the strategic and tactical level. In addition, there were occasions where safety advisors were not embedded within strategic teams. This is seen as a considerable risk to the agencies, and strategies must be developed that ensure Safety Advisor roles and functions are considered in any review of incident management arrangements.

6.8.4 The majority of responses related to safety processes and systems. However, there was considerable commentary on working around hazards and unfamiliar vegetation types. Hazardous trees and working in tall timber environments were common concerns, which present a risk to the agencies. It is acknowledged that there are individual agency policies and procedures around this, however it is recommended that a multi-agency strategy is developed as a matter of priority to improve awareness mitigation options and fireground safety, particularly in relation to hazardous trees. 6.8.5 The varying levels of skill and competency requirements for tree felling accreditation across Tasmanian and interstate agencies created safety issues and is seen as a significant risk to the responsible agencies (see detail in 6.3.9).

6.8.6 The Review has identified an opportunity for the agencies to develop standardised processes and systems. This is particularly important given the need to report accident/near misses and any subsequent investigations involving multiple agencies and levels of incident management.

6.8.7 The feedback provided in the survey indicates that the tool used to record decisions and significant issues (the ‘red log book’) is not being widely applied and its use across agencies is uneven. To maximise the value of this tool its use needs to be reviewed so that it is better utilised. There may be an opportunity to collaborate with the Bushfire and Natural Hazards CRC on improving and trialling an improved tool of this nature.

Tasmania Fire Service Page 40 Review of operations during the 2015–16 bushfires 6.8.8 While there is not much data received relating to an accident that occurred involving a heavy tanker rollover and interstate crews during the Review, it is noted. This incident was managed effectively at the state level involving relevant stakeholders and the Interstate International Liaison Unit (IILU). However, the agencies should review and/or develop procedures to ensure incident management personnel are equipped to provide critical incident management at the regional and/or IMT levels.

6.8.9 Paramedics were deployed to several Staging Areas to support on ground firefighting teams with reported good results and, as the following comment in the survey indicates, this support was well received and is an aspect that would be valuable to sustain:

Embedding Advanced Paramedics with the Strike Teams enhanced firefighter safety was a great resource.

Recommendation 8

That responsible agencies review a range of practices associated with safety, including: • reviewing and reinforcing the safety roles at the strategic and tactical level in Tasmanian responses • reviewing and/or developing processes and systems to identify and mitigate hazardous trees, including working within hazardous and tall timber environments • investigating accidents/near misses and communicating outcomes in a timely manner • developing standardised documentation and procedures that allow for the timely reporting, recording and investigation of accident/near misses • reviewing and/or developing procedures that support incident management personnel in the event of accidents/injures and/or fatalities • considering procedures and ‘trigger points’ for the deployment of medical support to Staging Areas.

Tasmania Fire Service Page 41 Review of operations during the 2015–16 bushfires 6.9 Interoperability

Context 6.9.1 Emergency Management (EM) in Tasmania compares favourably with other states in terms of its capacity to work together during times of community need. The Interagency Fire Management Protocol TFS, PWS and FT continues to be reviewed and improved. In addition, the strategies developed following the ‘Hyde Report’ have continued to develop ‘interoperability arrangements’ with key EM partners and stakeholders, including whole-of-government interoperability arrangements. The positive appreciation of the ways in which agencies in Tasmania work together was a common theme identified in the feedback. The following are some of the comments received:

Co-operation between all agencies was excellent. Team members were willing to share their experience and tools for the benefit of everyone. Interoperability was great. Interstate deployments were great, however there were some discrepancies on the ground. Proud of everyone's tireless efforts. Level of professionalism between all agencies done well. The interagency cooperation, not only among the fire response agencies but from others who attended through interoperability arrangements was done very well. Everybody (Tas or interstate) who arrived at IMT to work was received and respected for their knowledge and skill. We do this well. The multi-agency model within Tasmania is a great model and works well. The strong inter agency relationships with other agencies from across the country and New Zealand that enable a willingness to assist.

6.9.2 It is clear from the extensiveness of the positive commentary on interoperability in Tasmania that this is a real strength. That said, there are still aspects that can be improved.

6.9.3 Comments and responses from debriefs have identified a need to reaffirm the authority levels, roles and functions of both the MAC and Inter Agency Training Committee (IATC). This should be done to ensure the agencies continue to be relevant in an operational context and from a multi-agency capacity and capability coordination perspective.

6.9.4 The ‘Tasmanian Interoperability Register’ was activated for the first time during the 2015–16 bushfire season. Responses at all levels of incident management have been very positive about the assistance provided. Indeed, access to the skills that personnel possessed created a demand for their services, and there were comments relating to skills levels and benefits associated with ‘getting the same people back’. The agencies would benefit from identifying additional roles required and provide training to interested personnel (see Section 6.3 —Capacity and capability). In addition, consideration should be given to including these personnel during pre-season briefings and exercises (see 6.1.3).

