INTERIM REPORT The painting on the front cover, Mountain Ash, is by Kinglake artist Linda Haggar.

When the inferno swept through Kinglake on Black Saturday, Linda was at home with her husband Wayne. Her eldest daughter Kristin and husband, Heath, and their two children, 14-year old Shelby and 12-year old Oscar, were also with Linda.

While the adults successfully fought the blaze, Linda’s grandchildren comforted the family’s two pet dogs and a cat. All survived.

Linda was inspired to paint Mountain Ash when she fl ew over her property in a helicopter and viewed the devastated landscape below.

The Commission thanks Linda Haggar for making Mountain Ash available for reproduction throughout this report.

ISBN 978-0-646-51830-5 Published August 2009 2009 VICTORIAN BUSHFIRES ROYAL COMMISSION

INTERIM REPORT

THE HON BERNARD TEAGUE AO – CHAIRPERSON

RONALD MCLEOD AM – COMMISSIONER

SUSAN PASCOE AM – COMMISSIONER

ORDERED TO BE PRINTED

August 2009

By Authority

Government Printer for the State of Victoria

No. 225 – Session 2006–09

I 2009 Victorian Bushfi res Royal Commission—Interim Report

Parliament of Victoria 2009 Victorian Bushfi res Royal Commission ISBN 978-0-646-51830-5 II Published August 2009 The Honourable Chief Justice Marilyn Warren AC Lieutenant Governor of Victoria Government House Melbourne 3004

Dear Lieutenant Governor In accordance with the Letters Patent dated 16 February 2009, we have the honour of presenting to you our interim report. The Commission’s Terms of Reference require that we furnish by 17 August 2009 an interim report focusing on immediate actions that can be taken prior to the 2009–2010 fi re season. This report presents our interim fi ndings and recommendations.

Dated this 17th day of August 2009.

The Honourable Bernard Teague AO Chairperson

Ronald McLeod AM Susan Pascoe AM Commissioner Commissioner

III 2009 Victorian Bushfi res Royal Commission—Interim Report

IV PREFACE

Fire is a recurrent visitor in Australia’s environmental history. The fl ora and topography in Victoria render it one of the most bushfi re-prone parts of the planet. Even with this history, 7 February 2009 was a day of unprecedented tragedy in the State. One hundred and seventy-three people died in one of the worst bushfi res in Australian history. About 430,000 hectares of land were burnt, along with 2000 properties and 61 businesses. Entire towns were destroyed and around 78 communities were affected. The impact of these fi res is seared into the consciousness of those who lived through them.

Under such adversity many people responded with courage and compassion. The volunteers who fought the fi res and the individuals that supported their neighbours should be commended for their actions. Since the fi res, many others have helped support fi re-affected individuals and communities in the recovery process.

On 16 February 2009 the Victorian Government established the 2009 Victorian Bushfi res Royal Commission, with broad terms of reference, to investigate the causes of, preparation for, responses to, and the impact on infrastructure of the fi res that occurred in late January and early February 2009. In approaching this investigation the Commission has been acutely aware that the events of 7 February highlight the deadly consequences of extreme bushfi res. The need to give primacy to saving lives is, therefore, at the forefront of the Commission’s intentions and has underpinned its inquiries and recommendations.

In making its recommendations, the Commission recognises that the responsibility for protecting life, property, and community and environmental assets rests with the collective efforts of the whole community. Governments have obligations to ensure that people have the information, support and infrastructure to enable them to live their lives in relative safety and wellbeing. They also have important operational responsibilities in emergencies. Individuals who choose to reside in bushfi re prone areas need to ensure they are well informed about the nature of their environment. When bushfi re threatens, they must take responsibility for their own safety and for those in their care. They need to be well prepared in advance and have a realistic appreciation of the risks involved.

The Commission appreciates the importance of linking its processes with affected communities. Not only are the views of affected individuals important to understanding the progress and impact of fi re, but providing people with a forum to tell their stories to an independent Commission is an important part of the healing process. Around 2500 people have attended community consultations, made written submissions and/or appeared as lay witnesses before the Commission.

This report is an interim report. It is the result of the fi rst part of the Commission’s inquiries and focuses on recommending immediate actions that could be taken prior to the 2009–10 bushfi re season. The fi nal report is due on 31 July 2010 and will cover the full scope of the Commission’s terms of reference. The Commission will monitor the progress of its interim recommendations and consider whether longer-term factors warrant their modifi cation in its fi nal report.

We commend this report to the people of Victoria as a partial account of the events of 7 February 2009, with the intent of providing recommendations to improve the preparation for and response to the 2009–10 bushfi re season. We dedicate our work to the memory of those who died in the fi res, to those they left behind, to those who were injured and to those who fought to protect fellow Victorians.

The Hon Bernard Teague AO Ronald McLeod AM Susan Pascoe AM Chairperson Commissioner Commissioner

V 2009 Victorian Bushfi res Royal Commission—Interim Report

VI VII 2009 Victorian Bushfi res Royal Commission—Interim Report

VIII IX 2009 Victorian Bushfi res Royal Commission—Interim Report

ABBREVIATIONS

ABC Australian Broadcasting Corporation

AEMC Australasian Emergency Management Committee

AFAC Australasian Fire and Emergency Service Authorities Council

AGDCC Attorney-General’s Department Coordination Centre (Commonwealth)

AIIMS Australasian Inter-Service Incident Management System

AWS Automatic Weather Station

BoM Bureau of Meteorology

Bushfi re CRC Bushfi re Cooperative Research Centre

CAD Computer Aided Dispatch

CAP Common Alerting Protocol

CFA Country Fire Authority

CFS Country Fire Service (South Australia)

CIWS Community Information and Warning System

COAG Council of Australian Governments

COMDISPLAN Commonwealth Disaster Response Plan

CSC Customer Service Centre

CSIRO Commonwealth Scientifi c and Industrial Research Organisation

DACC Defence Assistance to the Civil Community

DECC Divisional Emergency Response Coordination Centre

DEECD Department of Education and Early Childhood Development

DERC Divisional Emergency Response Coordinator

DHS Department of Human Services

DIGO Defence Imagery and Geospatial Organisation

DPI Department of Primary Industries

DSE Department of Sustainability and Environment

EAS Emergency Alerting System

EMA Emergency Management Australia

ESTA Emergency Services Telecommunications Agency

FAQs Frequently Asked Questions

FDI Fire Danger Index

FFDI Forest Fire Danger Index

GFDI Grassland Fire Danger Index

ICC Incident Control Centre

iECC Integrated Emergency Coordination Centre

IFMPF Integrated Fire Management Planning Framework

X IMF Incident Management Facility

IMS Incident Management System

IMT Incident Management Team

IPND Integrated Public Numbers Database

MAV Municipal Association of Victoria

MECC Municipal Emergency Coordination Centre

MEMP Municipal Emergency Management Plan

MERC Municipal Emergency Response Coordinator

MFB Metropolitan Fire and Emergency Services Board

MOU Memorandum of Understanding

NEO Networked Emergency Organisation

NIBA National Insurance Brokers Association

OASIS Organisation for the Advancement of Structured Information Standards

OESC Offi ce of the Emergency Services Commissioner

RECC Regional Emergency Coordination Centre

SECC State Emergency Coordination Centre

SEOC State Emergency Operations Centre

SERCC State Emergency Response Coordination Centre

SERP State Emergency Response Plan

SEST State Emergency Strategy Team

SEWS Standard Emergency Warning Signal

TFB Total Fire Ban

The Manual Emergency Management Manual Victoria

TOR Terms of Reference

VBIL Victorian Bushfi re Information Line

VEMC Victorian Emergency Management Council

VFRR Victorian Fire Risk Register

VICSES Victorian State Emergency Service

XI 2009 Victorian Bushfi res Royal Commission—Interim Report

TABLE OF CONTENTS

PREFACE V

ABBREVIATIONS X

INTRODUCTION 1–8 OVERVIEW OF 7 FEBRUARY 2009 2

COMMISSION PROCESS 3

THE INTERIM REPORT 5

STRUCTURE OF INTERIM REPORT 6

PROTECTION OF HUMAN LIFE 6

SHARED RESPONSIBILITY 6

EMERGENCY SERVICES PERSONNEL 8

EXECUTIVE SUMMARY 9–32 INTERIM REPORT RECOMMENDATIONS 24

1 THE FEBRUARY 2009 FIRES 33–82 INTRODUCTION 36

THE WEATHER 36

FIRE BEHAVIOUR 45

FIRES EXAMINED 48

FIRE ACTIVITY PRIOR TO 7 FEBRUARY 49

BUNYIP 50

DELBURN 52

FIRE ACTIVITY ON 7 FEBRUARY 54

KILMORE EAST 55

HORSHAM 60

COLERAINE 62

POMBORNEIT–WEERITE 64

CHURCHILL 66

MURRINDINDI 69

REDESDALE 72

NARRE WARREN 73

BENDIGO 74

BEECHWORTH–MUDGEGONGA 76

FIRE ACTIVITY AFTER 7 FEBRUARY 78

PREVIOUS MAJOR FIRES 79

2 ENGAGING COMMUNITIES 83–102 COMMUNICATING WITH THE COMMISSION 84 XII FIRE-AFFECTED COMMUNITY CONSULTATIONS 86 3 SUBMISSIONS 103–118 THE SUBMISSIONS PROCESS 104

THE VALUE OF SUBMISSIONS 104

SUBMISSION DEMOGRAPHICS 105

RECURRING THEMES IN SUBMISSIONS 106

CONCLUDING COMMENTS 118

4 WARNINGS 119–154 BUSHFIRE INFORMATION, WARNINGS AND TRIGGERS 120

BUSHFIRE INFORMATION AND EDUCATION IN VICTORIA 121

BUSHFIRE WARNINGS: THE WELL-TRODDEN PATH 122

WHAT MAKES A GOOD BUSHFIRE WARNING? 124

BUSHFIRE WARNINGS: THE SYSTEM IN VICTORIA ON 7 FEBRUARY 129

BUSHFIRE INFORMATION DISSEMINATED PRIOR TO 7 FEBRUARY 131

BUSHFIRE WARNINGS ON 7 FEBRUARY 133

HOW DID THE COMMUNITY RECEIVE AND UNDERSTAND THE WARNINGS ON 7 FEBRUARY? 136

CONCLUSIONS ON THE CONSTRUCTION AND CONTENT OF BUSHFIRE WARNINGS 142

TOWARDS A LONGER TERM APPROACH — A NEW CATEGORISATION SYSTEM 143

LESSONS FROM THE 2005 WANGARY FIRES AND PROJECT PHOENIX 144

RETHINKING THE STANDARD EMERGENCY WARNING SIGNAL 146

THE USE OF SIRENS AS A BUSHFIRE WARNING 148

A TELEPHONY-BASED EMERGENCY WARNING SYSTEM 151

5 INFORMATION 155–172 REVISITING THE FDI AND THE FIRE DANGER RATING 156

BUILDING A SINGLE, MULTI-AGENCY BUSHFIRE INFORMATION WEBSITE FOR VICTORIA 160

THE VICTORIAN BUSHFIRE INFORMATION LINE 163

6 RELOCATION 173–186 INTRODUCTION 174

THE TERMINOLOGY OF EVACUATION 174

LEGISLATIVE AND POLICY FRAMEWORK 175

ARGUMENTS AGAINST COMPULSORY EVACUATION 178

RELOCATION ON 7 FEBRUARY 179

PROTOCOLS FOR RECOMMENDING TIMELY RELOCATION 183

7 STAY OR GO 187–204 THE CURRENT ‘STAY OR GO’ POLICY AS APPLIED IN VICTORIA 188

COMMUNITY IMPLEMENTATION OF THE STAY OR GO POLICY 194 THEMES IN THE EVIDENCE ON STAY OR GO 201 XIII 2009 Victorian Bushfi res Royal Commission—Interim Report

TABLE OF CONTENTS

8 RISK AND REFUGE 205–228 IDENTIFYING BUSHFIRE RISK 206

FIRE REFUGES AND SAFER PLACES 209

SCHOOLS AND THE SAFETY OF CHILDREN 226

9 INCIDENT MANAGEMENT: A CASE STUDY 229–260 AUSTRALASIAN INTER-SERVICE INCIDENT MANAGEMENT SYSTEM 230

CASE STUDY: KILMORE EAST FIRE 236

THE iECC 255

AIIMS AND INFORMATION — HOW IT MIGHT CHANGE 259

10 EMERGENCY MANAGEMENT 261–276 VICTORIA’S EMERGENCY MANAGEMENT ARRANGEMENTS 262

STATE EMERGENCY RESPONSE PLAN 264

ROADBLOCKS 273

11 COMMONWEALTH RESPONSE 277–284 DIVISION OF RESPONSIBILITIES 278

THE ‘ALL HAZARDS’ APPROACH TO NATURAL DISASTERS 279

COMDISPLAN AND COMMONWEALTH AID 280

COMMONWEALTH RESOURCES FOR DETECTING, TRACKING AND SUPPRESSING FIRES 281

COMMONWEALTH INVOLVEMENT UP TO AND ON 7 FEBRUARY 283

12 EMERGENCY CALLS 285–300 TRIPLE ZERO 286

THE ROLE OF ESTA 289

PREPARATION FOR 7 FEBRUARY 291

EVENTS OF 7 FEBRUARY 293

IMPROVING THE COORDINATION AND CAPACITY OF EMERGENCY CALL SERVICES 298

13 NEXT STEPS 301–304

XIV ENDNOTES 305–352 INTRODUCTION 306

1 THE FEBRUARY 2009 FIRES 306

2 ENGAGING COMMUNITIES 316

3 SUBMISSIONS 317

4 WARNINGS 318

5 INFORMATION 325

6 RELOCATION 329

7 STAY OR GO 331

8 RISK AND REFUGE 334

9 INCIDENT MANAGEMENT: A CASE STUDY 338

10 EMERGENCY MANAGEMENT 345

11 COMMONWEALTH RESPONSE 348

12 EMERGENCY CALLS 349

13 NEXT STEPS 352

APPENDIX 1 – PARTIES GRANTED LEAVE TO APPEAR 353–354

APPENDIX 2 – HEARING DAYS AND WITNESSES 355–360

XV 2009 Victorian Bushfi res Royal Commission—Interim Report

Source: Courtesy of The Herald & Weekly Times XVI To obtain a copy of the interim report or the executive summary, contact Information Victoria on 1300 366 356 or [email protected] If you would like to receive this publication in an accessible format such as large print or audio, please telephone 9651 5111, TTY 9651 5814 or email [email protected] EXECUTIVE SUMMARY 2009 Victorian Bushfires Royal Commission—Interim Report

Source: Jason South, courtesy of The Age 10 Executive Summary

Source: Jason South, courtesy of The Age 11 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

The following discussion summarises the Commission’s interim report, its conclusions, and the areas in which it has made recommendations for the 2009–10 bushfire season. A full list of the recommendations can be found at the end of the Executive Summary. Details of these conclusions and recommendations and the evidence that support them are set out in the interim report.

In February 2009 the whole of south‑east Australia was experiencing a severe and protracted drought. During January 2009 much of Victoria had no rain and most areas of the State had recorded near record lows. In late January 2009 heatwave conditions developed across Victoria and on 7 February many all-time temperature records were set. In Melbourne the temperature reached 46.4°C. The previous record was 45.6°C set on Black Friday (13 January 1939). These extreme conditions were recognised by the Victorian Government and fire agencies. Prior to 7 February, Victorians were warned that the forecast weather was worse than Ash Wednesday, and senior government officials, from the Premier down, warned that it was likely to be ‘the worst day ever in the history of the State’. These dreadful expectations were matched by the calamity that resulted on 7 February. Many long-serving Country Fire Authority officers had not experienced such fires. The rate of spread of the fires equalled the maximum previously recorded, and the prolific spotting made fire behaviour on the day unique. Reports referred to flames leaping 100 metres into the air, generating heat so intense that aluminium road signs melted. The plume of the fires created a convection effect that generated winds so strong that trees appeared to have been screwed from the ground. One hundred and seventy-three people died in the fires. The personal cost cannot be overestimated. The Commission has glimpsed the ruin and observed the raw emotions of those left behind. Whilst physical recovery is underway, many of the losses are permanent.

Commissioners Bernard Teague, Susan Pascoe and Ronald McLeod 12 Source: Paul Jones, courtesy of Fairfaxphotos.com Executive Summary

Figure 1: 2009 Victorian bushfires

Ouyen

Beechworth Nhill

Horsham Bendigo

Edenhope Castlemaine Yea

Dargo Ballarat Marysville Casterton Hamilton Melbourne Dandenong

Warragul Traralgon Colac

Yarram

Map source: Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0111

This map covers the fires up to 23 February 2009, including those discussed in this report.

The Royal Commission It is against this background that the Hon Bernard Teague AO, Mr Ron McLeod AM and Ms Susan Pascoe AM were appointed to be Commissioners of the 2009 Victorian Bushfires Royal Commission with Terms of Reference that required it to produce an interim report by 17 August 2009 and a final report by 31 July 2010. A Royal Commission is an administrative inquiry established by Executive Government which, by long tradition, operates independently. A Royal Commission is a valuable mechanism by which the circumstances of the involvement of government or government agencies in an event like the 7 February bushfires can be thoroughly examined in a public setting. A Royal Commission has broad investigative powers. It is not under a duty to reach a definitive verdict. It has a duty to report on the nature of its inquiries, explaining what conclusions were drawn from its investigations and what advice it should give the Executive Government based on its deliberations.

13 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Community consultations From the outset the Commission saw its interaction with all Victorians, and in particular those affected by the fires, as a vital cornerstone of its work. The Commission’s first priority was to meet with and listen to people from the communities directly affected by the fires. Between 18 March and 9 April the Commission held 26 community consultations in 14 fire locations. Some 1200 people attended. The consultations enabled the Commission to hear first-hand about people’s experiences and gain valuable insights into how individuals and communities had dealt with the disaster. It was a privilege to be allowed into these communities to hear highly personal accounts of the difficult experiences and losses suffered. Participants’ experiences have influenced the priority of issues covered in the Commission’s interim report. The people involved in the consultations talked about their preparation for the fire, how they felt the emergency effort was managed, the communication of warnings, and recovery efforts (Chapter 2). The four weeks of the consultations provided an important opportunity for those involved to come together and talk about their experiences. This, in itself, was a valuable outcome of the discussions.

Source: AAP Image

14 Executive Summary

Submissions Public submissions were invited from any person or organisation with information relevant to the Commission’s Terms of Reference. Over 1200 submissions were received prior to the closing date for the interim report. They have come from across Victoria, from people in fire-affected and unaffected areas, and from around Australia and overseas. The submissions have helped the Commission to frame its work program. They have contributed to identifying shortcomings and deficiencies that needed investigation. Many helpful suggestions and observations have been made that have assisted the Commission in assessing issues and priorities. Figure 2 summarises the topics raised and the number of submissions on each topic. The issues raised in submissions are summarised in Chapter 3.

Figure 2: Submissions by key topics

Number of Submissions

0 50 100 150 200 250 300 350 400 450 500 550

Fuel Reduction/DSE/ 485 Prescribed Burning

Fire Preparedness 430

Warnings 430

Planning & Local 340 Government

Stay or Go, 326 Evacuation, Refuges

Emergency Management 310 of the Fires Causes & Circumstances 276

Building/Rebuilding 183

15 Key Issues Economic Cost 156 of the Fires

Recovery Efforts 156

Emergency Communications 140

Essential Services 132

Insurance 65

Roads 64

Fire Detection 61

15 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Public Hearings Royal Commissions commonly conduct open and public hearings, which enable the gathering of evidence in a form that permits parties potentially materially affected by the evidence to be represented, and to be in a position to test the evidence. Counsel Assisting lead the evidence and the parties who have been granted leave to appear may cross-examine witnesses. In this way any concerns about natural justice and procedural fairness principles can be satisfied. The gathering of evidence in this fashion is a vital part of the Commission’s work. It has occupied a major portion of the Commission’s time to this point. Part of the function of Counsel Assisting is to test the evidence that is given, even if this is an uncomfortable experience for witnesses concerned. Ultimately, it is the three Commissioners who must decide what conclusions are drawn from the evidence that is called. Many witnesses called have been State officials or members of the emergency services agencies. Others have been expert witnesses or from organisations that have an interest in aspects of the Commission’s work. During each day of the public hearings, evidence was given by private individuals who were able to inform the Commission of their own experiences during the fires. In this way the Commission has been able to maintain a close connection between the community interest and the bodies associated with the management and response to the bushfires. The Commission was conscious of the widespread interest in its proceedings and arranged live web-streaming of the public hearings. This has been widely welcomed. Libraries throughout Victoria (including the State Library) made facilities available for people to view or listen to the live streaming and to access and download transcripts from the hearings. This has assisted the Commission in providing an open and accessible process for fire-affected communities and the wider Victorian community. The Commission thanks the State Library and all the other libraries for helping to make the hearings accessible to a very wide audience.

February 2009 fires February 7 was an extremely busy day for fire agencies with many small fires and a significant number of larger fires burning across Victoria. In many cases quick actions by the CFA meant that small fires were controlled quickly and caused minimal damage. For example, one of the smaller fires that warrants mention is one that started in Upper Ferntree Gully during the afternoon. Twenty-one CFA appliances and 168 personnel attended this fire, assisted by a heavy helicopter that was redeployed from Bunyip. The fire was eventually brought under control at about 9:30pm. The CFA described the fire as having the ‘most significant potential’ for losses on the day, because it burned at the foothills of Mt Dandenong, in a heavily populated area of Melbourne.

