Learning from Adversity (1939-2013) Taught Us? What Has 75 Years of Bushfire Inquiries Australian NationalMichael University Eburn David Hudson, Ignatious Cha, Stephen Dovers ABSTRACT: Over 75 years (starting with the 1939 Street Royal Commission into the Victorian bushfires and ending with the 2013 Hyde inquiry into the Tasmanian fires) no less than 29 Royal Commissions, coronial inquests and special inquiries have investigated Australian bushfires and produced in excess of 1640 recommendations for reform. That’s an average of one inquiry every two and a half years, each inquiry producing 57 recommendations or 22 recommendations per year. Rather than looking at the cause of, and response to particular events, this paper will review the inquiries themselves to identify common themes and ask: What have we learned and what are we yet to learn? More importantly what can we learn about the inquiry process and are ad hoc inquiries into single, even catastrophic events, the best way to identify the necessary learning for long term community resilience? 2 Introduction EFollowing 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.” 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. 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). 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. 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. 2 3 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. 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?’ 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. Recurring themes, across each category, can be identified as the examples in Appendix 2, below, show. 4 Discussion Ideally the product of 51 inquiries and over 1700 recommendations would be that the Australian community would understand and be prepared for catastrophic fire events and losses on the scale of the 2009 Victorian fires will never occur again. History suggests that this is unlikely; so what has been the value of these inquiries? Answering that question is not easy and not possible here; it may be that recommendations have been made and implemented and that has indeed mitigated the impact of the next fire event but it does not follow that similar issues have recurred and further recommendations are required. Just because an issue recurs does not mean it has not been acted upon. For example, In 1939 Stretton recommended the establishment of a state fire authority that became the Country Fire Authority. The presence of the CFA no doubt has significant impact on Victoria’s resilience to fires today but was never expected to stop all fires. It was beyond the scope of this research to explore if and how recommendations have been implemented but we believe it is still of interest to identify if there are ‘persistent lessons identified’. Even so, our simple survey shows over time and across jurisdictions, there are recurring themes and issues. That may, or may not, mean that ‘the recommendations are followed diligently’. Perhaps they have not been followed diligently as, over time lessons are learned and then forgotten, or lessons identified in one jurisdiction are not learned until a similar event occurs in another (but that may have changed given the rush by all Australian jurisdictions to implement the recommendations from the 2009 Victorian Bushfires Royal Commission). It may be that recommendations are being made that just cannot be implemented. Noting that radio communications is a problem during a fire and that work should be done to improve or investigate ways to ensure effective radio coverage does not create the technology, nor the budget to make this happen. Many of the issues identified are ‘wicked problems’: “A wicked problem is one for which each attempt to create a solution changes the understanding of the problem. Wicked problems cannot be solved in a traditional linear fashion, because the problem definition evolves as new possible solutions are considered and/or implemented.” So even if ‘followed diligently’ the recommendations may not, and cannot, solve the problem. It may be that the recommendations are indeed not ‘followed diligently’. The recommendations may be impracticable or rejected by the industry or government due to conflicting priorities, budget constraints or a belief that they are just not appropriate. There is no guarantee that a Royal Commission, whether constituted by a single Commissioner or a team will actually come up with useful and meaningful recommendations. Another issue may be competing recommendations. Diligently applying the recommendation from one Commission may require action contrary to another, and recommendations change over time. For example, following the 1983 Ash Wednesday fires Victoria amended the State Disasters Act ‘To provide for the appointment of a Minister as Co-ordinator-in-Chief’. The Review Committee took the view that The concept of a State Disasters Act which makes one Minister responsible for counter-disaster planning, preparedness, co-ordination of participating agencies and welfare relief measures is sound. In this regard, the Committee believes that the same mechanism should be superimposed on the existing structure of the State Disaster Plan by extending the legislation... The result of this modification would be that … [i]n the event of a declared disaster… the Minister would assume his responsibilities for the implementation and control of all measures to combat the disaster in his capacity as Co-ordinator-in-Chief.