6.9.5 Interstate and international help was greatly appreciated at all levels and received overwhelming support. In addition, interstate personnel were extremely positive in relation to their experiences and how they were supported during their deployment. It is important that interoperability arrangements and relationships continue to be developed and fostered nationally. Therefore, opportunities for cross-jurisdictional exercising, mentoring and training should continue to be encouraged and actively pursued (see also Section 6.3 —Capacity and capability).

Tasmania Fire Service Page 42 Review of operations during the 2015–16 bushfires 6.9.6 People reported it was difficult to access IT platforms and systems. While this should be reviewed in more detail (see 6.11) in terms of supporting interoperability, the agencies should review current IT processes ensuring there is improved capacity for personnel from different agencies and/or interstate jurisdictions to access IT at all levels of incident management.

Recommendation 9

That responsible agencies continue to promote and develop current interoperability arrangements, including: • reviewing the functions and authority level of MAC and the Inter Agency Training Committee (IATC) • reviewing the integration and coordination of emergency training between the IATC member agencies • increasing whole-of-government participation, particularly the current interoperability arrangements and ensuring opportunities are provided for ongoing training and exercise participation.

Tasmania Fire Service Page 43 Review of operations during the 2015–16 bushfires 6.10 Local knowledge

Context 6.10.1 The inclusion of local knowledge at emergency incidents was raised as a recommendation following the 2012–13 bushfire season and the subsequent ‘Hyde Report’. It is acknowledged that the agencies, wherever possible, have undertaken to increase local knowledge content within incident management since 2013 and that there have been continued gains in this regard, as indicated by the following comments: Everyone worked together astonishingly well given the breadth of agencies, experience, culture and local knowledge. Petty issues were mostly ignored or irrelevant. The local community was very supportive as were volunteers. The parks staff at Arthur River worked exceptionally long hours without days off because their knowledge of local area was needed. They didn’t complain and got the job done.

6.10.2 However, the review process has indicated additional work is required to ensure local knowledge is included within identified levels of incident management and forms part of the intelligence-gathering function. In addition, local knowledge may improve the process of local stakeholder engagement and/or consultation, assisting with overall incident communication.

6.10.3 In addition, review results point to a need to ensure local knowledge is maintained especially where interstate/international IMTs are engaged. Face-to-face debriefs with interstate and Tasmanian IMTs indicated that functional IMT positions were filled by personnel who did not necessarily have the depth of knowledge required for Tasmanian conditions. This created issues in relation to ongoing rotations and the time required to adjust, including familiarising with the agencies’ processes and systems. The review team believe 6.1.4 would also assist with improved local knowledge and integrated IMTs.

6.10.4 There is a need to clarify the role that local knowledge plays both on the fireground and in the IMT. The feedback contained in the survey suggests that many see ‘local knowledge’ as an abbreviation for direct engagement in operational decision-making, and this may not necessarily be the case. To clarify expectations on the part of both providers and seekers of local knowledge, it is proposed that TFS develop a protocol of what is expected by someone providing local knowledge. It is suggested that the embedding of local knowledge be viewed as an advisory role.

Recommendation 10

That responsible agencies: • continue to improve the process for ensuring that local knowledge is accessed at all levels of incident management • ensure that local knowledge is included in any future inter/intra-state fireground operations and Incident Management Teams • develop a protocol outlining what ‘accessing local knowledge’ entails to clarify expectations of local personnel.

Tasmania Fire Service Page 44 Review of operations during the 2015–16 bushfires 6.11 Communication systems and information technology

Context 6.11.1 Communication systems and information technology (IT) support almost every aspect of emergency response and incident management, providing the mechanisms for information-sharing and subsequent decision-making at all levels of incident management. The agencies were well supported by personnel from both areas who met difficult requests in the majority of circumstances. The following comments illustrate the appreciation of those involved: The Common Operating Platform (situational awareness) proved to be a really great tool for sharing incident data. Information from the fireground, rapid impact assessments, mud maps and way points were shared easily across agencies and within the management team. The TFS website again proved to be an excellent tool for keeping up to date on big picture issues, continuing to provide relevant information to communities and stakeholders over an extended campaign.

6.11.2 However, it is evident that communications can be improved with the help of additional expert advice and support in relation to preparedness planning and during incident management. At times, communication systems on the fireground and to incident management were problematic. This resulted in messages and information not being received by IMTs which affected, for example, intelligence gathering, situation reporting and subsequent IAP development. It must be acknowledged that information from the fireground is pivotal for decision-making at all levels of incident management, and the agencies need to investigate ways to improve communication processes and systems from the fireground.

6.11.3 The Review identified several areas where communication systems need to be improved, for example in the development of IAPs (as discussed in Section 6.4— Planning and Incident Action Plans). However, based on the importance of communication systems in support of incident management overall, there is a need for expert involvement at the technical level of any IMT communication planning. Wherever possible, the agencies must ensure this support is available to IMTs, particularly during the development of any multi-agency Level 3 IAP Communications Plan.

6.11.4 The dissemination of incident information is critical in support of incident management and fireground operations. The most important information, in terms of a tool to communicate incident information, is the IAP. The IAP is a flexible document that must change with changing circumstances, while maintaining the principle of management by objectives. To assist with the exchange of incident information and any subsequent updates, IT solutions should be identified that allow for the most up-to-date information to be available to personnel before deployment onto the fireground and ongoing during operational periods. This should not be seen as a solution that eliminates the need for paper-based forms of information, but as a tool that enhances and improves communication. This recommendation should be considered in conjunction with Section 6.4—Planning and Incident Action Plans.