Source: AAP Image 16 Executive Summary

Figure 3: Satellite image showing the fires burning at 3:55pm on 7 February 2009

Map source: Exhibit 32 – Tolhurst Expert Report (EXP.003.001.0017) at 0023

The Commission is examining 12 of the largest fires, in which lives were lost or significant damage occurred. These are the Kilmore East, Murrindindi, Churchill, Delburn, Bunyip, Narre Warren, Beechworth-Mudgegonga, Bendigo, Redesdale, Coleraine, Horsham and Pomborneit-Weerite fires. Chapter 1 of this report records some detail on each of these fires. Their location is illustrated in Figure 1. Detailed evidence has only been received on the Kilmore East fire, but the Commission intends to continue with its investigation of the fires in the next phase of its work. While the major damage from the fires occurred on 7 February, even after that date considerable fire activity remained. The Kilmore East–Murrindindi fire, for example, was not under control until 10 March and not considered safe until 27 April. Similarly, the Bunyip fire was not under control until 15 March. The Commission’s detailed examination of how the authorities dealt with the Kilmore East fire complemented other evidence it received on bushfire operations and policy, and has enabled it to reach conclusions on changes that should be implemented for the 2009 –10 bushfire season.

17 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Warnings and Information Timely warnings save lives. The community expects and depends on detailed and high quality information prior to, during, and after bushfires. The community is also entitled to receive timely and accurate bushfire warnings whenever possible, based on the intelligence available to the control agencies. Though they are distinct concepts, the provision of information (Chapter 5), warnings (Chapter 4) and the response to emergency calls (Chapter 12) are inextricably linked. Ongoing information about bushfires prepares the community and educates on the appropriate steps to take if a warning is issued. In contrast, a bushfire warning is specific advice about an imminent event. Such a warning should propel the community into action in response to a specific threat — ideally, armed with the information and education which has prepared them to respond. Prior to 7 February the State Government devoted unprecedented efforts and resources to informing the community about the fire risks Victoria faced. That campaign clearly had benefits, but it could not, on its own, translate levels of awareness and preparedness into universal action that minimised risk on the day of the fires. Indeed, no campaign will have universal success. The effectiveness of any campaign depends on the quality of information, the modes of dissemination and the willingness and capacity of people to hear, understand and act on the message. This is a shared responsibility between government and the people. However, there were a number of weaknesses and failures with Victoria’s information and warning systems on 7 February. Warnings were often delayed which meant that many people were not warned at all or the amount of time they had to respond to the warnings was much less than it should have been. The warnings that were issued often did not give people a clear understanding of the location and severity of the fire and how they should respond. The methods of delivery of the warnings were also inadequate. Some techniques for raising awareness such as the use of an emergency warning signal to capture people’s attention when warnings are broadcast were not used. Similarly, other avenues for issuing and raising awareness of warnings were not encouraged, such as the use of local sirens or the use of commercial radio and television. Finally, the sources of information and warnings that were available during the fire did not cope well with the level of demand. People had difficulty getting onto the relevant websites and about 80 per cent of the calls to the Victorian Bushfire Information Line were unanswered. Often the information available through these sources was incomplete or out of date. During the afternoon of 7 February the emergency telephone call services (Telstra’s Triple Zero service and the Emergency Services Telecommunications Authority) experienced unprecedented demand which resulted in serious failures. Large numbers of calls were not answered and many callers could not be connected to the relevant authorities, leading to a significant number of abandoned calls. The collapse of the system caused extreme stress to both the callers and the operators. There are opportunities to improve the content, sources and means of disseminating bushfire information and warnings to the public. The Commission’s recommendations cover the following:

■■ improving the quality of bushfire information and warning messages by adopting standard language already developed for national usage

■■ simplifying the format of bushfire warnings

■■ reintroducing the Standard Emergency Warning Signal to draw attention to broadcast warnings about life threatening fires

■■ extending the broadcasting of official warnings to commercial radio and television

■■ allowing the reintroduction of sirens in local communities where there is demand for them

■■ supporting the acceleration of the full introduction of a nationally developed telephone based automatic warning system

■■ pursuing research into the development of improved fire danger index systems

18 Executive Summary

■■ enhancing the role of the Bureau of Meteorology in issuing daily information on bushfire risk

■■ improving technology and processes to accelerate the updating of common bushfire information on agency websites

■■ increasing the capacity of the bushfire emergency networks, the Victorian Bushfire Information Line, Telstra’s Triple Zero service and the Emergency Services Telecommunications Authority to better handle peak demands, and to work more collaboratively during severe fire risk days. Many of these changes will need to be accompanied by an education campaign so that people understand the changes and how to interpret the information that is provided.

Protecting People During Bushfires

Stay or Go In Victoria, community response to bushfire is guided by a policy that directs residents to Prepare, Stay and Defend or Leave Early, known more commonly as the ‘stay or go’ policy (Chapter 7). This policy has been developed over many years and reflects an understanding from research into past fires that with proper planning and prior preparation, most buildings can be successfully defended from a bushfire. The alternative is to plan to leave early. An analysis of this policy approach against the background of the recent fires has led the Commission to conclude that there has been insufficient emphasis on the risks of staying and defending. Unquestionably the safest course is always to leave early. To stay may still be an appropriate option for some, particularly in less dangerous bushfires, but a number of conditions need to be satisfied. To stay requires considerable effort to prepare a property and make it defendable. But some properties, because of their nature and locality, will not be defendable in extremely dangerous bushfires. To defend a property successfully requires considerable physical effort and emotional strain. Often more than one person needs to be involved. It is a task for those who are physically fit and mentally strong. It is not a place for children, older people or the infirm. Properties also need to have a range of auxiliary equipment to bushfire standards, and an ample water supply that will not be affected by a loss of mains power. In addition, the concept of defendable space needs to be given stronger recognition as an important element in the range of bushfire protection policies and processes. These messages need greater acknowledgement in the written publications, training and advice provided by the CFA. The Commission has recommended that the emphasis of CFA community education literature and advice be changed and improved to more realistically acknowledge the risks of extremely dangerous bushfires. For those who choose to stay and defend, the risks should be spelt out more plainly, including the risk of death. People should also be encouraged to recognise that not all houses are defendable in all situations and contingencies need to be considered in case the plan to stay and defend fails. It is recommended that the CFA should have the authority to give specific advice about the defendability of individual properties and whether residents should relocate rather than trying to stay and defend. Aids for self assessment of a home’s defendability should also be improved and made more readily available. For those who plan to leave, there should be more explicit advice on triggers that should be used to determine when to go. People need to have options other than the simple alternatives of ‘stay’ or ‘go’. The experience of these fires demonstrates that a personal fire plan needs to recognise that a person’s preferred option may not be possible and sometimes fails. In the view of the Commission, the availability of local areas of refuge is an important and essential complement to the ‘stay or go’ policy.

19 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Refuges The State’s fire refuges policy introduced in 2005 has not resulted in any new refuges being established in Victoria, and has raised questions about the few existing refuges that continue to be recognised. In the Commission’s view, the current lack of refuges fails to provide for those who find themselves in danger when their plans fail, are overwhelmed by circumstances, change their minds, or have no plan. The lack of refuges in Victoria also fails to assist people in areas threatened by fire who are away from their homes, such as employees, visitors, tourists, travellers and campers. Any option, which reduces the risk to people in these circumstances, warrants consideration by the State (Chapter 8). A new approach, which is capable of providing more options for the community, should be embraced. Such an approach would shift the emphasis away from an exclusive focus on purpose built structures acting as refuges, and permit the use of existing venues (including car parks, amenities blocks and dam walls) and open spaces (such as ovals, sporting grounds and race tracks). A regime for designating community fire refuges should balance achievable criteria for their identification and operation, with the need to provide a range of options with appropriate minimum safety standards. The Commission has recommended that the State commence identifying and establishing designated community refuges, particularly in areas of high bushfire risk. The State suggested the Commission should consider other options such as ‘safer places in a neighbourhood, informal places of shelter and township protection plans’. In this context, the State said that it will, for the next bushfire season, start identifying appropriate sites as ‘neighbourhood safer places’ and will educate the public about the appropriate use of those places. This initiative is welcomed and supported by the Commission. The CFA should endeavour to give priority to providing resources to assist the defence of designated community refuges and neighbourhood safer places during the passage of a fire front to enhance the safety of those who may seek to rely on these facilities.

Relocation The Commission received little support for compulsory evacuation. However, the evidence before the Commission indicates that people need more guidance on whether they should plan to relocate because their house cannot be defended, and on the ease with which they can leave safely. There was recognition that bushfire warnings in some locations should advise people to urgently leave, even with an approaching fire (Chapter 6). The responsibility for recommending relocation should rest with the Incident Controller managing the fire, who is considered to be in the best place to make such judgments. The recommendations of the Incident Controller would be advisory. The existence of community designated refuges and neighbourhood safer places is relevant in this context as is advice from the police on the availability of safe open exit roads. Three government schools (Strathewen Primary School, Marysville Primary School, Middle Kinglake Primary School) and three kindergartens (Kinglake Kindergarten, Flowerdale Kindergarten and Marysville Kindergarten) were destroyed by fire on 7 February. Bushfire policies for schools in Victoria, as at 7 February, were less than ideal. There was no state-wide policy requiring government schools to evacuate, close or use a fire refuge in event of fire. Since 7 February, the Department of Education and Early Childhood Development (DEECD) has implemented significant policy changes:

■■ a new procedure for school closures on total fire ban days and days of extreme fire risk

■■ a safety audit of refuges in schools in the Eastern and Northern Metropolitan Regions

■■ provision of the Bushfire Safety Checklist to children’s services. DEECD is commended for moving quickly and decisively, but further work needs to be done. The Commission has recommended that DEECD complete its review of refuges and complete priority rectification work to refuges in schools. It should also review the adequacy of bushfire protection measures for kindergartens, child care centres, preschools and early learning centres. 20 Executive Summary

Local Government Local government is a significant player in regulating and supporting townships and communities under their jurisdiction. Recommendations have been made that will enable municipal councils to have a preventative role in leading and contributing to some initiatives aimed at helping to make their communities safer and to protect people during bushfires. They are being asked specifically to review their Municipal Emergency Management Plans to ensure that they include appropriate provision for refuges and relocations that may occur during bushfires.

Police Roadblocks Roadblocks were a particular source of frustration and annoyance during the fires. The main criticism was that they were applied too inflexibly and added an additional burden to people already highly stressed. The Commission has recommended that Victoria Police review its guidelines on the operation of roadblocks with the aim of creating a more flexible set of procedures, particularly for local people whose bona fides can be established (Chapter 10).

IDENTIFYING BUSHFIRE RISK Areas of Victoria at risk of bushfire are identified in several different ways. The evidence to date has revealed different processes for identifying areas at risk for the purposes of emergency management planning, land use planning and building regulation. The Commission notes that fragmented planning, including risk identification, was one of the factors that led to the development of the Integrated Fire Management Planning Framework endorsed in principle by the State in September 2006, but not yet implemented. The Commission endorses the concept of integrated, whole of government fire management planning. This has the potential to lead to the introduction of planning processes that make communities safer and are easier to use. This project should be given higher priority.

EMERGENCY MANAGEMENT Victoria’s Emergency Management Act 1986 was enacted following the Ash Wednesday bushfires in 1983, to provide a legislative foundation for emergency management involving an all hazards, all agencies approach, and appropriate coordination of all agencies involved in the response to, or recovery from, an emergency. The ‘all hazards’ approach to emergency management recognises that all emergencies cause similar problems and that many of the measures required to deal with emergencies are generic. The ‘all agencies’ aspect of Victoria’s emergency management arrangements recognises that all agencies have a role in emergency management and protecting the community from identified risks. Whatever arrangements the State chooses to follow during the forthcoming bushfire season, the Commission intends to examine further the emergency management arrangements for bushfires. This is considered necessary to ensure that the lessons from the 2009 bushfires can be taken into account in determining the strategic emergency management structure that will best serve Victoria for the future. From the evidence heard to date, the Commission believes that immediate changes are required to the State Emergency Response Plan (SERP). The SERP does not clearly designate the agency responsible for issuing warnings and recommending relocation. In addition, the means by which warnings were issued and evacuations were made on 7 February bore little resemblance to the arrangements in the SERP. Diffuse or unclear responsibility for warnings and relocation is at best unhelpful and at worst life threatening in an emergency. It is unsatisfactory that the SERP does not designate clearly the responsibilities of agencies and emergency response coordinators to issue warnings and to advise people to relocate during an emergency. The Commission has recommended that the SERP be amended to give clear responsibility to the control agency to issue warnings. (Chapter 10). To avoid confusion as to which agency is responsible for these matters, emergency response coordinators should not be responsible for warnings and advice to relocate.

21 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Operational Matters Examination of the management of the Kilmore East fire has identified several areas where the Commission is satisfied that it has sufficient evidence to warrant recommending some changes to operational arrangements for bushfire management (Chapter 9). Desirably, these changes would be in place before the next bushfire season. During the public hearings reference was made to the lack of statutory responsibility in the Country Fire Authority Act 1958 for issuing community warnings. The Commission is of the view that this responsibility should have been understood and accepted by the CFA as a normal part of its functions. However, to remove any ambiguity between the roles of the CFA and Victoria Police, the Commission has recommended that the legislation be amended. The State has indicated that it accepts the need for an amendment. Unambiguous arrangements should be in place for the next bushfire season. A complementary authority for the Chief Fire Officer of the Department of Sustainability and Environment is recommended in the form of a formal delegation of powers. Other recommendations have been made relating to the selection of the Incident Controller on the basis of competence, and to the widening of the responsibilities of the Incident Controller in issuing bushfire warnings including when staff may not be directly responsible for management of the fire. Finally, State Duty Officers’ responsibilities for ensuring that proper staffing and set up of pre-designated Incident Control Centres should be made more explicit.

Commonwealth Role The Commonwealth plays an important role in supporting the states and territories, particularly in the recovery phase. It continued this role after the 7 February bushfires, with considerable assistance, particularly from the Australian Defence Force. The Commonwealth has also encouraged national approaches to disaster management (Chapter 11). The Commonwealth has said it is willing to discuss with the states and territories the nature of its contribution, which the Commission welcomes. This includes exploring whether Commonwealth technology could be used to improve the contribution that remote imagery plays in supporting bushfire suppression operations. More regular contact between Commonwealth entities and state and territory fire agencies is recommended. This would strengthen the relationship and understanding of both levels of government.

Implementation by the 2010 Fire Season Overall, the State Government carries much of the responsibility for deciding on the direction of change, funding it, and charging the various State agencies with the implementation tasks that will arise from the Commission’s recommendations. The Commission is sympathetic to the views expressed by State’s Counsel in the final stages of the recent round of hearings that some matters raised in Counsel Assisting’s suggested recommendations would be difficult to implement in time for the 2009–10 bushfire season. As far as possible, the Commission has endeavoured to frame its recommendations with a realistic assessment of the State’s concerns in mind. The Commission agrees with the State that it is important to develop a comprehensive package of material to assist in the re-education of the community to understand the significant role individuals and households must play, in any new arrangements. Recommendations have been framed with this in mind. However, in some areas the lessons from the Commission’s analysis so far of the 2009 bushfires are so compelling that it would be unfortunate if the benefits of these changes are not made available to the community in the forthcoming bushfire season. The 2009–10 bushfire season might or might not be as serious as the past season. The awareness of the number of lives lost in 2009, strengthens the Commission’s resolve to encourage the State to do all in its power to implement those recommendations that have a direct bearing on the protection and safety of individuals and communities.

22 Executive Summary

fUTURE heARINGS The Commission is required to deliver a final report on 31 July 2010. A further 28 weeks of public hearings are scheduled to examine the issues specified in the Commission’s Terms of Reference. An outline of the program of hearings and topics to be covered is in Chapter 13 of this report. The overarching focus of the work of the Commission will remain on the protection of human life. Recommendations to minimise the likelihood of a reoccurrence of the tragedy of 7 February will be provided to the people of Victoria in memory of family and friends lost in the bushfires.

Recommendations The Commission makes 51 recommendations in this interim report. In making these recommendations the Commission focused predominantly on changes that can be implemented prior to the 2009–10 bushfire season to enhance the protection of human lives. The Commission has set dates for the relevant responsible party or parties to advise the Commission on the implementation of each recommendation. Specifically, parties are to provide to the Commission:

■■ an Implementation Plan by 30 September 2009 — being brief advice setting out the proposed response, allocated responsibilities and schedule to implement a recommendation; and

■■ a Delivery Report by 31 March 2010 — being a more detailed report on the progress made towards implementing each recommendation and, where appropriate, the outcomes and effectiveness of the response. In respect of each recommendation, the Commission is seeking a single report. Where a number of parties are responsible for a recommendation, the Commission would appreciate one party coordinating a single, consolidated report. Further, with respect to Recommendations 6.4 and 8.2, it would assist the Commission if the Municipal Association of Victoria coordinates the Implementation Plan and Delivery Report, consolidating the responses by relevant individual municipal councils. The recommendations from each chapter are listed below (not all chapters contain recommendations).

23 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

INTERIM REPORT RECOMMENDATIONS

Chapter 4 Warnings

RECOMMENDATION 4.1

The State ensure that bushfire warnings issued in Victoria:

■■ are founded on the principle of maximising the potential to save human lives;

■■ embody the principles encapsulated in Recommendation 8.5 of the Council of Australian Governments report, the National Inquiry on Bushfire Mitigation and Management (2004);

■■ embody the principles endorsed in the Australasian Fire and Emergency Service Authorities Council Draft Discussion Paper, A National Systems Approach to Community Warning (May 2009); and

■■ incorporate the use of the Common Alerting Protocol, as adapted for the Australian context. RECOMMENDATION 4.2

The State ensure that the content of bushfire warnings issued in Victoria reflects the principles set out in the Commonwealth policy paper Emergency Warnings — Choosing Your Words (2008). In particular, all bushfire warnings issued in Victoria must use clear language, avoid euphemisms, and contain explicit information in relation to:

■■ the severity, location, predicted direction and likely time of impact of bushfires on specific communities and locations; and

■■ the predicted severity of impact of the bushfire and whether a specific fire poses a threat to human life. RECOMMENDATION 4.3

The State commission research into the development of a new fire severity scale that denotes the risk posed by dangerous and extremely dangerous bushfires (similar to the cyclone categories 1 to 5). RECOMMENDATION 4.4

The State ensure bushfire warnings in Victoria are confined to two categories or stages:

■■ Bushfire Information — a message providing information to the community on a bushfire that is ‘going’ and has the potential to threaten public safety; and

■■ Bushfire Warning — a warning to the community about any dangerous or extremely dangerous bushfire, particularly one that is burning out of control and poses a threat to human life. RECOMMENDATION 4.5

The State ensure that the Standard Emergency Warning Signal (SEWS) be used in Victoria to precede each bushfire warning or group of warnings for bushfires that are dangerous or extremely dangerous, particularly for a fire that is burning out of control and poses a threat to human life, subject to appropriate limits on the maximum frequency of use. RECOMMENDATION 4.6

The State invite commercial operators to enter into a Memorandum of Understanding (MOU), similar to its MOU with the ABC, on the dissemination of bushfire warning messages and the use of the Standard Emergency Warning Signal by those operators.

24 Executive Summary

RECOMMENDATION 4.7

The Office of the Emergency Services Commissioner and the CFA develop guidelines for the use of sirens in communities that decide to use a siren as part of their response to bushfires. RECOMMENDATION 4.8

The Australian Government, Council of Australian Governments and the State determine whether it is technically possible to implement the second phase of the national telephony-based warning system (that is, the delivery of warning messages to mobile phones based on the physical location of a handset at the time of the emergency) with a view to implementation for the 2009–10 bushfire season.

Chapter 5 Information

RECOMMENDATION 5.1

The Australasian Fire and Emergency Service Authorities Council and the Bureau of Meteorology collaborate with researchers to explore options for the fire danger indices and fire danger ratings including:

■■ an additional fire danger rating beyond ‘Extreme’;

■■ adjusting the existing fire danger ratings to correspond to higher Fire Danger Index values; and

■■ developing a revised fire severity scale for use in bushfire warnings based on new fire danger ratings. RECOMMENDATION 5.2

The Bureau of Meteorology include the Forest Fire Danger Index and the Grass Fire Danger Index in its fire weather warnings and general weather forecasts on its website and in material distributed to the media. RECOMMENDATION 5.3

The State ensure that a single, multi-agency portal for bushfire information be established that uploads information simultaneously to both CFA and DSE websites. RECOMMENDATION 5.4

The State ensure that the single multi-agency portal for bushfire information be designed to allow Incident Control Centres to directly post information and warnings. RECOMMENDATION 5.5

The State ensure the Victorian Bushfire Information Line is funded to enable it to provide greater surge capacity during extreme events and to improve the efficiency of its internal information function.

25 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Chapter 6 Relocation

RECOMMENDATION 6.1

The State amend the State Emergency Response Plan so that the word relocation is used in preference to the word evacuation (except in cases where evacuation is clearly more appropriate). RECOMMENDATION 6.2

The CFA amend its policy Advice to the Community Before and During Wildfire to enable trained CFA personnel to recommend to particular households, communities or locations that they plan to leave early, based on an assessment of defendability, the vulnerabilities of the people there, and the degree of ease with which people are able to leave the area in relative safety. RECOMMENDATION 6.3

The CFA and DSE amend operational policies to require the Incident Controller to assess whether relocation should occur and to recommend relocation when warranted. RECOMMENDATION 6.4

Municipal councils review their Municipal Emergency Management Plans to ensure there is appropriate provision for relocation during bushfires, in particular, to indicate the location and arrangements associated with designated emergency relief centres.

