Learning from Adversity: What Has 75 Years of Bushfire Inquiries (1939-2013) Taught

LEARNING FROM ADVERSITY: WHAT HAS 75 YEARS OF BUSHFIRE INQUIRIES (1939-2013) TAUGHT US? Proceedings of the Research Forum at the Bushfire and Natural Hazards CRC & AFAC conference Wellington, 2 September 2014 Michael Eburn1,2, David Hudson1, Ignatious Cha1 and Stephen Dovers1,2 1Australian National University 2Bushfire and Natural Hazards CRC Corresponding author: [email protected] LEARNING FROM ADVERSITY | REPORT NO. 2015.019 Disclaimer: The Australian National University and the Bushfire and Natural Hazards CRC advise that the information contained in this publication comprises general statements based on scientific research. The reader is advised and needs to be aware that such information may be incomplete or unable to be used in any specific situation. No reliance or actions must therefore be made on that information without seeking prior expert professional, scientific and technical advice. To the extent permitted by law, the Australian National University and the Bushfire and Natural Hazards CRC (including its employees and consultants) exclude all liability to any person for any consequences, including but not limited to all losses, damages, costs, expenses and any other compensation, arising directly or indirectly from using this publication (in part or in whole) and any information or material contained in it. Publisher: Bushfire and Natural Hazards CRC January 2015 i LEARNING FROM ADVERSITY | REPORT NO. 2015.019 TABLE OF CONTENTS ABSTRACT ....................................................................................................................................................... 1 INTRODUCTION ............................................................................................................................................... 1 METHODOLOGY .............................................................................................................................................. 2 RESULTS ........................................................................................................................................................... 3 DISCUSSION .................................................................................................................................................... 3 CONCLUSIONS ................................................................................................................................................ 6 APPENDIX 1: INQUIRIES INCLUDED IN THIS REVIEW (BY YEAR) .................................................................... 8 APPENDIX 2: EXAMPLES OF RECURRING THEMES IN EACH CATEGORY ...................................................... 11 ii LEARNING FROM ADVERSITY | REPORT NO. 2015.019 ABSTRACT This paper reports on preliminary research conducted at the ANU on the effectiveness of formal, public post event inquiries. With a focus on inquiries into bushfires the paper presents a broad overview of the inquiries over time as well as a detailed review of the multiple inquiries into the 2003 Canberra fires to ask what has been learned from these processes. INTRODUCTION Following major natural hazard events, such as the 2009 Victorian ‘Black Saturday’ bushfires and the 2011 Queensland and Victorian floods, Australia usually engages in formal, complex, post-event inquiries to identify how the tragedy occurred and what can be done to prevent future occurrences. Since 1939 there have been over thirty inquiries into wildfires and wildfire management and at least another fourteen into floods, storms, other natural hazards and emergency management arrangements. Notwithstanding this plethora of inquiries, fires and floods continue to occur, property is damaged and lives are lost. In his report into the 1989 Hillsborough tragedy in the UK, Lord Taylor said: That it was allowed to happen, despite all the accumulated wisdom of so many previous reports and guidelines must indicate that the lessons of past disasters and the recommendations following them had not been taken sufficiently to heart… there is no point in holding inquiries or publishing guidance unless the recommendations are followed diligently. That must be the first lesson.1 Holding a Royal Commission or similar inquiry may give the impression that lessons are being learned and that, by following the recommendations of the last inquiry, the ‘problem’ of fires or disasters will be solved. The fact that catastrophic events continue to recur is evidence either that the community is failing to learn the lessons from the past, or the inquiries fail to identify the true learning – that catastrophic events may be inevitable, or that Royal Commissions are not the most effective way to identify relevant lessons from past events.2 This paper is a preliminary review of the recommendations from 51 inquiries into bushfire management and response Service to ask ‘what have we learned?’ The inquiries range from the 1939 Stretton Royal Commission into Victoria’s fires, to 2013 and inquiries into Tasmania’s wildfires, the Auditor General’s performance audit on bushfire readiness in the ACT and the Malone inquiry into the Queensland Rural Fire. The aim of the review was to identify recurrent themes or recurrent ‘lessons identified’ (if not learned).3 These findings will inform further work being funded by the Bushfire and Natural Hazards CRC that is seeking to identify if there are better ways to identify learning from the impact of natural hazard events. 1 The Hillsborough Stadium Disaster 15 April 1989; Inquiry by the Rt. Hon. Lord Justice Taylor, Final Report (London, 1990), [22] and [23]. 2 Neil Dufty, ‘Evaluating emergency management after an event: gaps and suggestions’ (2013) 28(4) Australian Journal of Emergency Management 15. 3 Attorney General’s Department, Australian Emergency Management Handbook Series, Handbook 8: Lessons Management (Commonwealth of Australia), p 3. 1 LEARNING FROM ADVERSITY | REPORT NO. 2015.019 METHODOLOGY The researchers identified some 257 inquiries into the preparation for and response to natural hazard events. From those we identified 51 that were solely related to bushfires and bushfire management and where the recommendations were readily available. The reports the subject of this review include operational reviews (such as the McLeod Inquiry into the Operational Response to the 2013 Canberra fires), Parliamentary inquires (such as the Parliamentary inquiry into the 2001/2002 Sydney fires), coroner’s inquiries, Auditor Generals’ reports on fire management and the operation of fire services, and commissioned inquiries (such as the Malone review of the Queensland Rural Fire Service). A list of the reports the subject of this review can be found in appendix 1, below. These inquiries produced 1727 recommendations. Having listed the recommendations, two of the researchers, Eburn and Hudson independently coded the recommendations into one of 5 broad themes; A – Shared responsibility; B – Preparedness; C – Response; D – Recovery; E – Fire agency organisation; and F – Research and technology. Where there was disagreement as to the coding the researchers discussed their differing interpretations and determined the appropriate code by consensus. At the same time, Cha conducted a review of three inquiries into the 2003 Canberra fires.4 This event was unique in that it occurred in one small jurisdiction and was the subject of three independent post event reviews. They were: 1. The McLeod Inquiry into the Operational Response to the January 2003 Bushfires in the ACT (2003); 2. The inquiry and inquest by Coroner Doogan, (The Canberra Firestorm: Inquests and Inquiry into Four Deaths and Four Fires between 8 and 18 January 2003 (2006)); and 3. Post-event litigation against the State of New South Wales that was heard in the ACT Supreme Court (Electro Optic Systems Pty Ltd v New South Wales; West v New South Wales (2012) 273 FLR 304). Although not strictly speaking a post event inquiry, the Supreme Court litigation did determine issues of fact that is the Court made findings of what occurred and whether or not the actions of the agencies was, legally, ‘reasonable’. In this review the question was asked, if these events present consistent findings as to what occurred and what should have occurred, is there a need to have fact-finding processes that extend for 10 years after the event? If the findings are not consistent ‘how can the community and fire agencies learn lessons from multiple processes?’5 4 Ignatious Cha, Learning Lessons from Fires: A study of post-disaster inquiries in the 2003 Canberra fires (Paper submitted in fulfilment of the requirements for the unit ENVS3010 Independent Research Project, The Australian National University, 2014). This research was conducted under the supervision of Eburn and Dovers. 5 Ibid, 2. 2 LEARNING FROM ADVERSITY | REPORT NO. 2015.019 This approach took both a broad view, looking at inquiries over 75 years and across the jurisdictions as well as a narrow focus, three inquiries into one event, to ask ‘What has 75 years of bushfire inquiries (1939-2013) taught us?’ RESULTS The distribution of recommendations, across the 6 categories, is shown in Table 1, below. Recommendations 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% A - Shared B - C - Response D - Recovery E - Fire agency F - Research responsibility Preparedness organisation and technology Recurring themes, across each category, can be identified as the examples in Appendix 2, below, show. DISCUSSION Ideally the product of 51 inquiries and over 1700 recommendations would be that the Australian

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