6.11.5 The reliance on IT has increased considerably to a point where it would be difficult to manage the expectations required of EM agencies, stakeholders and the community without technical and system support. Considerable commentary from interstate and international deployments related to difficulties with IT systems, particularly accessing data and the systems supporting incident management (see also 6.9.6). Tasmania Fire Service Page 45 Review of operations during the 2015–16 bushfires Recommendation 11

That responsible agencies and the Business Executive Services division of DPFEM review current procedures and/or arrangements for communications and information technology (IT) support during emergencies, including: • developing procedures to ensure incident communication plans include technical input and meet the operational requirements of the complex/incident • identifying options for streamlining IT systems and multi-agency compatibility requirements • reviewing and/or developing procedures and systems that further support the increased use of social media during emergency incidents – including public information and operational information • identifying and implementing IT solutions to improve the dissemination of incident information, including Incident Action Plans and any relevant operational information.

Tasmania Fire Service Page 46 Review of operations during the 2015–16 bushfires 6.12 Finance

Context 6.12.1 Incident management, mitigation and recovery activities can have significant financial implications at all levels of government. The agencies have fiscal responsibilities to ensure that incident expenditure and ongoing cost analysis is maintained, collated, and reportable. Commentary from the online survey and face-to-face debriefs indicates a degree of dissatisfaction, from both operations and support services, with the financial management of the 2015–16 bushfire season. The agencies need to develop options to ensure there is ongoing finance unit support, particularly at Level 3 incidents. The following comment in the survey – addressing the question of what needs to be improved – illustrates some of the issues: There was no identified Finance Officer at any of the IMTs which I worked, there was no reporting to or from the IMT relating to costs, and finance and costs were never an agenda item at any IMT meetings. This led to a perception that there was a bottomless pit of money to control the fires and nobody within the IMT questioned the need for purchases or expenditure

6.12.2 In addition, the Review has highlighted the difficulties associated with managing several different financial procedures and systems across the agencies, including payment of overtime, allowances, purchase orders etc. This contributed to issues relating to, for example, decreased efficiencies, reporting and post-incident reconciliations. The agencies and DPFEM Business Executive Services need to identify and implement options for standardising financial processes and systems that support interagency incident response (see also Section 6.5—Resourcing and resource-tracking).

6.12.3 The cost of air operations over the 2015–16 bushfire season was significant: around 50% of the total cost of 2015–16 can be directly attributed to firefighting aircraft. While it is acknowledged Tasmania had an unprecedented number of firefighting aircraft over the campaign, the agencies need to review current processes and systems to ensure that air operations has the appropriate financial systems and support in place.

Recommendation 12

That responsible agencies and the Business Executive Services (BES) division of DPFEM identify and develop options for improving the processes required to provide up-to-date incident expenditure, collection and inputting of relevant data and ongoing financial cost estimate analysis, including: • identifying ways to provide finance unit resources in a timely manner at relevant levels of incident management • reviewing the financial procedures and systems associated with all aspects of air operations, including the National Aerial Firefighting Centre and ‘call when needed’ • reviewing and/or developing interagency financial procedures that ensure, wherever possible, processes are streamlined during multi-agency incidents • identifying options and approvals for payment allowances and overtime within TFS and the process/documentation in general • developing surge capacity within BES during periods of increased workload and any required incident management support.

Tasmania Fire Service Page 47 Review of operations during the 2015–16 bushfires 7 Conclusion

The review team gathered an extraordinary amount of data from a broad range of agencies and personnel that have contributed to the bushfire efforts of 2015-16. It is fair to say that we have been privy to a considerable number of insights that will assist in identifying areas where our organisations can improve and, just as importantly, where we should recognise and celebrate our achievements.

Overall, 12 themes have been identified and a number of subsequent recommendations are contained within each theme.

It is acknowledged that there has been significant work undertaken previously in relation to recommendations from earlier reviews, however, the review team did identified several similarities within this report and the outcomes of previous bushfire reviews. The responsible agencies would benefit from conducting further analysis of previous reviews to ensure areas of commonality are considered.

To ensure the responsible agencies can measure continuous improvement, the review team recommends that agencies continue to conduct any future operational reviews using a similar process and systems of support.

Finally, the recommendations within this report should be seen as opportunities for lessons that may be learned and not as a list of what we may have done wrong. In analysing all the data the review team has tried to be representative of all the insights and observations people have chosen to share and are confident this report will assist the responsible agencies identify areas for continuous improvement. These opportunities to improve have been gleaned from the goodwill and sincere efforts of the people who contributed to the review. Insights that may assist in improvements have been taken from the experiences of many who were involved in these extraordinary events. Sadly, we also need to acknowledge that such events may become the ‘new normal’ and we would be wise to heed the lessons that can be learned.

Tasmania Fire Service Page 48 Review of operations during the 2015–16 bushfires