Source: AAP Image 26 Executive Summary

Chapter 7 Stay or Go

RECOMMENDATION 7.1

The CFA revise the publications and programs by which it communicates with the community about preparing for bushfires and what to do in the event of a bushfire to:

■■ reinforce existing advice that community members should prepare, and decide, well before a fire occurs, whether to leave early or stay and defend their homes; and

■■ clearly convey the following principles: −− the safest option is always to leave early rather than to stay and defend, −− not all homes are defendable in all circumstances and householders are advised to undertake an individual assessment of defendability, −− unless a property is defendable the advice is to leave early, −− the impact of topography, fire weather and fire intensity on defendability should be factored into household assessments, −− the risks of staying to defend include the risk of physical injury and death, −− contingencies are needed as the best-made plans may fail, −− even if a plan is to stay, preparations to enable leaving should also be made, including the preparation of a ‘relocation’ kit specifying the location of designated community fire refuges, −− there could be psychological impacts of staying to defend a property, −− it is inadvisable for children to be present during the defence of properties, −− practical steps are needed to protect the vulnerable. Families with young children, older people, and disabled people are advised to plan for early relocation, −− advice on triggers for when to leave to incorporate the need for flexibility, the dangers of leaving late and the undertaking that a warning may not be received, and −− advice in relation to the policy specifically targeted to urban communities on the urban/rural interface. RECOMMENDATION 7.2

The CFA consider the means of providing individual advice to residents in bushfire prone areas, as to the defendability of their homes. RECOMMENDATION 7.3

The CFA ensure its members are fully trained as to the changes to the advice to the community set out in Recommendation 7.1. RECOMMENDATION 7.4

The CFA train facilitators and educators and ensure manuals, brochures and other materials are enhanced to incorporate changes to the advice to the community in relation to the ‘stay or go’ policy and the changes recommended elsewhere in this report. RECOMMENDATION 7.5

The State and its agencies implement an advertising and awareness campaign on the changes to policy and practices as set out in this report, such as the Standard Emergency Warning Signal, telephony-based warning system, use of sirens by local communities, refuges and relocation.

27 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Chapter 8 Risk and Refuge

RECOMMENDATION 8.1

The CFA report to the Commission on the outcome of the trials of the Victorian Fire Risk Register and progress with its implementation. RECOMMENDATION 8.2

The Municipal Association of Victoria report to the Commission on the progress of amendments to Municipal Emergency Management Plans by those municipal councils trialling the Victorian Fire Risk Register. RECOMMENDATION 8.3

The CFA give priority where possible to provide resources to assist in the defence of designated community fire refuges and neighbourhood safer places at times when they are likely to be in use. RECOMMENDATION 8.4

The State replace the 2005 Fire Refuges in Victoria: Policy and Practice following its current review by the Office of the Emergency Services Commissioner. RECOMMENDATION 8.5

The State promulgate criteria for the identification and operation of neighbourhood safer places, and involve councils and local communities in their development and implementation as appropriate. RECOMMENDATION 8.6

The State to have commenced progressively identifying, establishing and advertising designated community refuges and neighbourhood safer places, giving priority to areas where bushfire risk is identified as high. RECOMMENDATION 8.7

Municipal councils record the location of designated community fire refuges and neighbourhood safer places in Municipal Fire Prevention Plans and Municipal Emergency Management Plans, and inform residents and visitors about their use and location. RECOMMENDATION 8.8

The State to have developed uniform signs for designated community fire refuges and neighbourhood safer places in Victoria. RECOMMENDATION 8.9

The CFA maintain an up to date, state-wide list showing the precise location of all designated community fire refuges and neighbourhood safer places, and provide the list to DSE, Victoria Police, the State Emergency Service, the Municipal Association of Victoria, the Office of the Emergency Services Commissioner, and the Victorian Bushfire Information Line. RECOMMENDATION 8.10

The State report to the Commission on the results of the implementation and effectiveness of its township protection plan program and neighbourhood safer places program.

28 Executive Summary

RECOMMENDATION 8.11

The Department of Education and Early Childhood Development complete a review of all refuges in all schools in areas at risk of bushfire. RECOMMENDATION 8.12

The Department of Education and Early Childhood Development give priority to rectification works to refuges identified in the Victorian Managed Insurance Authority report. RECOMMENDATION 8.13

The Department of Education and Early Childhood Development review the adequacy of bushfire fire protection measures in children’s services facilities including kindergartens, child care centres, preschools and early learning centres.

Chapter 9 Incident Management: a Case Study

RECOMMENDATION 9.1

The State ensure that State Duty Officers of the CFA and DSE be given direct responsibility for ensuring pre-designated level 3 Incident Control Centres within their respective control are properly staffed and equipped to enable immediate operation in the case of a fire on high fire risk days. RECOMMENDATION 9.2

The CFA and DSE agree procedures to ensure the most experienced, qualified and competent person is appointed as Incident Controller for each fire, irrespective of the point of ignition of the fire. RECOMMENDATION 9.3

The CFA and DSE ensure that where a level 3 Incident Controller or officer of equivalent ranking is satisfied that a bushfire warning is required, then such Incident Controller is authorised to release a warning where the designated Incident Controller is temporarily unavailable. RECOMMENDATION 9.4

The State amend the Country Fire Authority Act 1958 to provide that the Chief Officer has responsibility to issue warnings and provide information to the community concerning the risk of bushfires. RECOMMENDATION 9.5

The CFA effect a standing delegation of the responsibility for providing information and issuing warnings to the DSE Chief Fire Officer where a fire is directed to be under the control of a DSE Incident Controller.

29 2009 Victorian Bushfires Royal Commission—Interim Report

EXECUTIVE SUMMARY

Chapter 10 Emergency Management

RECOMMENDATION 10.1

The State amend the State Emergency Response Plan:

■■ so the control agency for a fire is responsible for issuing and communicating warnings; and

■■ to remove from emergency response coordinators the responsibility of ensuring the control agency gives consideration to alerting the public to dangers and potential dangers arising from an emergency. RECOMMENDATION 10.2

The State revise the Emergency Management Manual Victoria consistent with the interim report recommendations in relation to the ‘stay or go’ policy, warnings and relocations. RECOMMENDATION 10.3

The State settle the higher level emergency management and coordination arrangements that will apply during the bushfire season, noting that the Commission intends to take evidence on longer-term arrangements during its 2010 public hearings. RECOMMENDATION 10.4

The State report to the Commission on the outcome of the current review by Victoria Police of the State Emergency Response Plan. RECOMMENDATION 10.5

Victoria Police, in consultation with CFA and DSE, review the guidelines for the operation of roadblocks during bushfires, including how to:

■■ formulate the terms of a discretion to police on roadblocks to allow entry to: −− residents returning to their homes; −− people delivering relief and aid to residents and to animals; −− essential services crews; and

■■ expedite the exercise of the discretion in favour of persons able to establish their bona fides. RECOMMENDATION 10.6

The CFA and DSE amend operating protocols to ensure that when an Incident Controller requests Victoria Police establish a roadblock to an area threatened by a bushfire, the Incident Controller simultaneously issues a bushfire warning to residents of that area.

30 Executive Summary

Chapter 11 Commonwealth Response

RECOMMENDATION 11.1

The Commonwealth facilitate discussions between relevant Commonwealth agencies (including Emergency Management Australia, Defence, Defence Imagery Geospatial Organisation and Geoscience Australia) and state and territory fire services to identify ways in which Commonwealth resources might be applied more rapidly and effectively during extremely dangerous bushfires, including investigating the potential for these resources to be used for detecting, tracking and suppressing bushfires. RECOMMENDATION 11.2

The Commonwealth, through Emergency Management Australia, provide briefings at least once a year to state and territory agencies regarding arrangements available (including through Defence) to support jurisdictions during disasters and emergencies, including bushfires. State and territory representatives should advise relevant Ministers and the Chief Officers of emergency services (including fire services) of the outcomes of these briefings.

Chapter 12 Emergency calls

RECOMMENDATION 12.1

The Office of the Emergency Services Commissioner formally advise the Emergency Services Telecommunications Authority and Telstra Triple Zero of forecast severe fire risk days and particularly days where there is a risk of extremely dangerous bushfires. RECOMMENDATION 12.2

The State ensure the Emergency Services Telecommunications Authority (ESTA) is funded to provide greater surge capacity during extreme events, including establishing additional work stations for fire calls at ESTA centres. RECOMMENDATION 12.3

The State further promote, through the Council of Australian Governments, more effective emergency call service arrangements throughout Australia.

31 2009 Victorian Bushfires Royal Commission—Interim Report

Source: AAP Image 32 introduction 2009 Victorian Bushfires Royal Commission—Interim Report

introduction

Overview of 7 february 2009 1. In February 2009 the whole of south‑east Australia was experiencing a severe and protracted drought — a drought without precedent.1 During January 2009 many locations in Victoria experienced no rain at all. Most other locations were at near record lows.2 The drought continues.3 2. In late January 2009 exceptional heatwave conditions developed across Victoria, the most severe and prolonged in the history of south‑east Australia.4 On 7 February many all-time temperature records were set. In Melbourne the temperature reached 46.4°C. The previous record was 45.6°C, set on Black Friday, 13 January 1939.5 The duration of the heatwave was exceptional, with Melbourne setting a record for the most consecutive days above 43°C (three days).6 3. The countryside was parched. The heat and drought desiccated the vegetation of the forest floor.7 The fuel loads were extremely high.8 Those responsible for managing and fighting fires in Victoria compared the conditions with 1939 — prior to 7 February 2009 the most catastrophic bushfire season in Victorian history. They held a foreboding. There was an understanding that the landscape of Victoria was predisposed to ‘a catastrophic event’.9 4. This dreadful expectation was matched by the calamity that descended on parts of Victoria on 7 February. The fires were ‘so extreme, so feral, so catastrophic, so devastating’.10 The Chairperson of the 2009 Victorian Bushfires Royal Commission (the Commission), Bernard Teague, used these words to attempt to convey the sheer brutality of the impact of the fires, yet in a way they do not. Those who fought the fires, strived to save their homes, witnessed the force of fire after taking shelter, or were in communication with loved ones, now deceased, have provided more than words to the Commission. They have given a personal and emotional content to the evidence that has helped the Commission understand the nature of these terrible fires and the almost overwhelming loss that followed. 5. Long-serving Country Fire Authority (CFA) officers had not experienced such fires. The speed, the roar, the wind and the spotting were exceptional.11 The fires enveloped everything in their path: ‘it just came at people from — yes, they didn’t have a chance’.12 The rate of spread of the fires equalled the maximum previously recorded, and the prolific spotting made fire behaviour on the day unique. The flames leapt 100 metres into the air, generating heat so intense that aluminium road signs melted.13 The plume of the fires created a convection effect that generated winds so strong that trees appeared to be screwed from the ground.14 Tree trunks snapped because of the ferocity of wind.15

Source: AAP image 2 Introduction

6. One hundred and seventy three people died in these fires — one of the greatest peacetime tragedies in Australia’s history. The personal cost cannot be over-estimated. We have glimpsed the ruin and observed the raw emotions of those left behind. Whilst physical recovery is underway, many of the losses sustained can never be healed, and recovery will never be complete.16 7. It is against this background that the Commission was established and three Commissioners were appointed and required to produce an interim report by 17 August 2009 and a final report by 31 July 2010 (Box 1).

Box 1: The Commissioners

The Hon Bernard Teague AO, Chairperson, retired from the Supreme Court in 2008 after serving 20 years on the bench, the last six as Principal Judge of the Criminal Division. He was the first practising solicitor appointed as a judge of the Court in 1987. As a solicitor he specialised in libel cases. As a judge he presided over more than 90 murder trials. He has also chaired the Adult Parole Board. He was made an Officer of the Order of Australia on Australia Day in 2009. Mr Ron McLeod AM led the inquiry into the operational response to the 2003 ACT bushfires. He has been a career official in the Australian Public Service since 1958. He was a Senior Executive in the Public Service Board for many years before serving as a Deputy Secretary in the Department of Defence for 12 years. Mr McLeod has more recently been the Commonwealth and Defence Force Ombudsman, as well as the ACT Ombudsman. Ms Susan Pascoe AM has been a full-time Commissioner with the Victorian State Services Authority since September 2006 and chaired a number of Government inquiries. She was formerly Chief Executive of the Catholic Education Commission of Victoria, Chief Executive of the Victorian Curriculum and Assessment Authority, President of the Australian College of Education and Chair of the Australian National Commission for UNESCO. Ms Pascoe has contributed to state, national and international efforts to improve the quality and equity of education.

COMMISSION PROCESS 8. The scale of the tragedy of 7 February warranted the establishment of an independent body to ascertain what happened and to determine, as far as is possible, what needs to be done to reduce the likelihood of such loss of life again. A Royal Commission is well suited to undertaking such a task. For the purposes of the interim report, a short description of the nature of such a Commission is set out. 9. A Royal Commission is an administrative inquiry established by Executive Government and is a mechanism by which Executive Government obtains information. 17 The Commission is directed to inquire into and report on the fires that burned in late January and February 2009, and recommend on policies for preparation and response to bushfire. (The Commission’s terms of reference are at pages VI–IX of this report.) 10. While a Royal Commission reports to the Executive Government, by long tradition it operates independently. A Royal Commission is a valuable mechanism by which the circumstances of the involvement of government or government agencies in an event like the 7 February bushfires can be thoroughly examined in a public setting. 11. A Royal Commission has broad investigative powers. Its proceedings are generally inquisitorial and it is not subject to the strict rules of evidence that apply to a court of law. In this way, a Royal Commission is suited to uncovering facts that may not otherwise be discovered. Unlike a court of law, a Royal Commission is not under a duty to reach definitive conclusions. It has a legal duty to report and the report is limited to explaining what the Commission has done, what conclusions were drawn from its investigations and what advice it should give the Executive Government based on its deliberations.18

3 2009 Victorian Bushfires Royal Commission—Interim Report

introduction

12. When witnesses give evidence during the hearings of the Commission, that evidence is led and tested by Counsel Assisting. Counsel Assisting exercises the function of managing the investigations of the Commission, of reviewing the material that is generated by those investigations and of determining the evidence that should be led in public hearings. Part of the function of Counsel Assisting is to test the evidence that is given, even if that is an uncomfortable experience for witnesses concerned. It is important that this process be undertaken so that the Commission can be confident it can rely on the evidence placed before it. 13. Ultimately, the three Commissioners must decide what conclusions are drawn from the evidence that is called. It is the role of Counsel Assisting to undertake the detailed investigation work of the Commission, to ensure that any person who may be affected by the Commission’s findings may be confident that the Commissioners have approached the hearings with open minds. 14. In evaluating the evidence, while not bound by the legal system’s rules of evidence, the Commission has been mindful of those rules, for they represent the means worked out by the courts over many years for identifying the kinds of material that can safely be relied on.19 The Commission is therefore confident that the conclusions reached in this interim report are based substantially on material that would be admissible in a court of law. That evidence consists primarily of sworn evidence given during the Commission’s hearings and documents that have been tendered. 15. As the work of the Commission continues, and its focus shifts from investigating the events of 7 February to the question of reform, some different methods for obtaining relevant information will be employed to ensure an efficient use of time. In so doing, the Commission will continue to be mindful of the rights of individuals and the need to have regard to natural justice and procedural fairness. Details of these other methods will be available in due course.

Source: Courtesy of The Herald & Weekly Times 4 Introduction

the interim report 16. From the outset, the Commission took the view that its work should be accessible to individuals and communities directly affected by the fires, to the broader Victorian and Australian community, and to those from the international community with an interest in its work. 17. The Commissioners made it their first priority to listen in their local communities to people affected by the fires. These powerful sessions provided a human backdrop to the Commission’s deliberations and helped the Commissioners identify themes and priorities for their work. In addition, witnesses with direct experience of the fires have appeared formally before the Commission to tell of their experience and to provide opinions. The human dimension of the fires has also been vividly relayed in many of the written submissions that individuals, families, community groups and organisations have sent to the Commission. 18. To make its work accessible to as broad an audience as possible, the Commission moved quickly to establish a website and phone inquiry line, place submissions on its website, have the formal hearings streamed live on the world wide web, and have the transcripts of each day’s hearings made available the following day. 19. The Commission was required to produce an interim report that addressed matters that are amenable to immediate actions that could be taken for the 2009–10 bushfire season. This necessitated that the Commission identify relevant issues that could be the subject of evidence and would inform the interim report recommendations. The effort required to produce such evidence before the Commission, and consequently to report by 17 August, should not be underestimated, particularly given the time needed to set up an independent body at the outset, and to conduct the community consultations. To achieve the objectives for the interim report the Commission took oral evidence from 87 witnesses over a concentrated period of 37 days of hearings.20 Thousands of documents relevant to matters before the Commission have been read and considered. 20. This first block of hearings focused on warnings and information provided to the community on bushfires, to enable the Commission to make recommendations on vital issues that are important to the preservation of human life. 21. The evidence called focused on the provision and communication of community warnings. The evidence ranged from the use of modern telecommunications to the use of local sirens. Particular warnings issued and the prediction of fire were considered. The background and use of the Prepare, Stay and Defend or Leave Early Policy — the ‘stay or go’ policy — was the subject of evidence, as was the issue of fire refuges. 22. The interim report is a preliminary report produced to meet the specific direction of the terms of reference. The Commission has already received a volume of evidence that will not be reviewed in this interim report because it relates to matters more appropriate for the final report. 23. While accepting the need for the Commission to make recommendations in this interim report, the State and the Commonwealth both submitted that the Commission should refrain from making findings of fact in the interim report. These submissions are in part based on a concern to prevent possible damage to the reputations of particular individuals and organisations. 24. The Commission recognises the need for care in relation to findings and recommendations in the interim report. The evidence is not complete in a number of areas that have come under scrutiny in the Commission. The Commission understands that, in some cases, an impression may be given by partial evidence that would change once all the evidence on the subject is received. 25. The Commission has decided that where evidence does not relate directly to any recommendations made in this interim report, it will refrain from making any findings about that evidence until it releases its final report. The Commission has taken this approach even in relation to matters that it thinks are unlikely to be the subject of any further evidence, because in the absence of any pressing need to make such findings in this interim report, it is preferable to reserve judgment so as to ensure that any interested person has the greatest opportunity possible to put relevant evidence or submissions before the Commission. 5 2009 Victorian Bushfires Royal Commission—Interim Report

introduction

26. The Commission has had to reach conclusions on some issues of fact to enable it to frame the recommendations. The Commission is satisfied that the recommendations contained in this interim report are based on a solid evidentiary foundation. 27. The Commission notes the remarks of Justice Stretton in the introduction to his Commission Report provided after the bushfires of 1939: ‘that facile wisdom which comes after an event is not wisdom, but foolishness’. 21 In deliberating over evidence and making recommendations, the Commissioners are aware that they are reviewing events through the prism of hindsight.

STRUCTURE OF INTERIM REPORT 28. To provide context to the later analysis, the first chapter of this report presents a summary of the main fires that burned in Victoria in January and February 2009. This is followed by chapters on the various means of community engagement, and a summary and analysis of the contents of written submissions. 29. Matters that were dealt with in the formal hearings, which have a bearing on the interim report, are treated in chapters on warnings, bushfire information, relocation, the ‘stay or go’ policy, risk and refuges, incident management, emergency management, the Commonwealth response and emergency calls. The final chapter notes issues that will be the subject of future hearings. 30. A number of matters discussed in this interim report have been referred to parties for trialling, further investigation or further consideration. These matters will be the subject of reports and are listed in the final chapter.

protection of human life 31. The loss of 173 lives and the destruction caused by the fires on 7 February were the principal reasons for the constitution of this Commission. In his opening address, the Commission Chairperson proposed that the protection of human life should be the general focus to guide the work of the interim report. This position was supported by the State and other represented parties. The evidence given by witnesses and the views expressed in the many hundreds of submissions provided to the Commission further confirm the overwhelming desire of the Victorian community to avoid a loss of life on such a scale again. The Commission adopts the protection of human life as the fundamental guiding principle in framing the recommendations for this interim report and hopes that this principle will also motivate those responsible for implementing the Commission’s recommendations.

Shared responsibility 32. The various roles played by fire agencies in preparing the community and in protecting lives in the circumstances of 7 February have weighed heavily in the Commission’s consideration of the evidence, and in its reflections and recommendations. Such an emphasis is a natural and proper feature of an inquiry of this kind. However, the necessary focus on the role of agencies and the State should not obscure, and should not be seen as diminishing, the responsibility of the community in preparing itself for, and protecting itself against, the extreme hazards posed by bushfires. 33. The long-term aim expressed in the Victorian policy and legislative framework for community safety in bushfires is to build resilient communities, meaning those in which individuals, households and entire communities are able to effectively draw on personal, social and structural resources to positively take steps to protect themselves against the risks posed by bushfires. This approach uses the language of partnership between agencies and communities. Agencies, as an embodiment of the state, accept responsibility to educate and inform and to protect the community using the resources available to them. Community members accept responsibility for their own decisions.

6 Introduction

Source: Courtesy of The Herald & Weekly Times 7 2009 Victorian Bushfires Royal Commission—Interim Report

introduction

34. The Commission’s recommendations should be read and understood with an appreciation that where agency action is recommended, community participation is implied. Where warnings are required, so too is a commitment by the community to be alert to fire weather conditions, to tune in to warnings, and to act on them. Where agencies are asked to assist with tools and advice to assess defendable space, community members are asked to use every available resource to assess and prepare their properties. Designated community fire refuges and ‘neighbourhood safer places’ are important. So too are privately arranged safer places. Agencies must actively promote awareness about bushfire and preparedness. The community must avail itself of the educational resources provided, and must take seriously the obligation to prepare.

emergency services personnel 35. The CFA is justifiably a proud organisation. The history of the CFA has been detailed before the Commission. Time after time, over the decades since its formation, its members have been prepared to make enormous sacrifices for the good of the Victorian community, sometimes at the cost of their lives. The evidence of the Chief Officer of the CFA is that the organisation comprises 59,000 volunteers supported by 400 career firefighters and 700 career support and administrative staff.22 The self-sacrifice and bravery of the men and women who volunteer, and the State’s continuing debt to these people, were highlighted by the events of 7 February. 36. The firefighters of the Department of Sustainability and Environment (DSE) and the Metropolitan Fire and Emergency Services Board (MFB), and firefighters from other Victorian fire authorities, from elsewhere in Australia and overseas, also deserve similar praise for their generosity and commitment in assisting their CFA colleagues, and the residents of Victoria, during the bushfires. 37. On 7 February the State of Victoria called on men and women in a number of other services and agencies to help manage the devastation that lay in the wake of the fires. A mighty response was mounted. Those associated with CFA, DSE, MFB, Victoria Police, Victorian State Emergency Service, Emergency Services Telecommunications Agency, Victorian Bushfire Information Line, Networked Emergency Organisation agencies, the Australian Defence Force, businesses, not-for-profit organisations and members of the community generously responded and kept on responding in the days after the initial impact of the fires. Accounts of individual bravery and self-sacrifice have been provided in evidence and these illustrate the commitment of all. This was a magnificent contribution that we publicly acknowledge in this report. 38. The sacrifice and dedication of the thousands of volunteers is a striking example of the community taking responsibility for itself. So, too, are the many accounts of people helping each other in the midst of overwhelming fires and unspeakable loss. The Commissioners are hopeful and optimistic that the recommendations for changes to the legislative and policy framework will only strengthen an already resilient community. 39. Without in any way diminishing the outstanding contribution of all members of these organisations, the Commission’s role requires it to continue to examine the functions, protocols and administration of the main emergency service organisations so that lessons can be learnt from this disaster. The Commission’s primary guiding principle, the protection of human life, demands no less.

8 THE FEBRUARY 2009 FIRES 1 2009 Victorian Bushfires Royal Commission—Interim Report

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Box 1.1: Terminology to describe fire events

Area of fire – the area of burnt ground, measured in hectares, that a fire covers on the ground surface.

Blacking out – the process of ensuring that all stumps, branches and burning items are extinguished.

Contained – indicates that the spread of the fire is halted even though it may still be burning within the perimeter or control lines.

Control line – a natural or constructed barrier, or treated fire edge, used in fire suppression and prescribed burning processes to limit/prevent the spread of fire.

Crowning – occurs when the fire reaches the canopies of the trees; the fire may then jump, or run, from one crown to the next.

Direct attack – a method of fire attack where wet or dry firefighting techniques are used.

Dozer – an earth-moving vehicle with a large blade used to construct control lines.

Fire ground – the area in the vicinity of the wildfire and fire suppression operations, and the area immediately threatened by the fire.

Fire line – see control line (above).

Going – an assessment that a fire exists and is expanding.

Graders – an earth-moving vehicle with a small blade used to assist in the construction of control lines.

Indirect attack – the use of backburning as a method of suppressing and confining a fire.

Intensity – the heat output per length of fire line. Intensity is primarily influenced by the rate of spread of the fire and the quantity of fuel consumed.

Pumper – generally a 2WD firefighting vehicle, designed for urban operations, equipped with a large capacity pump and a limited capacity water tank. It requires reticulated water for firefighting operations.

Rappel crew – firefighting teams that abseil onto a fire ground via helicopter and ropes.

Rate of Spread – the forward progress of the head fire or another specified part of the fire perimeter (usually reported in kilometres per hour).

Red flag warning – critical warning for the fire group that necessitates an acknowledgment.

Safe – an assessment that no further suppression action or patrols are considered necessary.

Slip-on unit – equipment comprising a small water tank, a hose reel, a pump, and an engine that can be slipped onto a Land Cruiser or patrol-sized vehicle.

Spotting – the sparks and embers that are carried by wind and convective activity and that start fires outside the main firefront. Spotting and the development of spot fires most commonly occur in front of and around the lead edge of fires, but can also occur along the sides.

Strike team – usually five or six firefighting vehicles and crews deployed to operate as a cohesive unit on the fire ground.

Tanker – generally a 4WD firefighting vehicle, designed for rural operations.

Under Control 1 – a fire assessment that the complete perimeter of the fire is secured, no breakaway is expected, but continuous patrolling and mopping up is still required.

Under Control 2 – a fire assessment that the complete perimeter of the fire is secured and no breakaway is expected.

34 The February 2009 Fires

Source: AAP Image 35 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

This chapter presents a description of the main fires, their ignition and subsequent passage. The description of the Kilmore East fire is more extensive than others as it is the only fire that has been examined in depth during the public hearings, although there is still further evidence to be heard even in respect of that fire. The Commission will complete its examination of the Kilmore East fire and the other fires in the next block of hearings.

Introduction 1.1 This chapter provides the context for matters discussed in the interim report. The description of the fires is sourced principally from the evidence of Mr Russell Rees, Chief Officer of the Country Fire Authority (CFA), Mr Ewan Waller, Chief Fire Officer of the Department of Sustainability and Environment (DSE), together with evidence received from expert and lay witnesses. It focuses on fire ignition, its subsequent movement, and the broad fire agency response. Fire warnings are discussed in Chapter 4, although an outline of warnings for each fire is given below. 1.2 Accounts of the fires vary, as material was provided to the Commission in a range of formats. The narrative is incomplete since the Commission has yet to hear from many of the operational personnel who directly managed the fires. They will be able to provide further information to the Commission, as will other lay witnesses during future hearings. Once this additional information is received, this narrative of the fires will be updated for the final report. 1.3 A more comprehensive narrative of the Kilmore East fire is provided in the interim report, because the Commission has heard greater detail on this event. 1.4 Where timings have been provided in statements and evidence, they are outlined below. For the purposes of this chapter only, timings have been described using the 24-hour clock. Witnesses have drawn these from their own recollections or records, or from details on the CFA Incident Management System (IMS) and the DSE FireWeb.1 Where timings were not specified, they are absent. Fires are listed according to the time they were reported. Discussion on the fires is separated into:

■■ fire activity before 7 February

■■ fire activity on 7 February

■■ fire activity after 7 February. 1.5 To put this narrative of the fires in perspective, a summary of weather information provided by the Bureau of Meteorology (BoM) is set out first, followed by observations on fire behaviour.

The Weather 1.6 Weather conditions are invariably an important factor in all fire analysis, but a fuller understanding of the abnormal weather conditions leading up to, and on, 7 February is crucial to considering the subsequent impact of the fires. Weather information outlined below is largely drawn from the evidence of Dr Mark Williams, Regional Director of the Victorian Office of the BoM. 1.7 Central Australia has warmed 1.5–2.0°C over the last century.2 Over the last 12 years, Victoria has experienced warmer than average temperatures, and the last decade has been the warmest on record, breaking records going back 154 years.3 During the same period, there has been very little above average rainfall and most of Victoria received either below or well below average rainfall. A large portion of southern Victoria, notably the area that surrounds Melbourne, received the lowest rainfall on record. The same has been experienced in western Victoria.4 Dr Williams stated that:

The whole of south-east Australia has suffered a severe and protracted drought which is without historical precedent. In central Victoria the 12-year rainfall totals have been around 10 to 20 % below the 1961–90 average and 10 to 13 % below the lowest on record for any 12-year period prior to 1997.5

1.8 Across Victoria the average annual rainfall during this drought has been 555 mm, compared with 36 a long-term average (1961–1990) of 653 mm.6 The February 2009 Fires

Figure 1.1: Victorian rainfall deciles January 2009

Mildura Hay

Goulburn

Ouyen Wagga Wagga Swan Hill Canberra Deniliquin

Albury Echuca Cooma Perisher Valley Benalla Horsham Bendigo

Omeo

Ballarat Casterton Melbourne Bairnsdale

Geelong Latrobe Valley Portland Warrnambool Wonthaggi

Cape Otway Wilsons Prom.

February 2009

Mildura Hay

Goulburn

Ouyen Wagga Wagga Swan Hill Canberra Deniliquin

Albury Echuca Cooma Perisher Valley Benalla Horsham Bendigo

Omeo

Ballarat Casterton Melbourne Bairnsdale

Geelong Latrobe Valley Portland Warrnambool Wonthaggi

Cape Otway Wilsons Prom.

Source: Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0032 and 00347

Note: Rainfall deciles for January and February 2009 indicate that Lowest on record both months are ‘very much below average’.8 Across central and eastern Victoria, there is a strong association between drought Very much below average and the occurrence of major bushfires.9 Below average 37 Average 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Figure 1.2: Victorian annual mean temperature, 1910–2008, standardised against the 1961–1990 average

Australian Bureau of Meteorology 2

1

Mean T Anomaly (ºC)

–1

–2 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Source: Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 003010

Note: The annually averaged mean temperature for Victoria has deviated from the 1961–1990 average. The solid line represents an 11 year moving average.11 The grey areas indicate below average temperatures and the red areas indicate above average temperatures.12

2008–09 bushfire season 1.9 During the three months from October to December 2008, most of Victoria received near-average to above average rainfall.13 In contrast, the early part of 2009 was exceptionally dry, with below average to record low rainfall for January, particularly in central and western parts of Victoria. Melbourne had its second driest January on record. The dry weather continued during February 2009, with most of the western half of Victoria experiencing well below average rainfall.14 In fact, there was ‘dipole activity’, with wet monsoonal activity in northern Australia and very hot, dry conditions further south.15 1.10 After a relatively mild start to 2009, exceptional heatwave conditions developed across south-east Australia in late January. The last week of January witnessed one of the most severe, prolonged heatwaves in south- east Australia’s recorded history.16 Dr Williams noted that ‘very, very hot air and very, very high temperatures [were] experienced in Victoria during that period’.17 In southern South Australia, and much of central, southern and western Victoria, maximum temperatures widely reached their highest levels since at least 1939.18 Melbourne experienced three consecutive days over 43°C — a new record.19 1.11 The week leading up to 7 February was characterised by a series of high-pressure systems to the south of Victoria, which moved eastwards from the Great Australian Bight into the Tasman Sea. The air heated over land throughout this period, and this continued until 7 February. The set of charts in Figure 1.3, from 23:00 on 6 February to 05:00 on 8 February, demonstrate, in six-hourly intervals, the static high-pressure cell in the Tasman Sea on 7 February and the passage of the pressure trough across Victoria.20

38 The February 2009 Fires

Figure 1.3: The 6-hourly passage of the pressure trough across Australia on 7 February 2009

National Meteorological Oceanographic Centre National Meteorological Oceanographic Centre 11:00am EDT Friday 6 February 2009 5:00am EDT Saturday 7 February 2009

TC “Freddy” L L L x Check latest x L x 5 Kt L x 997 cyclone warnings 998 x 998 996 1000 1004 L 990 x 1004 1001 L x 998

1012 1012 1004 1020 1012 1012 35 Kt H 1004 1004 x H x 1011 H 1020 x 1018 1012 L 996 x 25 Kt L H 986 x x 1004 996 981 988 1014

National Meteorological Oceanographic Centre National Meteorological Oceanographic Centre 11:00am EDT Saturday 7 February 2009 5:00pm EDT Saturday 7 February 2009

TC “Freddy” 1004 Check latest cyclone warnings TC “Freddy” Check latest L cyclone warnings 5 Kt x L L x x 1000 2 Kt 998 988 1002 L L L L x 989 x x x 1007 999 1002 1005

1008

L 1020 1012 x 1004 L x H 1000 998 1016 H 1008 x 996 x 1016 30 Kt 1018 996 1019 1024 988 L 35 Kt x 976 L

National Meteorological Oceanographic Centre National Meteorological Oceanographic Centre 11:00pm EDT Saturday 7 February 2009 5:00am EDT Sunday 8 February 2009

TC “Freddy” TC “Freddy” L Check latest 6 Kt L x cyclone warnings x 989 2 Kt 1000 988 1000 Check latest L L x 1004 cyclone warnings 1004 x 1000 999

1012 1012 L L x x 1005 1020

1012 1020 1012 1012

1004 H x 1004 H x H 996 1020 H x x 996 1019 1026 988 1027 988

35 Kt 45 Kt

Map source: Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0042 21 39 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

1.12 As a result of these conditions, the BoM issued numerous forecasts and warnings of severe fire weather conditions in the week leading up to 7 February. The BoM also issued 205 public and fire weather publications (products) between 11:00 Friday 6 February and 05:00 Sunday 8 February.22

Weather conditions on Saturday 7 February 1.13 On the evening of 6 February, a high-pressure system located in the Tasman Sea was directing very hot air over much of Victoria. A cold front was located across southern Western Australia extending to the south of the Bight, and was moving eastwards towards Victoria.23 1.14 On 7 February temperatures rose quickly, and strong gale-force north-westerly winds began to reach ground level.24 By 11:00, temperatures were near 40°C, with relative humidity already below 20 per cent in many parts of the state. Both forest and grass fire danger indices were well into the extreme category by 11:00 in western and central Victoria. Fire danger indices (FDI) were approaching Extreme in the rest of Victoria.25 1.15 Many all-time site records were set in Victoria on 7 February, including Melbourne (154 years of records), where the temperature reached 46.4°C, far exceeding its previous all-time record of 45.6°C set on Black Friday (13 January 1939). It was also 3.2°C above the previous February record, which was set in 1983.26 1.16 During the day, temperatures reached mid 40°C in many parts of the state and relative humidity was mostly below 10 per cent. North-westerly winds had either maintained or increased in strength during the morning. Mount Gellibrand Automatic Weather Station (AWS) was by then recording storm-force winds (90 kilometres per hour), while winds of 40–60 kilometres per hour were recorded over much of the state. Forest and Grass Fire Danger Indices were significantly into the Extreme category in nearly all of the state.27 1.17 In the far south-west, a strong, gusty, south-westerly wind change entered the state at about 12:30, dropping temperatures and increasing relative humidity. At this stage no shower activity was associated with the change.28 Many places had now reported, if not their hottest day on record, then their hottest for February. Wind gusts to 115 kilometres per hour were reported at Mount William and Mount Gellibrand, while gusts over 90 kilometres per hour were recorded at a number of other sites.29 The strong and gusty south-westerly wind change moved eastwards at a rate of about 30 kilometres per hour. Fire danger ratings remained well into the Extreme category ahead of the wind change, and in central parts of the state these did not drop below Extreme until up to an hour after the change.30

Source: AAP Image 40 The February 2009 Fires

Figure 1.4: A post event analysis of the hourly surface positions of the wind change on 7 February 2009

MilduraMildura

Robinvale

Ouyen Walpeup Murrayville Swan HillHill

Hopetoun Kerang 12am

YarrawongaYarrawonga Albury Echuca RutherglenWodonga Hunters CorryongHill Charlton Wangaratta NhillNhill Ap Donald SheppartonShepperton Wangaratta Benalla

HorshamHorsham Ap BendigoBendigo Euroa Bright Mangalore Longerenong Falls Creek Redesdale Seymour Mt Hotham StawellStawell Castlemaine Mansfield EdenhopeEdenhope Avoca VICI Mt Buller OmeoOmeo Eildon Yea Mt Hotham Gelantipy Mt WilliamArarat Ap Kanagulk Kilmore Gap Combienbar Dargo BallaratBallarat Marysville CastertonCasterton Melbourne Ap Cann River Westmere Coldstream Mt Nowa NowaOrbost Mallacoota Hamilton Mt Baw Baw LavertonMelbourne Mt Moornape Bairnsdale Mallacoota Hamilton Sheoakes Mt Dandenong Bairnsdale Orbost Avalon Dandenong VICF Mortlake VACH Frankston Warragul EastSale Sale GeelongGeelong Ap Frankston LatrobeTraralgon Valley Warrnambool South Channel Is Portland Ap Mt GellibrandColac VICD 9pm Portland Warrnambool AireysAnglesea Inlet Cowes Cerberus Lorne Yarram Ap Port Fairy Wonthaggi Yarram Cape Nelson Rhyll VICJ Apollo Bay Pound Creek Cape Otway

Wilsons Promontory 3pm Noon 6pm Hogan Is

Source: Exhibit 3 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 004331

Note: Fixed and portable Automatic Weather Station (AWS) locations are indicated by place names. Stylised arrows indicate the north-westerly winds ahead of the wind change and south-westerly winds behind the wind change.32

41 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

1.18 Mr Rees described in his statement the weather features common to bushfire disasters in Victoria:33

… Wind direction propels the growth of a fire. Changes in wind direction can rapidly increase the size of fire, and the risks to fire firefighters and the general community. In Victoria hot dry winds often come from the north and northwest and are often followed by a southwest wind change. In this situation … the side of a fire can quickly become a much larger fire front (head of the fire).34

1.19 The passage of the south-westerly front was a feature of the ferocity and destruction of the Ash Wednesday fires.35 1.20 On 7 February the western district fires [albeit on a smaller scale] provided an indication of what was to come with the Kilmore East and Murrindindi fires:

■■ At Coleraine the eastern flank of the fire was not contained before the wind change at 13:23. There was concern for the township of Coleraine and fire behaviour was at its worst upon arrival of the change.36

■■ The Pomborneit fire initially threatened Swan Marsh township. The arrival of the south-westerly change at approximately 4:15 relieved the situation and turned the fire towards Lake Corangamite.37

■■ At Horsham the fire on the eastern flank was largely contained by the time of the arrival of the south-westerly change at 16:28 but it was recognised that, had the flank of this fire not been secured, the township of Horsham may have been threatened.38

The diagram below, taken from the statement of Mr Rees, depicts the impact of the south-westerly change on the fireground and the subsequent enlargement of the fire front.

Figure 1.5: Common fire behaviour in Victorian weather conditions

New fire head Point of origin

(a)

(c) a) fire being blown by a northerly wind b) southwesterly wind change c) the eastern flank has become a much larger fire front (b)

North

Head

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 005339

1.21 In the south, it took only minutes for the wind to change from north or north-west to south-west, while at some locations north of the ranges the change in wind direction took an hour or more.40 The thunderstorms forming in the smoke plumes above fires east and north east of Melbourne (known as pyrocumulonimbus) began to produce lightning (photo 1.1 and diagram 1.1).41 Due to the heat that is generated from the condensation, the pyrocumulonimbus cloud is likely to have doubled the intensity of the fires.42 Pyrocumulonimbi were formed because of the particular extreme weather and fire conditions on 7 February. The air mass was very hot and almost dry, although it did contain small amounts of water vapour. While the general direction of the surface fire was in a southerly direction, spotting also occurred to the east, due to 42 differences in wind direction at various levels of the atmosphere within the pyrocumulonimbus cloud.43 The February 2009 Fires

Photo 1.1: Massive convective plume on northern flank of the Kilmore East Fire at 15:25 Diagram 1.1: Pyrocumulonimbus cloud development

Cloud forms when moisture in rising air starts to condense

Mid-level winds

Air heated by fire carrying moisture and soot from Soot burnt fuel.

Hot Air Hot Air

Photo source: Richard Alder Source: Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R)­ at 006744 Source: Exhibit 22 – Statement of M Williams (WIT.013.002.0001) at 006845

1.22 To support the fire agencies, in 2007–08 the BoM placed a meteorologist in the then Emergency Coordination Centre for that fire season, and again in 2008–09 in the Integrated Emergency Coordination Centre (iECC).46 In addition, in 2009, it deployed 4 portable weather stations before 7 February, a fifth on 7 February, and 8 overall during the fire emergency.47 1.23 Ash Wednesday on 16 February 1983 is used by fire agencies as a benchmark for subsequent major fire events. Table 1.1, provided to the Commission by Mr Rees, indicates the forecast temperatures on 15 and 16 February 1983 compared with 7 February 2009. The more severe forecasts generally eventuated on 7 February 2009, highlighting their severity.

43 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Table 1.1: Comparison of fire weather estimates for 15 and 16 February 1983 and 7 February 2009

Relative Forest location Temp Humidity % Wind Dir Wind speed Wind change

Swan Hill 42 10 N 15 Swan Hill 42 10 N 25 Swan Hill 46 5 NW 40–65 SW 35 18–22 Hamilton 35 15 N 20 Hamilton 40 10 N 45 Hamilton 40 13 WNW 45–70 W 40 11–15 Bendigo 37 15 N 15 Bendigo 37 15 N 30 Bendigo 37 15 N 45–75 WSW 35 17–21 Ballarat 34 15 N 20 Ballarat 38 10 N 45 Ballarat 41 6 WNW 50–80 W 40 15–19 Shepparton 39 10 N 15 Shepparton 39 10 N 30 Shepparton 42 4 NW 45–75 SSW 30 20–00 Mangalore 38 15 N 15 Mangalore 39 15 N 30 Mangalore 43 5 NW 45–70 S 30 19–23 Melbourne 34 15 N 15 Sea breezes pm Melbourne 39 10 N 45 Melbourne (Tullamarine) 44 7 NNW 55–85 W 35 16–20 Orbost 34 20 NNW 15 Sea breezes pm Orbost 38 15 NNW 30 Orbost 40 14 NNW 20–40 SSW 35 20–00

Forecast issued at 17:00 hrs on 15/02/83 for 16/02/83 Forecast issued at 10:30 hrs on 16/02/83 for 16/02/83 Forecast issued at 14:45 hrs on 04/02/09 for 07/02/09

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 006748

44 The February 2009 Fires

Fire Behaviour 1.24 Fire behaviour results from the interaction of fuel, weather, topography and the fire itself. Overlaying this basic framework is a direct link between drought, increased fire activity and more intense fire behaviour.49 1.25 This summary of the fire behaviour on 7 February is drawn largely from the evidence of Dr Kevin Tolhurst, senior lecturer and researcher at the University of Melbourne. 1.26 The weather conditions leading up to 7 February, and the combination of the drought and the heatwave, led to increased combustibility and volatile fire behaviour because many of Victoria’s normally moist forests were dry.50 These forest fuels carried the fire more easily than ordinarily expected. In turn, this led to fires of exceptional severity. So the conditions leading up to 7 February not only dried out Mountain Ash forests, which ordinarily would have been too moist to burn, but also added additional fuel loads to these forests.51 1.27 Areas of bush had also died due to the cumulative effects of the drought over preceding years. Mr David McGahy, the Arthurs Creek-Strathewen CFA Brigade Captain who has lived in the area for 40 years, observed:

… [the bush] was dying because of the cumulative effect of all the dry years. It was in a lot of trouble, the bush. I remember talking to one of the DSE chaps and he said, ‘If we cop a fire through here, it’s had it, this bush. It’s not going to regenerate because it is under too much stress now.’ So it was extreme. The week before we had had two or three days of 45 and it was just extreme. We knew if it came, it was going to be something special.52

1.28 The fine fuels were desiccated by the conditions and they added again to the fuel load. Fine fuels respond much more to the short-term conditions such as the temperature, relative humidity and local wind conditions. Woody fuels — twigs, branches and fallen leaves — add to the heat coming off the burnt area. They also add considerably to the heat in the main convection column which, in turn, drives the fire. Normally those woody fuels burn behind the firefront and do not contribute much to the nature of the fire. However, when there is a large fire, under these dry conditions, they can add considerably to the convection column, which influences the whole firefront.53 1.29 The fires of 7 February did not progress in a single, easily distinguishable line — there was a ‘fire zone’ that extended kilometres ahead of the firefront.54 As described in the paragraphs below, this zone contained spotting that started further fires, which in turn burnt some areas well ahead of the main firefront. Subsequently, the main firefront passed over the same areas, further burning any remaining fuel. This process expedited the progress of the fires. 1.30 The fires varied in description and behaviour:

■■ classic grass and scrub fires in western Victoria55

■■ conventional bushfires progressing from ground fires to flame heights of 30(+) metres56

■■ extensive spotting directly sighted 13–14 kilometres ahead of firefronts and estimated up to 35 kilometres ahead of firefronts, with greater spotting over shorter distances, causing additional fires to ignite57

■■ spot fires further from the firefront, burning in the direction of the prevailing wind, while spot fires closer to the main firefront burnt back towards the fire.58

45 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Photo 1.2: Spot fire activity on the southern escarpment of the Hume Range, north east of Whittlesea, at 16:27, 7 February 2009

Photo source: Richard Alder Source: Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 006759

1.31 The fires did not progress in a neat linear movement across the countryside. It was a chaotic series of surging fires, with spontaneous spotting kilometres ahead of the firefronts.60 While flanks of the fires could be identified and in some cases secured, the heads of the fires were largely hidden in smoke and generated a deafening roar. Their location was not readily known until the fires were observed affecting houses, properties and other locations. From the Kangaroo Ground fire tower, Mr Gavin McCormack described the fire behaviour as: ‘the fire continued to spot in front of itself, but the fire kept catching up with the spotting. It looked liked waves of fire’.61 1.32 In summary, Dr Tolhurst advised the Commission that ‘the conditions that we saw on 7 February were as extreme as we have ever seen them’.62 7 February was anticipated to be, and in every respect turned out to be, a day of extreme fire conditions. 1.33 The fires and the conditions have been characterised in evidence before us as unprecedented.63 1.34 The volunteer Captain of the Kinglake CFA Brigade, Mr Paul Hendrie, provided the Commission with a memorandum distributed in his CFA region in preparation for 7 February. The memorandum referred to fire conditions including potential flame heights of 35 metres, spotting of 8 kilometres, a head fire rate speed of 2.5 kilometres per hour.64 In relation to fire tactics the memorandum stated ‘Crews should expect first attack to be ineffective unless the fire is small’.65

46 The February 2009 Fires

1.35 Dr Tolhurst thought these figures were based upon a fuel load of about 12 tonne per hectare, half the likely average in the Yarra Ranges and a long way short of the fuel loads observed in January by CFA personnel. Dr Tolhurst indicated the calculations contained in the memorandum were an underestimation of the likely conditions.66 Nevertheless, the information contained in the memorandum, and the flame height figure in particular, is important. The safe distance, because of heat radiation, from flame is calculated at four times flame height. Thus with a 35 metre flame height the safe distance from the fire is 120 –150 metres.67 Flame height of 35 metres indicates a crown fire — a fire driven by open wind leading to an increased rate of speed of the fire.68 1.36 Mr Waller provided the Commission with a chart that demonstrates the intensity of fires that burned on 7 February against other significant fire events.

Figure 1.6: The intensity of fires that burned on 7 February

Average Fireline Intensity (on flat ground) Based on max weather observations near to fire and existing models – assumes 25 t/ha fuel load –

kW/m FFDI

80,000

189 Black Saturday 7 Feb 2009 Ash Wednesday actual fire behaviour was as 70,000 high if not higher.

171 Ash Wednesday 16 Feb 1983 60,000

50,000 100 Black Friday Fire behaviour spectrum 13 Jan 1939 that we are unlikely to bridge with conventional control techniques.

40,000

87 Tatong Fire 16 Jan 2007

30,000

20,000

10,000 25 Active crown fire possible

Current limit to suppression (direct attack) 4,000 10 – aircraft, machines, water

<1,000 Planned burning – hand tools – 1939 technology

Source: Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 001769

1.37 Figure 1.6 indicates the limitations for direct attack on an intense fire. The fires of 7 February burned at a level of intensity of between 70,000 and 80,000 kilowatts per metre. Direct attack by conventional fire fighting techniques is restricted to fires of intensity of approximately 3500 to 4000 kilowatts per metres. This low level produces flame heights of just a couple of metres.70 1.38 In these circumstances, the importance of first attack, a quick response to the reported fire, was well understood. As Mr Rees pointed out in his evidence, ‘once out of control, containment could not be possible’.71 47 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Fires Examined 1.39 The CFA indicated there were a total of 1386 incidents reported on 7 February — 592 grass and bushfires, 263 structure fires and 156 reported incidents that were false alarms.72 The CFA identified 47 fires that had the potential to become ‘very severe fires’.73 A number of fires managed by DSE developed into large fires on public land but involved no threat to life or private property. Many of these fires were contained and extinguished. Of the fires that were not readily contained on or before 7 February, 14 of those 47 became ‘major fires’.74 1.40 The Commission has chosen to examine 12 fires where lives were lost or significant damage occurred. These are Kilmore East; Murrindindi; Churchill; Delburn; Bunyip; Narre Warren; Beechworth-Mudgegonga; Bendigo; Redesdale; Coleraine; Horsham; and Pomborneit–Weerite. 1.41 The Commission has recorded some detail in this interim report on each of these fires. More detailed evidence has only been received on the Kilmore East fire and is reflected in this report, though that evidence is also not complete. 1.42 In reporting these fire events and the response of the fire agencies, it is necessary to include technical terms used by the fire agencies. These terms are defined in the box at the beginning of this chapter (Box 1.1).

Naming of Fires 1.43 It became evident that the naming of fires was an issue on 7 February and it has remained an issue for the Commission. Fires were known by their point of origin, or by a name used early in the fire’s development. This became problematic on the day, as fires that began in one location spread rapidly; the continued reference to their point of origin confused many. This report refers to the fires by the names adopted by the Commission during evidence.

Warnings 1.44 This chapter provides limited information on warnings. Information was initially drawn from statements made by Mr Rees. The Commission received more information on warnings from 774 ABC Radio and its regional stations in Ballarat, Bendigo, Horsham, Mildura, Sale, Shepparton, Warrnambool and Wodonga.75 A short section on warnings is included for each fire to identify initial and critical warnings. However, this information is incomplete, and will be dealt with more comprehensively in later chapters. There is a more detailed discussion of warnings in Chapter 4 and some further analysis of warnings for the Kilmore East fire in Chapter 9.

Firefighting Resources 1.45 Significant state resources were mustered to fight the fires on 7 February and for weeks thereafter. The CFA comprises 59,000 volunteers supported by over 1100 career staff, firefighters and administrative personnel.76 The CFA indicated that on the day it engaged approximately 12,000 CFA firefighters, including those at Incident Control Centres (ICCs), and over 1000 operational vehicles. This reflects a considerable surge capacity. The State had close to 50 aircraft at its disposal but flying conditions on the day limited the use of fixed-wing aircraft.77 1.46 In comparison, Mr Waller indicated that DSE had 2347 public land firefighters available, with 569 ready for immediate deployment on 7 February.78 They maintained over 1000 firefighters on firegrounds in the week leading up to 7 February and over the subsequent four weeks. 79 The firefighters are often referred to as DSE personnel but are more correctly identified as Networked Emergency Organisation (NEO) personnel.80 The Metropolitan Fire and Emergency Services Board (MFB) also contributed crews to the fires, although specific numbers were not provided to the Commission.81

48 The February 2009 Fires

Fire Activity Prior to 7 February 1.47 There was considerable fire activity prior to 7 February and the account below is drawn from evidence to the Commission by Mr Waller.

2 February 1.48 On 2 February DSE firefighters were deployed at 64 fires: 20 were going, 21 were contained and 26 were considered under control. Most of these fires were caused by lightning. The NEO committed 1295 people to firefighting.82 (As noted above, technical fire terms are defined in the box at the beginning of this chapter.)

3 February 1.49 On 3 February DSE firefighters were deployed at 67 fires: 20 were going, 21 were contained and 26 were considered under control. Most of these fires were caused by lightning. The NEO also committed 1050 people to firefighting.83 1.50 Lightning overnight ignited Bunyip State Park (two fires) and lightning ignited another fire (Nariel Ski Hut Fire), 7 kilometres south-east of Nariel in north-east Victoria.84 1.51 All sectors of the Delburn fire were contained at 16:00 on 3 February but, as it was in difficult and heavily forested terrain, significant patrolling and blacking out was required on 4 February.85

4 February 1.52 On 4 February DSE firefighters were deployed at 35 fires: 10 were going, 10 were contained and 15 were considered under control. The NEO committed 1045 people to firefighting.86 1.53 The fire at Nariel Ski Hut in north-east Victoria continued to cause concern for firefighters. The fire was located in remote, inaccessible country, making containment difficult. Ground crew and aircraft were deployed to the fire.87 1.54 The Bunyip fire was reported to have started at 17:00 on 4 February.88

5 February 1.55 On 5 February DSE firefighters were deployed at 16 fires: 5 were going, 5 were contained and 6 were considered under control. The NEO committed 1051 people to firefighting.89 1.56 The Bunyip fire continued to pose a significant risk, with the potential to spread rapidly if not contained. In anticipation that this fire would not be safe by 7 February, an integrated CFA/DSE Incident Management Team (IMT) was established at the Pakenham ICC. Further strategies were developed to contain movement of the fire, and crews constructed mineral earth control lines around its perimeter.90

6 February 1.57 On 6 February DSE firefighters were deployed at 20 fires: 9 were going, 6 were contained and 5 were considered under control. The NEO committed 1365 people to firefighting.91 Of the going fires, the following were considered significant at that time and were being managed by DSE:

■■ Bunyip fires (going) — 123 hectares

■■ Nariel Ski Hut (contained at 10:00 on 5 February but still active)

■■ Dargo — White Timber Spur (going), started during the day from lightning.92 1.58 For the Dargo fire, rappel crews were sent in as initial attack, with retardant laid by aerial support, but feedback was that the fire was ‘too hot’ to contain.93 Additional crews from Dargo and heavy machinery were dispatched to assist.94 1.59 It was not expected that the Dargo fire and Nariel fires would cause ‘significant concern’ during the day of 7 February, nor that the Bunyip fire would affect the power line easement through the Bunyip State Forest.95 1.60 Given that the Bunyip fire did prove to be more significant than first thought, it is explained in more detail below. The Dargo fire is not examined further in this interim report. 49 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Bunyip

Figure 1.7: Bunyip Ridge Track fire progression map

Point of origin

Nar Nar Goon Garfield Bunyip

0 2 4 Kilometres

Drouin

Warragul

Source: Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 089596

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Fire Origin Parkland

Summary information Fire Danger Index The maximum fire danger index (FDI) was 81 at Coldstream AWS at 16:34 and an FDI of 111 was recorded at Latrobe Valley AWS at 13:30.97 Fatalities No fatalities98 House losses 24 houses99 Overall area burnt 26,200 hectares100 Firefighting resources At its peak, the fire was attended by 82 NEO personnel, in addition to tankers, dozers and 68 slip-on units.101 Also deployed were 900 CFA personnel and 159 appliances; 2 air cranes (up to 7 February); and 2 water-bombing aircraft (these were assigned concurrently as crews 50 were deployed).102 The February 2009 Fires

1.61 The township of Drouin, on the edge of this fire area, has a population of 8000 people. The fire area encompasses the rural area of Labertouche, with a population of 1000.103 1.62 At 17:21 on 4 February, a fire at Bunyip State Park — the Bunyip Ridge Track — was reported to DSE. The point of origin was 5 kilometres north-east of Tonimbuk, in native forest. As the fire was on public land, DSE was identified as the control agency. A joint DSE/CFA IMT was established at Belgrave on 4 February.104 When it became apparent that the fire would not be readily controlled and when more severe weather was forecast, the IMT relocated to Pakenham ICC on 5 February. During 5–6 February, the fire grew to approximately 170 hectares.105 1.63 As the fire had not been extinguished beforehand, planning for 7 February was carried out for a ‘worst case’ outcome. It was anticipated that, under strong northerly winds, the fire could escape and run towards private property and other assets. Fire spread predictions were prepared on 6 February for the period 12:00–23:00 on 7 February. These gave an indication that the fire would, without control measures, extend to at least Warragul and southerly to Drouin.106 1.64 At around 03:00 on 7 February, the fire breached control lines on the eastern flank, burning through Mountain Ash and mixed species forest, with considerable spotting. The fire could be seen clearly from the Mount Gordon fire tower near Marysville.107 Crews were withdrawn because of safety concerns. Fire behaviour was erratic for around 3 hours before it moderated around daybreak. It had travelled about 7 kilometres in a south-easterly direction into adjoining farmland.108 1.65 From daybreak, aircraft bombed the fire using water and retardant to hold, for as along as possible, the southern movement of the firefront. Major runs occurred after midday, ultimately burning out of the forest area into cleared land. 109 The fire spotted and ran extensively through the farmlands but the southern edge was largely controlled into the night of 7 February. With the wind change it moved extensively in the forest to the east.110 1.66 The fire was contained at 17:30 on 4 March, having burnt approximately 26,000 hectares, including nearly 19,000 hectares of forest and park. It was declared Under Control at 14:00 on 15 March.111

Warnings 1.67 Key emergency and infrastructure managers were briefed on the afternoon of 6 February. Community meetings were held in towns in the predicted path of a fire escape, including Tonimbuk, Labertouche and Jindivick. All meetings were well attended by residents.112 1.68 The first external update to the community was at 20:30 on 5 February.113 The first urgent threat message for Garfield North, Tonimbuk, Labertouche, Robin Hood, Drouin West, Buln Buln, Tarago, Jindivick, Jindivick North, Longwarry, Longwarry North and Bunyip was issued at 13:30 on 7 February.114

51 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Delburn

Figure 1.8: Delburn fire progression map

Thorpdale South

Yinnar

Delburn Allambee East

Darlimurla

Boolarra Dickies Hill Junction

Mirboo North

0 2 5 Kilometres Budgeree

Source: Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0111115

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Parkland

Summary information

Fire Danger Index Evidence not yet before the Commission Fatalities No fatalities116 House losses 30 houses117 Overall area burnt Evidence not yet before the Commission Firefighting resources Evidence not yet before the Commission

52 The February 2009 Fires

1.69 The Delburn fires were a group of three fires (Creamery Road, Ashfords Road and Delburn) that burnt in late January until they ultimately joined together.118 The Ashfords Road fire was reported at 07:00 on 28 January, the Creamery Road and Delburn fires were reported on the afternoon of 29 January.119 The fire was initially managed by CFA as the points of origin were on private land and the initial ICC Point was at the Fish Farm, north of Boolarra. Later on 29 January, the ICC was moved to the DSE offices in Traralgon, with DSE managing the fire.120 Overnight on 29 January the ICC was moved to Churchill.121 1.70 Poor communications between fire operations on the ground and the various ICCs (some distance away) hampered coordination of the firefighting effort. Communications around Boolarra were problematic and fire operations were assisted by the use of a Mobile Communication Van.122 Firefighters resorted to the use of their mobile phones with limited success. 123 In addition, Victoria Police roadblocks prevented an ambulance, water carriers, and firefighters (without identification) from proceeding to where they were needed.124 1.71 On 29 January, the IMT Operations Officer (the local CFA Group Officer) instructed Victoria Police to evacuate residents of McIntoshes Road, north of Boolarra.125 1.72 At 10:30 on 30 January, a town meeting was held in Boolarra where local community members were briefed on the fire by CFA representatives.126 During this meeting, at the suggestion of the CFA Captain, the local CFA Group Officer indicated he would sound the CFA siren when the town came under ember attack.127 This occurred at about 13:30 and is further described in Chapter 4.128 1.73 The fires were declared contained at 16:00 on 3 February, but because it was in difficult and heavily forested terrain, significant patrolling and blacking out was required subsequent to 3 February.129 The Churchill fire was originally considered a division of the Delburn fires before it was independently managed.130

Source: Courtesy of The Herald & Weekly Times 53 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Fire Activity on 7 February 1.74 The 7 February fires that ultimately proved difficult to contain and the times when they were reported are: (going — 4 February) Bunyip131 (going — 28 to 29 January) Delburn 132 11:49 Kilmore East133 12:26 Horsham134 12:36 Coleraine135 13:17 Pomborneit–Weerite136 13:33 Churchill137 15:00 Murrindindi138 15:11 Redesdale139 15:32 Narre Warren140 16:34 Bendigo141 18:09 Beechworth–Mudgegonga142

Figure 1.9: Fires adjacent to Melbourne on 7 February

Bendigo Maiden Gully

Seymour Mansfield

Redesdale

Kilmore East Complex Murrindindi Complex

Melbourne

Bunyip

Geelong

Morwell

Churchill / Jeeralang Delburn

Source: Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0132143

Note: The fires around Melbourne depicted on this map Interim Final Fire Perimeter produced by the Bushfire CRC, caused many of the deaths, 144 54 house destruction and burnt areas on 7 February. The February 2009 Fires

Kilmore East

Figure 1.10: Kilmore East interim fire progression map

Strath Creek

Point of origin at 11:47 hrs

Kilmore Flowerdale

Clonbinane

Glenburn

Kinglake West

Marysville Whittlesea Kinglake

Narbethong

St Andrews Dixons Creek Chum Creek

Healesville

0 4 10 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0097 145

Interim Final Fire Perimeter

Built Up Areas

Roads

Approx Point of Origin

Summary information Fire Danger Index The maximum FDI was greater than 100 at Kilmore Gap AWS at 14:42, and an FDI of 97.3 was reached at Viewbank AWS at 16:30.146 Fatalities 121 fatalities147 House losses 1244 houses148 Overall area burnt The combined total size of the Kilmore East and Murrindindi fires was 255,300 hectares.149 Firefighting resources The peak CFA resource commitment over the Kilmore East and Murrindindi fires was 514 appliances and 2750 people (the figures were not presented separately).150 At the time the fire crossed the Hume Highway at 14:00, 32 NEO tankers, 7 slip-on units, 8 dozers and 9 support vehicles were on the fireground.151 One air crane and 2 other helicopters were working the Kilmore East fire.152 An unknown number of MFB appliances were deployed to the Kilmore East fire by mid-afternoon.153

55 2009 Victorian Bushfires Royal Commission—Interim Report

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1.75 Towns in the heart of the fire area were Kinglake, Kinglake West, St Andrews and Wandong, all with a population of about 1500. Smaller towns affected included Toolangi, Dixons Creek, Chum Creek, Hazeldene and Clonbinane, each with a population between 500 and 900. The fires came close to Yarra Glen (population 2600) and Whittlesea (population 4500).154 1.76 At 11:49 the Emergency Services Telecommunications Agency (ESTA) took a call for a fire at Saunders Road, Kilmore East, in undulating pasture country interspersed with native vegetation alongside cleared and standing plantations. Initial reports were from the Mount Hickey fire tower, together with reporting on the ground through Triple Zero calls.155 At 12:08 the Kangaroo Ground fire tower operator sighted the fire and reported it to the Kangaroo Ground ICC.156 As the point of origin was on private land, the CFA was identified as the control agency for this fire.157 The Kilmore East fire was managed from the Kilmore ICC located at the Kilmore fire station.158 The Incident Controller was initially the local CFA Brigade Captain.159 He was relieved by a career staff member at 16:30.160 The Kangaroo Ground ICC operated as a Divisional Command on 7 February but overnight the management of the Kilmore East and Murrindindi fires was rearranged.161 According to the evidence of Mr Rees, from the morning of 8 February, Kilmore and Kangaroo Ground ICCs managed the Kilmore East fire and Alexandra and Woori Yallock ICCs managed the Murrindindi fire.162 1.77 The fuel loads in and around areas where the Kilmore East fire burned — Mount Disappointment, Humevale, Strathewen, Kinglake and Glenvale — were extremely high. Senior, highly experienced CFA volunteer officers inspected these areas 3 to 4 weeks before 7 February. They were horrified by the fuel loadings; 40 to 50 tonnes per hectare. There was a recognition they would be unable to control fire in these areas.163

The first phase of the fire 1.78 Mr Rees defined the first phase of the fire as ‘that period before it has crossed the Hume Freeway’.164 1.79 At about 11:50 5 local brigades (Kilmore, Broadford, Clonbinane, Wandong and Wallan) were paged to respond to the fire.165 At 11:51 the Kilmore Brigade received a second pager message to respond to a second fire on the Wandong–Kilmore Highway, 3 kilometres south of Kilmore. One pumper was deployed.166 At 12:02 a further 7 brigades were deployed, including the Midway Forest Industry Brigade.167 A strike team of 5 tankers responded about 30 minutes later.168 Aircraft were also requested; however, due to the conditions at the time, aircraft were ineffective in direct attack and were used to protect assets.169 A fire-spotting aircraft operated from about 12:30 to 13:30.170 Two aerial line scans were conducted at 12:45 and 12:55, leading to the production at the iECC of a fire prediction map at 13:40.171 A further map based on the line scan was produced at 17:43. The line scans were not passed to the ICC at Kilmore.172 According to Mr Rees, further line scans were not able to be completed until 21:45 that evening.173 1.80 Initial efforts were directed at controlling the fire before it crossed the Hume Highway into more open country; however, this was unsuccessful.174 At 12:45 it was requested that the Hume Highway be closed.175 The fire crossed the Hume Highway at Heathcote Junction at 13:58.176 At that time, the firefront was reported to be 3 kilometres wide, between Clonbinane Road and the Broadford–Wandong Road.177 The fire had a very elongated shape under the influence of north-westerly winds, with a length to breadth ratio of approximately 7:1.178 Given the terrain and fuel conditions, it was difficult for many appliances to access the fire edge from the north.179 Significant resources were deployed to the southern edge of the fire to protect townships from Whittlesea into the Yarra Valley and Healesville area.180 1.81 At the Kangaroo Ground fire tower, local weather observations at 13:45 were 47°C and relative humidity of 7 per cent.181 At about 14:30 winds were gusting 60–70 kilometres per hour and the temperature was 43°C.182 Burnt leaves were falling on the fire tower as early as 14:13.183

56 The February 2009 Fires

The second phase of the fire 1.82 Mr Rees defined the second phase of the fire as the period after it crossed the Hume Highway and went into the slopes of Mount Disappointment.184 1.83 Between 14:00 and 17:00 the firefront travelled another 6 kilometres under the influence of a 60–90 kilometres per hour north-westerly wind, through timber plantations and agricultural land, before entering forest areas. It then travelled across the Great Dividing Range at Mount Disappointment (reaching the base of Mount Disappointment at 15:30), and then onto the Whittlesea–Yea Road, just south of the settlement of Kinglake West.185 Spotting was reported at Smith Gully at 16:00.186 Between Wandong and Kinglake, the forest fuels of Stringybark and Peppermint species, with pockets of Manna Gum, Grey Gum and Mountain Ash, resulted in significant spotting.187 The fire travelled at up to 8 kilometres per hour to the crest of Mount Disappointment.188 1.84 On 7 February Arthurs Creek and Whittlesea CFA Brigades were not attached to strike teams.189 They were operating independently in their areas of responsibility.190 The Arthurs Creek–Strathewen Brigade Captain learnt of the Kilmore East fire from his Group Officer ‘some time after midday’.191 He did not receive any advice on the fire from the Kilmore ICC or the Kangaroo Ground Divisional Control Centre.192 His brigade first responded to fire (after several false alarms) at 15:43.193 He received a ‘red flag’ warning at 17:45 of a pending ‘very strong southerly change...in the next 10 minutes’.194 Once spotting commenced he was unable to access Strathewen but eventually drove into the hamlet at about 19:00.195 Nearly every structure in the hamlet was burnt.196 Analysis by the Bushfire Cooperative Research Centre (Bushfire CRC) suggests that the fires reached Strathewen from a north-westerly wind and also via a major firefront approaching from the south.197 1.85 At Kinglake, power failed across the town at 16:55 and soon after smoke was heavily entering the town from the direction of St Andrews.198 By 17:30 Kinglake was under heavy ember attack with spot fires occurring close to the CFA station. It was dark.199 Embers started burning in the town at 17:45. Ms Sharon McCulloch, owner and operator of the National Park Hotel described the experience: ‘Embers were now hailing down and being blown with such force onto the hotel roof that I thought there was every chance of something in or around the hotel catching fire’.200 Ms McCulloch and her husband managed to save their hotel, although this meant they could not actively protect their home. It survived. On reflection, she said:

There really didn’t seem to be any rhyme or reason why some buildings burnt and others didn’t. The firestorm was indiscriminate. Some people stayed to fight the fire and lost, some people evacuated and their houses remain standing.201

1.86 By the time the fire had reached the Whittlesea–Yea Road, it was reported to be approximately 6 kilometres wide.202 Between 17:00 and 18:00 spot fires were reported at Humevale, St Andrews (at 17:46) and Steels Creek.203 The Kangaroo Ground fire tower operators, Ms Colleen Keating and Mr Gavin McCormack, made the following observations:

… it just appeared out of nowhere … It appeared to have, like, jumped 10, 15 km, just the spotting … Then it took off like basically a main fire … It took off like a rocket.204

And subsequently:

A spotfire … is normally a gradual development. These were almost a spontaneous development into a large fire.205

1.87 Residents defending their homes described the fires from inside their houses. Mr John O’Neill, of Steels Creek, described the experience of his family:

Almost immediately, the fire front hit us … Burning embers slapped into our windows and the rest of the house ... it was like being inside a washing machine on spin cycle, and full of fire and embers … the firefront lasted about 45 minutes … we spent the following seven hours fighting the fires and defending our main house.206 57 2009 Victorian Bushfires Royal Commission—Interim Report

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1.88 The first reports of casualties were received at the Kangaroo Ground Divisional Control Centre at 17:00 from the Arthurs Creek Captain.207 The fire reached the National Park Hotel on Main Road, Kinglake at approximately 17:45.208 The Kangaroo Ground tower had advised by radio of the wind change occurring at Kangaroo Ground at 17:43.209 At 17:55 the tower recorded the wind change blowing at over 90 kilometres per hour and reported it to the fireground.210 By 18:00 CFA tankers, pumpers and communications vehicles were responding to new fires at Humevale, Strathewen, Arthurs Creek, Yarra Glen, Gruyere and Healesville. All of these fires were caused by spotting.211 1.89 At 18:01 the wind change had come through St Andrews.212 When the south-westerly wind change reached these fires between 18:00 and 19:00, it was not possible to secure the eastern flank of the fire due to the heavy forest and plantation fuel loads.213 The main fire, and the subsequent spot fires, headed in a north- easterly direction, burning through heavy fuels.214 At 19:40 the fire was recorded in Flowerdale.215 The Kilmore East–Wandong section of the fire headed generally north along the Hume Highway towards Reedy Creek impacting at 20:00, burning through the remainder of the Wallaby Creek catchment, the Kinglake National Park and the Mount Disappointment Forest.216 Progressively through the evening it impacted the settlements of Hazeldene and Silver Creek. The fire was recorded at Mudgegonga at about 22:00.217 1.90 From Strathewen and Humevale, the fire headed generally north, through Kinglake central, Castella and along the Melba Highway towards the settlement of Glenburn. The Kilmore East fire did not join with the Murrindindi fire on 7 February.218 The fire was never under control on 7 February.219 1.91 Throughout the night of 7 February, and the following days, as the fire reached grassland, it was stopped and the edge of the fire progressively secured. However, in forested areas, particularly in the Maroondah catchment, Toolangi State Forest and Yarra Ranges National Park, containment was difficult. In particular, the fire caused considerable concern around the Healesville area over the next few days as containment works, including back burning, continued.220 The fire was listed as contained on 16 February.221

Warnings 1.92 Some warning messages for the Kilmore East fire were issued from the Seymour Regional Emergency Coordination Centre (authorised by the Regional Coordinator) and from the iECC (authorised by the State Duty Officer), in addition to those issued from Kilmore ICC.222 1.93 At 12:40 an initial awareness message was issued for the Kilmore East fire for Kilmore East, Wandong and Clonbinane.223 Urgent threat messages were issued progressively for communities to the south-east and east of the fire, and subsequently updated as further information was available.224 At 13:59 an urgent threat message was issued for Wandong.225 At 14:40 an urgent threat message was posted to the CFA website for the community of Wandong, and messages were progressively posted for the communities of Hidden Valley (at 15:05), Whittlesea (at 15:33), Heathcote Junction and Upper Plenty (at 16:05), Humevale, Arthurs Creek, Eden Park, Nutfield and Doreen (at 16:35) and for communities from Kinglake to Flowerdale (at 17:55).226 1.94 At 17:20 an urgent threat message was released from Kangaroo Ground Divisional Control Centre indicating Wandong, Wallan, Wallan East, Eden Park, Whittlesea, Humevale, Bruces Creek, Upper Plenty, Kinglake West, Pheasant Creek, Smiths Gully, Kinglake, Flowerdale, Glenburn and Hurstbridge might be affected by the fire.227 It also referred to road closures.228 Urgent threat messages had been drafted earlier in the afternoon (from 14:30) at Kangaroo Ground Divisional Control Centre, but had not been released as the fire was being controlled from the ICC at Kilmore.229 1.95 At 18:45, an urgent threat message posted to the CFA website noted that Wandong, Wallan, Wallan East, Eden Park, Whittlesea, Humevale, Bruces Creek, Upper Plenty, Kinglake West, Pheasant Creek, Smiths Gully, Kinglake, Flowerdale, Glenburn and Hurstbridge might be directly affected by fire.230 1.96 As the fire continued to burn through the night, an urgent threat message was posted to the CFA website at 22:32 advising of possible direct attack on Broadford, Broadford East in the area of O’Gradys Road, south of Broadford, Broadford–Wandong/Sunday Creek Road, Reedy Creek and Tyaak. Residents were 58 advised not to expect firefighting trucks to be in attendance if the firefront approached their properties.231 The February 2009 Fires

1.97 On the morning of 8 February, the fire was described as burning in the Yarra Valley near Kinglake, in a north- easterly direction. At 04:38 an urgent threat message was posted to the CFA website stating that Kinglake, Kinglake West, Toolangi, Glenburn, Strathewen, Chum Creek, Dixons Creek, Castella, Pheasant Creek, Doreen, Yan Yean, Woodstock, Mernda, Mittons Bridge, Hurstbridge, St Andrews, Panton Hills, Arthurs Creek, Smiths Gully, Christmas Hills, Healesville, Yarra Glen, Coldstream, Tarrawarra and Steels Creek had been or might be directly affected by this fire.232 1.98 Further messages posted to the CFA website at 09:29 on 8 February advised that the fire was burning towards the Glenburn area, in particular Glenburn and settlements to the north and north-east along the Melba Highway, and Yea River Valley towards Murrindindi. Warnings were also posted for Yea, Seymour and Toolangi.233 Warnings issued for the Kilmore East fire are discussed further in Chapter 9.

Source: Pat Scala, courtesy of The Age

59 2009 Victorian Bushfires Royal Commission—Interim Report

1 THE FEBRUARY 2009 FIRES

Horsham

Figure 1.11: Horsham interim fire progression map

Point of origin at 12:24 hrs Horsham

Approx 12:53 hrs

Wind change at 16:29 hrs

Approx 13:19 hrs

Approx 14:15 hrs

0 2 4 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0099234

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Fire Origin

Summary information Fire Danger Index The maximum FDI was greater than 100 at Horsham AWS at 14:00 and again at 14:30.235 Fatalities No fatalities236 House losses 68 houses237 Overall area burnt 2200 hectares238 Firefighting resources The peak CFA commitment was 41 appliances and 253 CFA personnel. DSE crews from the Horsham area also assisted. Local water-bombing aircraft were used when weather conditions permitted.239

60 The February 2009 Fires

1.99 This fire occurred on the outskirts of Horsham, a regional centre of over 13,000 people. The area directly affected by the fire was Haven, with a population of 940 people.240 1.100 At 12:26 ESTA took a call for a fire at Remlaw Road, Vectis, west of Horsham, burning through crop and grazing land in a south-easterly direction.241 As the point of origin was on private land, the CFA was nominated as the control agency.242 An ICC located at the DSE Office in Horsham managed the fire.243 1.101 Tankers were deployed from 4 local brigades and subsequently, at 12:33, a further 6 tankers were requested.244 Aircraft were requested at 12:46.245 1.102 The light-to-moderate fuel loads meant the fire was of moderate-to-high intensity, but it was fast running in a south-easterly direction. At approximately 13:15, the fire was entering the Wimmera River area and, as the fire burned through the dry river bed and surrounding river flats, the River Red Gums and associated scrub provided elevated fuels, resulting in spotting being reported around the Haven area.246 The fire burned the Horsham Golf Club, destroying the club house and burning the rough areas of the golf course.247 1.103 At 14:15 the fire’s run to the south was stopped.248 Most of the eastern flank of the fire was contained, although a narrow section of the fire broke out with the wind change, which moved through Horsham at 16:28.249 Had most of the eastern flank not been secured, the town of Horsham might have been threatened.250 By 16:52 the fire was reported to have crossed the Western Highway and was subsequently controlled and stopped at various land features, including roadside and irrigation channels.251 At 18:20 it was reported that the fire was stopped at the Horsham–Lubeck Road.252 It was listed as contained at 15:31 on 8 February.253

Warnings 1.104 An urgent threat message for the communities of Haven and McKenzie Creek, through to Wonwondah, west of Horsham, was posted to the CFA website at 13:20.254 An urgent threat message for the communities of Haven, McKenzie Creek, Bungalally, Green Lake and west of Horsham, was posted to the CFA website at 14:56. This warning noted that when the wind change came through the area, the communities on the eastern side of the Western Highway between Drung Drung South and Horsham might be under threat. A further message providing information on the progress of the wind change was posted at approximately 16:35. An alert message was posted at 22:55 advising of fire suppression activity continuing in the area. 255

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Coleraine

Figure 1.12: Coleraine interim fire progression map

Approx 15:21 hrs

Point of origin at 12:35 hrs

Wind change at 13:23 hrs

Coleraine

0 2 4 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0101256

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Approx Point of Origin

Summary information Fire Danger Index The maximum FDI was greater than100 at Hamilton AWS at 13:00 and an FDI greater than 100 was reached at Casterton AWS at 12:00.257 Fatalities No fatalities258 House losses 1 house (as reported on 8 February)259 Overall area burnt 775 hectares260 Firefighting resources Resources were progressively deployed from local brigades and other regions. At the fire’s peak, there were 55 CFA appliances attending, including a number of forest industry brigade vehicles, with approximately 280 personnel. At least 35 DSE fire personnel attended this fire.261

62 The February 2009 Fires

1.105 At 12:36 ESTA took a call about a grass fire in undulating grazing land adjacent to the Glenelg Highway, north-west of Coleraine.262 As the point of origin was on private land, the CFA was nominated as the control agency.263 A CFA ICC, located at the DSE Heywood offices, managed the fire.264 1.106 At 12:36 5 CFA tankers were deployed and 2 water-bombing aircraft were requested at 12:42.265 Local reports indicated that the fire was growing rapidly and at 12:43 a further 8 tankers were requested.266 1.107 The fire behaved typically for a fire occurring in the western districts, albeit in extreme weather conditions.267 The countryside is undulating grazing land and fuel loads were medium to relatively heavy.268 The fire ran through a dry creek bed to the south-west of the town and then, following the wind change at 13:23, burned in a north-easterly direction.269 The eastern flank of the fire was not contained before the wind change. The timing of the wind change was critical to the safety of the town. Fire behaviour was at its worst in the heavy fuel areas with flame heights reported at approximately 12 metres.270 1.108 There was concern that the wind change would push the fire into the town of Coleraine. Plans to evacuate the Coleraine District Health Service were made although evacuation did not eventuate.271 The fire was stopped at its most easterly point at 15:21, and was formally listed as contained at 17:21.272

Warnings 1.109 The first urgent threat message for this fire was posted to the CFA website at 13:30 for Muntham, Coleraine and Hilgay. The message stated that the fire was burning immediately west of Coleraine, had jumped the Glenelg Highway, and was burning in an easterly direction. A prior alert or awareness message was not issued for this fire. Updated urgent threat messages were provided as the fire progressed. At 18:16 a threat downgrade message was posted to the CFA website, advising that the fire was contained. 273

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Pomborneit–Weerite

Figure 1.13: Pomborneit–Weerite interim fire progression map

Point of origin at 13:15 hrs Lake Corangamite

Weerite Approx 15:07 hrs

Wind change at 14:15–15:10 hrs

Pomborneit North Lake Purrumbete

Pomborneit

0 2 4 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0103274

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Fire Origin

Summary information Fire Danger Index The maximum FDI was greater than 100 at Mortlake AWS at 13:30.275 Fatalities No fatalities276 Overall area burnt 1300 hectares277 Firefighting resources The CFA deployed 42 appliances and 298 personnel to this fire.278

64 The February 2009 Fires

1.110 At 13:17 an initial call was recorded of a grass and scrub fire west of Pomborneit/Stony Rises and south of the Princes Highway at Weerite.279 As the point of origin was on private land, the CFA was identified as the control agency for the fire.280 The ICC was located at Colac in a temporary DSE facility.281 1.111 At 13:18 5 local brigades were paged to respond to the fire. At 13:21, aircraft were requested although subsequent advice at 13:42 indicated that the prevailing weather conditions meant aircraft could not operate. Police were requested to close roads. 282 1.112 The fire burned south, crossing and damaging the Geelong–Warrnambool railway line. At 13:42 VLine was contacted to stop trains using the damaged railway line.283 Ground resources were progressively increased to protect the Swan Marsh township.284 The south‑west wind change was reported as passing Mount Pardon at 14:15, which is about 5 kilometres south of the fire area.285 When it reached the fire, the direction of the wind changed and headed north-east towards Lake Corangamite. As a result, the additional resources protecting Swan Marsh were redeployed for direct attack. At approximately 15:07 the fire crossed Pomborneit Foxhow Road and continued unchecked in a north-easterly direction until 16:35, when it was reported as stopped.286 1.113 The fire was listed as contained at 12:11 on 8 February.287

Warnings 1.114 The first urgent threat message was posted to the CFA website at 14:15 for ‘Scollers Road, Caters Road Settlement and Swan Marsh [sic]’. At 14:25 an awareness message was posted for Pomborneit, Stonyford and Swan Marsh.288 At 19:18 a message was posted on the CFA website advising that the threat had been downgraded to alert status.289

Source: © Newspix / Renee Nowytarger

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Churchill

Figure 1.14: Churchill interim fire progression map

18:32 hrs Wind change 18:30 hrs at 18:16 hrs

18:15 hrs Churchill 22:18 hrs 18:40 hrs 19:00 hrs 18:20 hrs Point of origin 18:22 hrs 18:20 hrs at 13:32 hrs 18:40 hrs 19:04 hrs 14:45 hrs 18:55 hrs 18:36 hrs 18:45 hrs 15:20 hrs 20:10 hrs 14:10 hrs 16:50 hrs 17:13 hrs 14:15 hrs Spot Fire 19:39 hrs 17:11 hrs 17:18 hrs

Spot Fire 15:56 hrs 17:28 hrs

Spot Fire 15:00 hrs 16:24 hrs

Spot Fire 20:36 hrs

Spot Fire 18:00 hrs Spot Fire 18:05 hrs

Spot Fire 15:02 hrs

Wind change Spot Fire 18:04 hrs at 18:06 hrs Yarram 0 4 8 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0105290

Interim Final Fire Perimeter

Built Up Areas

Roads

Approx Point of Origin Parkland

Summary information Fire Danger Index The maximum FDI was 82.7 at Latrobe Valley Aerodrome at 16:00 and an FDI greater than 100 was reached at Yarram Airport AWS at 14:00.291 Fatalities 11 fatalities292 House losses 247 houses293 Overall area burnt 24,500 hectares294 Firefighting resources The peak CFA commitment to this fire was 227 appliances and 1250 personnel.295

66 The February 2009 Fires

1.115 The main communities affected in this fire were Callignee (population 495) and Hazelwood South (population 533).296 1.116 At 13:33 a fire was reported in open country but rapidly spreading uphill into a Blue Gum plantation on the south side of Glendonald Road, 3 kilometres south-east of Churchill.297 This report was received concurrently with one from the public direct to the Churchill CFA Fire Station. As the point of origin was on private land, the CFA was identified as the control agency for the fire.298 The ICC was located at Traralgon, initially as a Divisional headquarters, then as an ICC.299 The Churchill fire was originally considered a division of the Delburn fires before it was independently managed.300 1.117 At 13:35 4 brigades were paged to respond to the fire. On arrival at 13:39 additional tankers were requested. At 13:36 aircraft were requested although, at the peak of the fire, aircraft were unable to operate because of weather conditions. The fire quickly burned into pine and gum plantations to the south and south-east, through steep gullies, north facing slopes and valleys of the Strezlecki Ranges.301 Fuel loads were high due to a mixture of natural and plantation fuels. The main fire front travelled 7 kilometres in 50 minutes and, by 14:20, the fire had reached Jeeralong Creek West Branch.302 1.118 Spotting was reported up to 20 kilometres ahead of the fire outside Yarram and then, by 14:40 near Balook. 303 At 15:02 a spot fire was reported at Jack River, 6 kilometres west of Yarram. At 16:50 there was reporting of multiple spot fires around the township of Yarram.304 By 17:15 the main firefront was approaching Mount Tassie, with spot fires on the east side of the mountain.305 1.119 Between 18:00 and 18:30 the wind change altered the direction of the fire, resulting in continued spotting but in a north-easterly direction towards Callignee, Traralgon South and Koornalla.306 At 18:04 a spot fire was reported 9 kilometres east of Yarram on the South Gippsland Highway. At 18:05 a further spot fire was reported on the Hyland Highway, 4 kilometres north of Yarram. It burnt into the Won Wron State Forest. At 18:10 a spot fire was reported on the Currajung Woodside Road, 4 kilometres east of Carrajung South.307 1.120 The wind change meant that 13 kilometres of the eastern flank, from near Churchill to Mount Tassie, was burning through steep, inaccessible country that carried high fuel loads of native forest and pine and Blue Gum plantations.308 This had a progressive impact on areas such as Hazelwood South, Koornalla, Traralgon South, Callignee, Callignee South, Callignee North, Jeeralang North, Devon, Yarram and Carrajung South.309 By around 20:00 the rate of spread had slowed; however, the fire was continuing to spread in a north-easterly direction.310 While much of the fire was stopped on 8 February, some areas remained inaccessible and burning continued in heavy fuel areas. The fire was listed as contained at 17:00 on 19 February.311 1.121 Loy Yang Power Station was identified as strategic infrastructure at risk, and substantial planning for its protection was undertaken. Ultimately, the fire did not affect this area but there was concern about the critical communications assets on Mount Tassie, including Loy Yang system controls and a variety of commercial and emergency communication transmitters.312 The ABC FM transmitter failed on Mount Tassie; however, the ABC continued transmitting on the AM band.313

Warnings 1.122 From 13:51 there were a series of alerts and urgent threat messages.314 An urgent threat message was posted to the CFA website at 14:05 stating that the communities of Hazelwood South, Jeeralang, Jeeralang North and Jeeralang Junction might be affected by fire. At 15:45 alert messages were posted for the communities of Jumbuck, Le Roy, Budgeree East, Valley View, Traralgon South and Balook, and an urgent threat message was extended to the communities of Balook, Le Roy, Jumbuck, Valley View and Budgeree East.315 1.123 At 16:20 alert messages were posted to the CFA website for the communities of Madalya, Womerah, Callignee, Callignee South, Callignee North, Carrajung, Carrajung South and Won Wron. These were upgraded to an urgent threat message for Womerah and Macks Creek at 16:30. The communities of Devon North and Yarram were also included in urgent threat messages at 16:40.316 67 2009 Victorian Bushfires Royal Commission—Interim Report

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1.124 At 17:05 Woodside, Alberton, Tarraville, Manns Beach, Robertsons Beach, Woodside Beach and McLoughlins Beach were included in alert messages. At 17:28 an urgent threat message was posted for the communities of Alberton, Tarraville, Port Albert, Langsborough, Manns Beach and Robertsons Beach. At 18:03 Devon North, Yarram and Calrossie were added to this warning, as were campers in the coastal area between Port Albert and Woodside Beach.317 1.125 At 18:10, with the onset of the wind change, further alert messages were posted listing communities such as Willung South, Willung, Stradbroke, Stradbroke West, Giffard West, Darriman, Hiamdale and Gormandale.318 1.126 Following the wind change at 20:25 an urgent threat message was issued advising that the Glendonald Road fire was currently burning in and around Traralgon South, Callignee, Callignee North and Callignee South. At 20:47 the communities of Carrajung South and Carrajung Lower were included in an urgent threat message advising of impact in 20 minutes or less. At 01:05 on 8 February, following an unexpected change in conditions, further urgent threat messages were posted for the townships of Carrajung South, Carrajung Lower, Won Wron and Woodside.319 Messages were issued to lower alert levels, when appropriate, on 8 February.320

Source: Courtesy of The Herald & Weekly Times 68 The February 2009 Fires

Murrindindi

Figure 1.15: Murrindindi fire progression map

Yea Eildon Limestone

Taggerty Rubicon

Murrindindi

Point of origin

Buxton Glenburn Enoch Point

Marysville

Toolangi

Narbethong

Dixon’s Creek Chum Creek

0 4 8 Kilometres Healesville

Source: Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 0896321

Murrindindi Bushfire

Kilmore Bushfire

Roads

Fire Origin

Parkland Fire Tower

Summary information Fire Danger Index The maximum FDI was 81 at Coldstream AWS at 16:34 and an FDI of 92 was reached at Eildon AWS at 16:31.322 Fatalities 38 fatalities323 In addition, on 17 February one ACT firefighter died as a result of a fallen tree branch.324 House losses 590 houses325 Overall area burnt 168,542 hectares326 Firefighting resources Records show that 167 NEO personnel, 4 CFA personnel, 2 dozers and 3 slip-on units attended the fire on 7 February. This increased significantly through to 12 February, by which date 660 NEO personnel, 1 dozer, 1 tanker and 94 slip-on units were deployed, along with 69 970 CFA personnel and 187 tankers.327 2009 Victorian Bushfires Royal Commission—Interim Report

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1.127 Marysville was most affected by this fire, with a resident population of 517. The area surrounding Marysville has a population of 1200 people.328 1.128 Just before 15:00 a fire at Murrindindi Mill was reported to the Broadford and Alexandra DSE offices from the Mount Despair fire lookout tower.329 The point of origin was estimated to be 2 kilometres south of Murrindindi on private land within the fire protected area,330 and while this was not clear in the early stages of the fire, DSE became the control agency for this fire. 331 Fire control was through a DSE ICC at Alexandra.332 DSE had already deployed IMT personnel from Alexandra to support the CFA IMT managing the Kilmore East fire.333 This included information and situation officers. Because of this, DSE advised that the Alexandra IMT was initially under-resourced.334 1.129 CFA resources were deployed from the Yea Group and were the first to arrive at the fire.335 All local DSE fire line resources that had not been deployed to the Kilmore East fire (which was reported at 11:49), were deployed to the Murrindindi fire (being crews from Toolangi, Alexandra and Broadford).336 The Toolangi DSE crew is recorded as responding at 15:00, with an estimated time of arrival of 15:30, although the first DSE resources were recorded as arriving at the fire at around 16:15.337 Care was taken not to direct crews to take roads that might be affected by this fire, with the Alexandra crew taking a circuitous route. This initial attack on the fire included 6 personnel, 1 tanker, 2 slip-on units and 1 ‘first attack’ dozer.338 1.130 Early observations reported by the IMT were of severe fire behaviour, with flames 20 metres high and an estimated rate of spread of 8 kilometres per hour. Spotting was estimated at 5 kilometres.339 Post-fire analysis indicated this was under-estimated — the likely spread of the fire was around 12 kilometres per hour with spotting to 15 kilometres.340 The Alexandra DSE Office estimated a rate of spread of 8 kilometres per hour earlier in the day, based on the weather forecast. This was twice the speed of fire spread normally experienced in forest fire.341 1.131 The severity of the fire behaviour precluded direct attack, and both DSE and CFA resources concentrated on community and asset protection. Aerial support was sought to manage fire spread.342 1.132 The fire spread rapidly into the forests of the Black Range, between the Melba and Maroondah Highways, and began spotting when it reached the top of the range. In fact, the fire was burning in forest 3 kilometres from its point of origin, until it reached the outskirts of Narbethong, a further 17 kilometres away. Additional response resources were mobilised.343 The Mount Gordon tower observer reported that at 16:20 the fire was crossing the Black Range.344 The tower was abandoned at 16:30.345 1.133 Two water-bombing aircraft and 1 light helicopter left Mansfield, arriving at the fire around 15:45.346 Water bombing was ineffective, due to the weather conditions, and each aircraft only made one bombing run.347 Additional dozers and graders were deployed from DSE and Murrindindi Shire for control line construction. DSE ground crews were deployed to communities to the east and west of the Black Range.348 1.134 The fire moved across the Black Range very quickly and was spotting long distances. At 16:30 spot fires and ember attack were reported in the Narbethong area, and aircraft were forced to suspend operations due to the increasingly hazardous flying conditions.349 The Bushfire CRC Report indicates fire spread was likely to have been the result of ‘substantial spotting’.350 1.135 Fire crews were hampered by new fires created by spotting; these were moving towards the Marysville area. Firefighters continued to work on asset protection under extremely difficult conditions. A back burn was attempted around 18:00 east of Marysville, although it was quickly abandoned ‘when it became hazardous and was going to be overrun by the main fire’.351 1.136 After 18:30 the south-westerly wind change arrived. Advice from DSE indicates the wind change arrived earlier and passed through the area with greater force than forecast. 352 The wind continued to change direction during this period, making it difficult to identify the direction of spotting and firefront movement.353 Lightning from intense smoke plumes and atmospheric interaction with the south-west change triggered other fires between the Murrindindi and Bunyip fires.354

70 The February 2009 Fires

1.137 The eastern flank of the fire became an extensive front. Asset protection was extremely hazardous.355 The spot fires that had grown in the Narbethong and Marysville areas now joined and burnt towards Marysville, from both the south-west and south-east. 356 A convoy of about 50 cars, led by Police, left Marysville at 16:45.357 Embers started falling in the town at about 18:50.358 CFA and DSE appliances withdrew to the Gallipoli Park Oval where some community members sheltered.359 Embers were recorded falling in Marysville at 18:50 and many houses in the town were destroyed within an hour.360 The wind change led to the fires reaching Buxton at 19:30 and travelling as far north as Taggerty.361 1.138 The fire eventually slowed under cooler conditions early on 8 February. It continued to burn for another 26 days before it was contained. This was after an immense effort in the forest on control line construction, back burning and burning out to stop the fire moving south and threatening the water catchments of Melbourne.362 1.139 The fire was listed as contained at 18:00 on 5 March and Under Control 2 at 11:00 on 13 March.363

Warnings 1.140 Mr Waller commented that early in the fire, the IMT was hampered by a lack of information on the fire, as aerial observation was not possible and it was travelling through remote areas.364 At 15:45 an awareness message was issued indicating there was a fire in the Murrindindi area moving south-east.365 1.141 At about 16:20 an urgent threat message was prepared and sent from the Alexandria ICC for Clonbinane, Mount Disappointment, Kinglake, Heathcote Junction, Upper Plenty, Humevale, Reedy Creek and Strath Creek.366 However, it was not posted on the website.367 At 16:45 an urgent threat message was issued for Narbethong.368 At 17:15 an urgent threat message was sent to agencies, media and the Victorian Bushfire Information Line (VBIL) for Marysville, Narbethong and Buxton, and at 17:34 a threat message for Marysville was relayed on 774 ABC Radio.369 1.142 At 17:20 an urgent threat message relating to Yea and Whittlesea roads was released. A further urgent threat message for areas from Kinglake to Flowerdale was released, although this second message was not posted to the CFA website until 17:55.370 An urgent threat message for Buxton was also raised prior to 18:00.371 Further urgent threat messages were issued through the night.372

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Redesdale

Figure 1.16: Redesdale interim fire progression map

Mia Mia

Point of origin at 15:11 hrs Approx 15:25 hrs

Approx 15:15 hrs Approx 15:27 hrs

Approx 15:20 hrs

Wind change at 18:35 hrs

Approx 15:42 hrs

Glenhope Approx 16:00 hrs

Barfold Metcalfe

Approx 17:00 hrs

Baynton Sidonia Approx 18:00 hrs

0 2 4 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0107373

Interim Final Fire Perimeter

Built Up Areas

Roads

Waterways

Fire Origin

Summary information Fire Danger Index The maximum FDI was 87.2 at Redesdale AWS at 16:00.374 Fatalities No fatalities375 House losses 7 houses (as reported on 8 February)376 Overall area burnt 9500 hectares377 Firefighting The CFA’s peak commitment to the fire was 73 appliances and 400 personnel. DSE fire personnel resources also attended this fire.378

72 The February 2009 Fires

1.143 At 15:11 a fire at Coliban Park Road, Redesdale was reported to the CFA.379 As the point of origin was on private land, the CFA was identified as the control agency, although responsibility passed to DSE when the fire was burning on public land after 7 February. 380 The ICC was located at Huntly, Bendigo, which was the ICC for the Maiden Gully fire. 381 1.144 At 15:11 5 local brigades were paged. At this time no aircraft were available for this incident. Two strike teams were activated at 15:30.382 The fire burned through undulating grassland and scrub fuels and grazing country with steep gullies and washaways.383 It burnt in a south-easterly direction and crossed the Metcalfe– Redesdale Road at 15:27 and the Kyneton–Heathcote Road at 15:42. At 16:49 Victoria Police was advised to close Watchbox Road to traffic. Further road closures followed.384 1.145 Direct attack on this fire was made wherever possible. However, due to the terrain, dozers and other equipment were needed to secure the fire edge. The speed of this fire was so rapid that there was concern that the fire might reach the Cobaw Ranges or further beyond to the communities of Lancefield and Carlsruhe. This did not eventuate.385 1.146 At approximately 18:30 the wind change reached the fire. Approximately two-thirds of the eastern flank of the fire was secured. The remaining eastern flank that did break away was in rough steep-gullied country. This part of the fire was progressively contained.386 1.147 Over the next few days firefighters continued to secure the fire.387 This involved the strategic redeployment of resources between this fire and the nearby Maiden Gully fire. The fire was listed as contained at 09:56 on 10 February.388

Warnings 1.148 At 16:13 an urgent threat message was posted on the CFA website for the communities of Barfold, Langley and Metcalfe East. At 16:47 a revised alert message was posted for the communities of Sidonia, Pastoria, and other communities to the east of Kyneton.389 1.149 As the fire progressed, urgent threat messages were updated, advising ‘the communities of Pipers Creek, Carlsruhe, Woodend North, Newham, Cadello and Carbow [sic]’ to be alert and implement their fire plans. The messages advised that when the wind change arrived the fire would run in a north-easterly direction. Residents in Redesdale, Glenhope, Baynton and Baynton East, and residents in the areas between Glenhope, Baynton, Redesdale, Heathcote, Tooborac and Pyalong, were advised that they might also be under threat when the wind change passed through.’390 1.150 Threat messages were downgraded to alert status on 8 February, as the fire was controlled. Further urgent threat messages were issued when the fire again threatened communities on 9 February.391

Narre Warren 1.151 The Commission has not yet taken evidence on the Narre Warren Fire that began at 15:32.392

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Bendigo Eaglehawk Figure 1.17: Maiden Gully interim fire progression map393

Point of origin at 16:33 hrs

Approx at 17:00 hrs Approx at 17:30 hrs

Long Gully

Approx at 18:00 hrs

Wind change Approx at 19:00 hrs at 18:44 hrs

Approx at 19:30 hrs

Specimen Hill Approx at 18:30 hrs

0 0.5 1 Kilometres

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0109394

Interim Final Fire Perimeter

Roads

Railway

74 Approx Point of Origin Parkland The February 2009 Fires

Summary information Fire Danger Index The maximum FDI was greater than 100 at Bendigo AWS at 15:31.395 Fatalities 1 fatality396 House losses 58 houses397 Overall area burnt 330 hectares398 Firefighting resources The CFA deployed 70 appliances and 420 personnel to the fire. DSE fire equipment and personnel were also deployed (numbers not provided).399

1.152 This fire burnt a small area of Bendigo, including Bendigo West and parts of Long Gully.400 1.153 At 16:34 a fire at Bracewell Street, Maiden Gully, Bendigo was reported.401 The fire was a classic ‘interface fire’ as it burned in and amongst houses and commercial premises on the outskirts of a large provincial city.402 Resources from the Bendigo region had already been deployed to the Redesdale fire.403 As the point of origin was on private land, the CFA was identified as the control agency and managed it from the Huntly ICC (from where the Redesdale fire was also managed).404 1.154 Three brigades responded at 16:35. An unspecified number of additional brigades were paged at 16:38.405 The fire burned through disused mining country in and about the townships of Maiden Gully, Long Gully, California Gully and Eaglehawk.406 Resources were deployed as the fire spotted into grassland from scrubby areas where access was difficult. Early in the fire’s development, as it ran to the south-east, it burnt houses and other structures. The wind change, which moved through the area at approximately 18:45, extended the fire to the north-east.407 1.155 The existence of relatively large tracts of vacant, unused land, coupled with scrub and recreation areas, made control extremely difficult.408 While the fire was limited by an area of land in Pascoe Street, where fuel reduction had been undertaken, crowning and short distance spotting occurred elsewhere hampering firefighting efforts.409 The fire burned within 1.5 kilometres of the centre of Bendigo and posed a considerable threat to the city before being contained at 21:52.410 1.156 The Bushfire CRC Report indicates that the Bendigo fire spread was faster by a factor of two to three times more than what was predicted using either the Forest Fire Danger Meter or the Project Vesta model (a comprehensive research project to investigate the behaviour and spread of high intensity bushfires). The Bushfire CRC suggests that the very open nature of the forest resulted in higher wind speeds under the canopy than is assumed by either model.411

Warnings 1.157 An awareness message providing initial advice for the Maiden Gully area was posted to the CFA website at 17:17.412 Numerous warnings and commentary were provided from 17:10 through to 21:10.413 At 21:37 an urgent threat message was posted noting that the fire west of Bendigo and Specimen Hill was burning in a northerly and north-easterly direction, and a section of the fire was moving towards Eaglehawk. Residents in the Upper California Gully Road and Hall Street area were warned that their area was under ember attack. This information was updated progressively through the night as the fire was brought under control.414

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Beechworth–Mudgegonga

Figure 1.18: Beechworth–Mudgegonga fire map

Beechworth

Baarmutha Stanley

Point of origin Bruarong at 13:32 hrs

Gundowring Glen Creek Murmungee

Dederang

Taylor Gap Mudgegonga

Gapsted

Running Creek

Merriang Myrtleford

Ovens

Buffalo Creek Happy Valley

Havilah Eurobin 0 2 4 Kilometres

Source: Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 0897 415

Interim Final Fire Perimeter

Built Up Areas

Roads

Fire Origin

Parkland

Summary information Fire Danger Index The maximum FDI was 42 at Hunters Hill AWS at 13:06 and an FDI of 126 was reached at Wangaratta AWS at 13:30.416 Fatalities 2 fatalities417 House losses 29 damaged or destroyed418 Overall area burnt Approximately 31,000 hectares419 Firefighting resources On 7 February 35 NEO personnel, 2 tankers, 2 dozers and 12 slip-on units attended the fire. Another 50 CFA personnel and 18 tankers responded together with 1 helicopter and 2 fixed-wing aircraft. From 8–12 February up to 386 NEO personnel per day attended the fire, with 7 dozers, 8 tankers and 39 slip-on units. Up to 644 CFA personnel and 24 tankers 76 were deployed,420 together with appliances from Hancocks Plantations and the NSW Rural Fire Service.421 The February 2009 Fires

1.158 The largest population in the immediate area is Yackandandah (population 2100). The towns most affected were Gapsted (population 294), Mudgegonga (population 385) and Dederang (population 422). The outer areas of Stanley (population 689) were also affected.422 1.159 At around 18:09 on 7 February a fire was reported to the DSE Beechworth depot via a mobile phone call from the Beechworth DSE office.423 At around the same time a DSE staff member at the depot received a phone call from a member of the public reporting the fire. The point of origin was reported to be around 4 kilometres south of Beechworth.424 As the point of origin was on public land DSE was the control agency for the fire.425 The ICC was located at the Beechworth DSE office and at Ovens from 8 February.426 It was a joint DSE/CFA ICC. 1.160 Personnel at the Ovens, Beechworth and Bright DSE work centres were deployed to the fire.427 At 18:10 the DSE Incident Controller called back a strike team he had stood down at 18:00 (expecting them to be deployed to the Kilmore East fire the next day). The team responded to the Beechworth fire, along with local CFA crews, at an estimated arrival time of 18:30 (earlier in the day a Beechworth DSE task force had already been deployed to assist the CFA at the Kilmore East fire).428 1.161 Access to the fire was hindered near the point of origin due to sagging power lines.429 Reports from the fireground indicated that the fire was moving rapidly under the influence of a strong north, north-westerly wind, gusting up to 60 kilometres per hour, with subsequent spotting.430 Initial fire behaviour was not extreme given that the fire was burning over areas previously burnt in 2002–03. However, the south-easterly spread of the fire into steep, inaccessible areas with heavy fuel loads led to some extreme fire behaviour.431 Spotting occurred a ridge ahead of the firefront.432 1.162 The first attack dozer was at the fire by 19:00. At about this time 2 fixed-wing bombers and a light helicopter based at Mansfield were deployed. The bombers made several drops until nightfall when they were stood down.433 1.163 The fire was burning in a south-easterly direction, through a steep, inaccessible sluiced area containing heavy, unburnt forest fuels. This limited access for CFA crews. Crews therefore worked the northern flank. Live low-hanging power lines prevented direct attack, and so indirect attack was undertaken.434 Heavy smoke and limited fire line communications during the night made it difficult to estimate where the fire was. Overnight Victoria Police organised road blocks across the area.435 1.164 Throughout the night the power outage created significant issues for the operation of the ICC. Communications, situation reporting and planning activities were constrained, and communication and coordination were conducted on mobile phones and from vehicles.436 1.165 During the night the Incident Controller decided that due to the cramped conditions in the Beechworth ICC, the ICC would be relocated to Ovens from 07:00 on 8 February. That location was better equipped as a level 3 facility.437 1.166 At 06:00 on 8 February the size of the fire was estimated to be 20,000 hectares. Access to parts of the fire was restricted as a major transmission line through the fireground needed to be rebooted. In addition, there was a large number of lightning strikes across the region, and a fire near Bogong Village that also required firefighting resources.438 1.167 The fire was contained after 9 days (16 February), having burnt approximately 31,000 hectares, including 20,000 hectares of forest and park. Areas where fuel had been reduced through burning had a significant effect on the spread and eventual control of this fire.439 It was reported contained at 10:30 on 16 March and Under Control 2 at 11:00 on 25 March.440

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Warnings 1.168 Due to the power failures distribution of warnings was in the first instance by mobile phone.441 At 19:10 the first urgent threat message for Stanley, Barwidgee Creek and Mudgegonga was issued.442 Subsequent urgent threat messages were sent out through the evening and the following day. On 7 February these were for Stanley, Barwidgee Creek, Mudgegonga, Yackandandah and Bruarong. On 8 February Rosewhite, Murmungee, Ovens and Myrtleford were included in the threat messages.443 1.169 Overnight the location of the fire could not be confirmed. A number of precautionary warnings were issued and these were also issued to towns later found not to be threatened.444

Other Fires 1.170 Numerous other fires occurred on the day but are not being examined by the Commission because, amongst other factors, many were successfully contained. One such fire was the Upper Ferntree Gully fire at Quarry Road, which was reported to ESTA at 15:42. This fire burned 9500 hectares. Twenty-one CFA appliances and 168 personnel attended the fire.445 A heavy helicopter was also redeployed from Bunyip to the fire.446 The fire was reported as contained at 19:10 and was controlled at 21:27.447 This fire, which was relatively small in size, resulted in no fatalities and only one house destroyed.448 However, it was assessed by the CFA as having the ‘most significant potential’ for losses on the day, because of the conditions and its location at the foothills of Mount Dandenong, in a heavily populated area.449

Fire Activity after 7 February 1.171 After 7 February the Murrindindi and Bunyip fires continued to burn.450 On 8 February a fire ignited at Wilsons Promontory.451 Many IMTs continued operating on a 24-hour basis.452 The East Tyers–Thomson fire was contained on 16 February but not declared Under Control 2 until 30 March.453 The Beechworth fire continued to burn until 25 March.454 1.172 Weather conditions deteriorated on 23 February posing initial risks to the southern edge of going fires.455 While the CFA recorded 135 grass fires on that day, only 3 developed into significant fires — Upwey (igniting at 14:28), Muskvale near Daylesford (igniting at 14:55), and Won Wron (ignition time not advised).456 1.173 Weather conditions deteriorated again through the weekend of 28 February–1 March.457 On 1 March a joint CFA/DSE/Victorian State Emergency Service media release was issued warning of an extreme weather threat.458 The warning predicted an onset of increasing temperatures and strong northerly winds right across the State.459 Total fire bans were declared on 2 and 3 March.460 1.174 As a result of these concerns comprehensive preparations were undertaken over the weekend and into Monday 2 March. On 2 March, weather for 3 March was predicted to include very strong northerly winds.461 In addition, the police sent out a text message to nearly all Victorian mobile phone customers, warning them of pending and extreme fire and wind changes.462 1.175 On 3 March this prediction was updated. Wind speeds were revised down and humidity was higher than estimated. Ultimately, the weather did not deteriorate as badly as predicted.463 Humidity remained relatively high and this enabled new fires to be more easily controlled. That said, the CFA responded to 195 grass fires over the period 2–3 March.464 1.176 Following these weather patterns, some rainfall fell across the state. Although not significant enough to end the fire season, it assisted ground crews in dampening any fires that remained.465 1.177 Twenty-six days after ignition, the Kilmore East–Murrindindi fire was reported contained on 5 March, under control on 10 March and safe on 27 April. Due to the dry conditions, much of the firefighting was directed at and managed by back burning.466 The Bunyip fire was reported contained on 4 March and under control on 15 March.467

78 The February 2009 Fires

Previous Major Fires 1.178 Maps from the Report of the Inquiry into the 2002–2003 Victorian Bushfires, comparing areas burnt across Victoria in 1939, 1983 and 2003, are presented in figures 1.19 –1.22. 468 The Commission has added a map for the 7 February fires. While the total area burnt in the 2009 fires is less than these earlier fires, the impact on lives and homes lost has been much greater.

Figure 1.19: 1939 Victorian bushfires

Ouven

Corryong

Bright

Mansfield Stawell Omeo Yea Ararat Dargo Ballarat Marysville Casterton Cann River Orbost Hamilton Melbourne Bairnsdale

Warragul Sale Geelong Traralgon Colac Portland Warrnambool Cowes Lorne Yarram

Apollo Bay

Source: Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 0999 469

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Figure 1.20: 1983 Victorian bushfires

Echuca Corryong Nhill Wangaratta

Horsham Bendigo Bright

Seymour Mansfield Stawell Omeo Yea Ararat

Ballarat Marysville Casterton Cann River Orbost Melbourne Bairnsdale Mallacoota Dandenong Warragul Sale Frankston Traralgon

Portland Warrnambool Anglesea Cowes Lorne Yarram

Apollo Bay

Source: Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) [13] 470

80 The February 2009 Fires

Figure 1.21: 2003 Victorian bushfires

Murrayville

Wodonga Corryong Wangaratta

Bright

Omeo

Dargo Cann River Melbourne

Sale Geelong Traralgon Colac

Source: Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) [14] 471

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Figure 1.22: 2009 Victorian bushfires

Ouyen

Beechworth Nhill

Horsham Bendigo

Edenhope Castlemaine Yea

Dargo Ballarat Marysville Casterton Hamilton Melbourne Dandenong

Warragul Traralgon Colac

Yarram

Source: Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0111472

82 ENGAGING COMMUNITIES 2 2009 Victorian Bushfires Royal Commission—Interim Report

2 ENGAGING COMMUNITIES

From the outset the Commission saw its interaction with all Victorians, and in particular those affected by the fires, as a vital cornerstone of its investigation into the fires. This chapter begins with a brief overview of the full range of initiatives implemented by the Commission to engage with the community. It then moves to the primary focus of this chapter — a detailed account of the community consultations held in March and April 2009 and a summary of the issues raised. The chapter concludes with a brief account of the involvement of lay witnesses in the first round of public hearings.

Communicating with the Commission 2.1 Initial interaction with the community began through avenues such as the offices of the Premier, the Governor-General, the Victorian Attorney-General, the Prime Minister, the Department of Premier and Cabinet, the Department of Justice, Members of Parliament (federal and state), the Supreme Court of Victoria and local municipalities. A broad array of material was received by the Commission either directly or through referral, including:

■■ offers for services (pro bono and paid)

■■ personal accounts of the fires

■■ complaints about how the emergency services responded to the fire

■■ submissions to the Commission

■■ copies of academic publications, books, research papers and previous reports

■■ enquiries about how the Commission could provide support to individuals affected by the fires. 2.2 Processes to manage the initial contacts were put in place by the Commission Secretariat. A toll free 1800 number was provided as an enquiry line, an email enquiry address commenced operation on 24 February 2009, and the Commission website was launched on 16 March.1 2.3 Commission staff responded to initial contacts by phone, email or post, and, where appropriate, provided contact details for other agencies providing bushfire assistance. These agencies included the Victorian Bushfire Reconstruction and Recovery Authority, the Victorian Bushfire Case Management Service and Bushfire Legal Help.2 In addition, a process for the lodgement of formal submissions to the Commission was advertised and commenced operation in March (Chapter 3).

Consultations in Fire-affected Communities 2.4 The Commission’s first priority was to meet with and listen to people from those communities directly affected by the fires. Between 18 March and 9 April the Commission held community consultations in fire-affected locations. The community consultations were an important foundation for the work of the Commission. Beginning its work in bushfire-affected communities enabled the Commission to hear first-hand about people’s experiences, and gain valuable insights into how individuals and communities responded to current bushfire-related policies and programs. The community consultation process is outlined in paragraphs 2.14–2.31.

Communication Facilitated by the Commission 2.5 The Commission website, launched in March, provided information about the Commission and its processes, including the community consultations, the submissions process and how to view submissions, the role of the public hearings and their dates and times, and a media centre. During the hearings interested people were able to view the transcripts on the Commission website from the following day. 2.6 Also, to maximise immediate access to its work, the Commission provided live web-streaming of the hearings. This proved to be extremely popular. During the first block of hearings, more than 5700 people logged in to watch, including approximately 100 ‘unique browsers’ watching from outside Australia. A lower-bandwidth audio-only option was also provided early in the hearings, which increased in popularity. Approximately 80 per cent of those listening to or watching the hearings were from Melbourne and about 10 per cent were from Sydney. The overseas viewers resided in countries such as the United States, New Zealand, China, Thailand, 84 Singapore, Canada and the United Kingdom. Engaging Communities

2.7 Libraries throughout Victoria (including the State Library of Victoria) made facilities available for people to view or listen to the live streaming and to access and download transcripts from the hearings. This assisted the Commission in its commitment to providing an open and accessible process for fire-affected communities and the wider Victorian community. The Commission thanks the State Library and all the other libraries for helping to make the hearings accessible to a wider audience.

Lay Witnesses to the commission 2.8 Following the community consultations, the Commission interviewed a substantial number of people directly affected by the fires. Many of these people agreed to appear as lay witnesses in the hearings. These witnesses provided an invaluable and unique perspective on what took place during the January and February fires and the impact of those fires. Many provided harrowing details of their experiences. The Commissioners commend these witnesses for being willing to provide their testimony to assist with the Commission’s deliberations. More information on lay witnesses is provided at paragraphs 2.77–2.90.

Written Submissions 2.9 From 18 March, submissions were invited from any person or organisation with information relevant to at least one of the Commission’s terms of reference. Over 1260 submissions were received by 18 May, the cut-off date for submissions to be considered for the interim report. Submissions continue to be received and will be considered as part of the Commission’s further work. 2.10 The Commission received submissions from across Victoria, the rest of Australia and overseas. The content of these submissions is discussed in Chapter 3. 2.11 These submissions have assisted the Commission in a range of ways, by:

■■ providing a pool of valuable resources from which to scope topics to be considered by the inquiry

■■ drawing attention to individuals or organisations with expertise relevant to the inquiry

■■ providing insights into complex technical issues

■■ identifying people who may wish to give evidence before the Commission as lay witnesses

■■ illustrating the wide range of opinion on some matters

■■ alerting the Commission to research that has been undertaken or technology that is already available. 2.12 Chapter 3 of this report provides more detailed information about the important role the submissions have played, and will continue to play, in the Commission’s investigations. 2.13 The Commission extends its appreciation to all who have contributed written submissions.

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Fire-Affected Community Consultations

Box 2.1: Standard greeting at community consultations

Why are we here? Why are you here? What do we hope to achieve?

We are here to listen to what you choose to tell us about the fires and their impact. We would like to hear your stories and your views on what we can learn from them and what you think matters most.

We are not taking evidence. This is not that sort of process. That will happen later when the formal hearings begin.

The Royal Commission has extremely wide terms of reference. You have a copy of them on the tables. There are many issues we could investigate. We seek your views on the critical issues and the priority we should attribute to them.

Purpose of these consultations 2.14 These were the introductory words spoken by the Commission Chairperson, Bernard Teague, at each of the community consultations conducted by the Commission over 22 days in March and April (Box 2.1). Twenty-six separate consultation sessions occurred in 14 fire-affected communities across Victoria. Over 1250 people attended the sessions (Table 2.1). 2.15 As indicated by the Chairperson, the purpose of the consultations was to gather early and immediate information about the impact of the bushfires and to hear directly from the individuals affected. 2.16 It was explained that the forums were not formal Commission hearings and the information obtained would not be viewed as evidence. Rather, the participants’ experiences represented important qualitative insights into what happened and why. The Commissioners were seeking assistance to identify key issues for further research and investigation, before any formal hearings began. Participants’ experiences would also influence the priority issues for attention in the Commission’s interim and final reports. 2.17 Over the four weeks of consultations it became apparent that they also provided other benefits. In a number of cases the consultations represented one of the first opportunities for some people to come together and discuss what might be the future of their communities in the aftermath of the fires. In many instances participants met others for the first time, exchanged contact details and discussed how they could remain connected and continue working together on recovery. This process also helped some to articulate their feelings about the fire and, therefore, assisted in the healing process. The impact upon individual recovery and the drawing together of communities were important outcomes of the discussions. 2.18 The Commissioners gratefully thank the people who participated in the community consultations. It was a privilege to be allowed into these communities to hear first-hand accounts of their difficult experiences and losses. Amongst feelings of utter devastation, each community demonstrated generosity and dignity in sharing their experiences with the Commission. This personal reference point underscored the importance of the Commission’s work as it entered into the more formal processes.

Method of Consultations 2.19 It was not possible for the Commission to hold consultations in all communities affected by the fires. Accordingly the consultations were held in the 14 most affected communities (Table 2.1). Potential participants were informed of the consultations by state-wide media advertisements and other local posters and publicity. Local government personnel also advised community members of the forthcoming sessions. Only members of the affected communities were invited to register and participate. In most communities, participants had a choice between two forums held at different times on the same day.

86 Engaging Communities

2.20 Each consultation was chaired by a professional facilitator, and all followed a common agenda and process. The intention was to create a safe atmosphere and a simple, straightforward format that would enable participants to speak frankly among themselves, in the presence of the Commissioners. The sessions were not open to anyone outside the community, including the media. Many media representatives chose to attend the opening of each session and to speak with participants during breaks. This arrangement retained the integrity of the process but enabled media representatives to gather personal stories from those willing to share them publicly.

Table 2.1: Schedule of community consultations, March – April 2009

Number of Fire-affected Communities Date Time Participants

Myrtleford and the surrounding district Wednesday 18 March 1:00pm–2:30pm 85 including the communities of Mudgegonga, Barwidgee Creek, Kancoona and Rosewhite Flowerdale and the surrounding district Friday 20 March 11:30am–1:00pm 80 or 2:30pm–4:00pm Kinglake and the surrounding district including Monday 23 March 11:30am–1:00pm 167 the communities of Castella, Glenburn and or 2:30pm–4:00pm Toolangi Kinglake West and the surrounding district Tuesday 24 March 11:30am–1:00pm 103 including the communities of Whittlesea and or 2:30pm–4:00pm Pheasant Creek Bendigo and the surrounding district Wednesday 25 March 11:30am–1:00pm 62 or 2:30pm–4:00pm Wandong and the surrounding district including Friday 27 March 11:30am–1:00pm 124 the communities of Clonbinane, Kilmore, or 2:30pm–4:00pm Kilmore East and Reedy Creek St Andrews and the surrounding district Sunday 29 March 11:30am–1:00pm 81 or 2:30pm–4:00pm Yarra Glen and the surrounding district Monday 30 March 11:30am–1:00pm 108 including the communities of Chum Creek, or 2:30pm–4:00pm Dixons Creek, Steels Creek, Healesville and Warburton Traralgon and the surrounding district including Wednesday 1 April 11:30am–1:00pm 72 the communities of Churchill, Callignee, or 2:30pm–4:00pm Jeeralang Junction, Gormandale, Devon, Hazelwood North and Hazelwood South Boolarra and the surrounding district including Thursday 2 April 9:30am–11:00am 74 the communities of Darlimurla, Yinnar and Mirboo Labertouche and the surrounding district Thursday 2 April 2:30pm–4:00pm 78 Marysville and the surrounding district Monday 6 April 11:30am–1:00pm including the communities of Grantville, or 2:30pm–4:00pm Buxton, Narbethong and Taggerty 102 Tuesday 7 April 11:30am–1:00pm or 2:30pm–4:00pm Horsham and the surrounding district Tuesday 7 April 1:00pm–2:30pm 46 including Haven Strathewen and the surrounding district Wednesday 8 April 11:30am–1:00pm 74 or 2:30pm–4:00pm

Total Participants 1258

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2.21 In table-based discussions people were invited to respond to three specific questions:

■■ What was the impact of the bushfires on your community?

■■ What worked well to prepare your community?

■■ What didn’t work well in your community, and what should be done differently? 2.22 The facilitator requested that the small groups at each table be self-managing, and that they appoint a person to report back on their conversation to the whole group. There were three suggested ground rules: respect each other’s views; say if you disagree; and, outside of the forum, do not attribute comments or views to those who expressed them. People were asked to contribute as individuals, not as representatives of any particular body or organisation. 2.23 During the table-based discussions the Commissioners moved from table to table, listening to the different conversations. A Commission staff member was assigned to each table to take notes of the conversations. 2.24 At the conclusion of each session there was a plenary discussion, with table spokespersons reporting their responses back to the full forum, followed by an opportunity for general discussion. This plenary discussion was video recorded, for later reference by the Commission, and the facilitator or a scribe also recorded a summary of the major points made during the plenary discussion. 2.25 In some consultations, in which the numbers were small enough, the entire process was conducted in plenary, without table-based discussions. On these occasions the same three questions were used. 2.26 The sessions typically ran for one and a half hours. They each concluded with the Commissioners thanking people and indicating other ways in which they could engage with the work of the Commission if they wished. Each consultation included a morning tea, light lunch or afternoon tea as a further opportunity for Commissioners to speak with the community members in an informal manner. 2.27 Following the visit to each community, a brief summary of the major themes emerging from the consultation(s) was forwarded to participants and posted on the Commission website.

Recording the narratives 2.28 The record of each consultation was a summary of notes taken by Commission staff, the facilitator/scribe and the Commissioners, and the video of the plenary comments. The informal records did not attribute comments to particular people. The video-recording was for the Commission’s internal use only. 2.29 While common themes emerged across the fire-affected communities, each had distinctive features. The details of emphasis and perspective, even dissent, were sometimes quite marked. Further, within communities, many opposing views were expressed, often with equal emphasis. For example, there were as many people who spoke positively about the protective nature of brick homes over weatherboard constructions as those who were critical of the number of brick homes that seemingly exploded or imploded. While this chapter focuses primarily on the commonality of issues and views, it does so noting the diverse perspectives held to varying degrees within and across communities. 2.30 The first question that people were asked to address concerned the impact of the fires on their own lives and that of their communities. Here the Commission heard stories of people, families and whole communities torn apart by the random and unpredictable nature of the fires and the devastation they caused. People spoke of loss of lives, livelihoods, property, stock, houses, community infrastructure and the community itself, along with experiences of dislocation and population depletion, disruption to schooling and childcare, and upheaval at every level. 2.31 This chapter does not attempt to capture or record the grief, devastation and trauma of the people, as commitments were given that unfiltered emotion could be expressed without fear of attribution. Their experiences were nonetheless powerfully expressed and compassionately received by the Commission.

88 Engaging Communities

The key issues raised in consultations 2.32 The Commission analysed the key themes emerging from the discussions. The plenary notes from the consultations, and the notes taken by the facilitator/scribe, Commissioners and Commission staff were collated and summarised. Some 60 issues were discussed in response to the following questions:

■■ What worked well to prepare your community?

■■ What didn’t work well in your community, and what should be done differently? 2.33 The responses from these questions were categorised and then grouped into these themes:

■■ communications and warnings

■■ community preparedness

■■ fuel reduction

■■ emergency management and coordination

■■ recovery efforts

■■ buildings and infrastructure. The balance of this chapter is organised around these headings. 2.34 As described in paragraph 2.28, the Commission sought to capture the reactions and opinions of participants using scribes and a video-recording of the plenary session. The subsequent exercise of writing reports of each consultation, for posting on the Commission website, enabled summary and analysis to occur close to the event. What is represented in the graphs below is illustrative of issues raised across the 14 communities. The graphs do not purport to be based on a technical analysis of issues. 2.35 A number of quotations are included in this chapter to illustrate the general themes and issues raised. These are not quotations from the community consultations themselves, as the Commissioners made a commitment to listen to the stories of fire-affected individuals in a safe, local environment where they could speak frankly and without attribution. Rather, the quotations are drawn from the testimony of lay witnesses who spoke publicly before the Commission in the first round of formal hearings. The quotations illustrate the key issues raised at the consultations.

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Communication and warnings

Figure 2.1: Communication and warnings

Number of Communities

0 2 4 6 8 10 12 14

Issues with Triple Zero

ABC

CFA scanners/ website

Press + Radio + TV as well as ABC

Mobile problems/ satellite phones

Sirens

Timelag

Warnings linked to Fire Danger Index

Ways in which people obtained information/issues with warnings

Source: Community consultations, March–April 2009

2.36 All but one community (Horsham) reported severe communication difficulties and frustration about the failure of essential systems. People spoke of clogged mobile systems and of uneven coverage, the long delays or lack of success in getting through to Triple Zero, and of internet and landline phone outages. In some communities, such as Flowerdale, participants said that unreliable and inadequate power supply and phone coverage (mobile and landline) had been a longstanding grievance. Lay witnesses Mrs Carol Matthews of St Andrews and Ms Karen Ward of Mudgegonga described similar experiences:

It was just ringing, ringing, ringing. Just couldn’t get through.3

The phone lines in Mudgegonga are old copper … when we had dial up it could take a week to download anything, so we went to satellite which was practically no better, and on a hot day like that, and with so many people accessing it, we would never have been able to get onto the computer and have a look at the CFA websites.4

2.37 There were varied views on the effectiveness of 774 ABC Radio. Some community members spoke of the ABC’s exceptional service while others, particularly in Strathewen, St Andrews, Dixons Creek and Chum Creek, were aggrieved that information about their area was not aired until well after the firefront had passed. At several consultations, the naming of the fires by 774 ABC Radio was reported as exacerbating misinformation and confusion. Examples included the St Andrews fires being referred to as Kilmore East; Steels Creek referred to as Murrindindi; and Boolarra referred to as Delburn (Murrindindi and Delburn being districts, not specific locations). However, it is important to note that fires are not named by the ABC and they only report the information as provided by the fire authorities.

90 Engaging Communities

2.38 Common to most assessments were expressions of frustration that the ABC did not provide ‘real-time’ information about the location or direction of the fires, with the time lag for some communities being up to three hours. Nonetheless, these criticisms were often accompanied by statements about the ABC information being only as reliable and current as that which was provided to it. Mr Denis Spooner of Strathewen, Mr David O’Halloran of Flowerdale and Mr Peter Brown of St Andrews spoke of the time lag problems as follows:

No mention was made of Strathewen, St Andrews, until an hour after the places had been burnt out.5

Flowerdale apparently got one warning, which I didn’t hear, but they got one warning and one warning only, and by the time there was a second warning, I’m told, which was around 9 o’clock, it was all over.6

On reflection, I regret relying on the ABC to the extent that I did. It gave me the impression that we had more time before the fire front arrived than we had in reality.7

2.39 Most people with access to Country Fire Authority (CFA) scanners found them to be an invaluable mechanism for staying informed. Conversely, the CFA website was criticised. Those who retained internet access reported significant inaccuracies and time lags in the website information. Mr David Brown of Strathewen confirmed this:

People who had access to the CFA scanner knew pretty much by sort of 3:30[pm] that Strathewen and St Andrews were in the firing line, as opposed to sort of a lot of us who were relying on [ABC Radio] 774.8

2.40 Most communities reported that the only warnings of any force were those delivered by the government and the media in the week prior to 7 February, though many conceded that these warnings did not awaken them to the extent of the risk. Many communities suggested that the Fire Danger Index used by the CFA, and other authorities, ought to be adopted and communicated to the public as a standard measure for all communities. Mr Illiya Ananiev of St Andrews supported this:

All we are looking for is a category 1, 2, 3 or 5, and maybe a colour, red, yellow, green, to mix in with it.9

2.41 A final issue pertains to warning sirens. A recurring suggestion was that the sirens used by the CFA in some communities to gather its members ought to be upgraded with stronger and varying warning tones for the benefit of the whole community. Some people suggested that such a system could be similar to the hurricane/cyclone warning systems used in Australia’s north. The evidence of Dr Lachlan Fraser of Marysville illustrates similar concerns raised about warning tones:

It [the siren] certainly wasn’t the wail that we are accustomed to when there’s a fire at other times of the year, so to me that didn’t indicate that there was a fire in our local area that the siren was sounding about.10

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Community preparedness

Figure 2.2: Factors affecting community preparedness: individual and local preparations

Number of Communities

0 2 4 6 8 10 12 14

CFA information sessions

Pumps, generators, etc

Fireguards

More education on feral fires and wind changes

Non-native trees

Preparation of house/clothes

Telephone trees

Water availability/sprinklers

Lack of water

Individual preparation Local preparation

Source: Community consultations, March–April 2009

2.42 Many discussions about preparedness were prefaced by expressions of futility. The ferocity and speed of the fires left many feeling helpless and many of those who believed they were ‘fire ready’ were overwhelmed by what transpired. Mr Bevan Gobbett of Clonbinane reflected similar views in his evidence:

You could have put a hundred fire tankers and Elvis in front of my house that day and you would have killed a hundred fire tankers and Elvis.11

2.43 There was general consensus that individuals have primary responsibility for preparing their own properties for bushfire threats. Many people stated that this involved minimising fuel levels around homes, preparing fire plans, testing and maintaining pumps and ensuring that hoses and hose fittings were fire resistant. 2.44 Frustration was expressed in some communities about too few green waste and hard rubbish collections; restrictive council regulations about burn-offs and tree clearance; and neighbours who gave little or no attention to reducing fuel loads on their properties. As supported by Mr Ananiev:

The CFA is trying to do the right thing, saying yes, make it safe, but the council won’t let you.12

2.45 Local CFA information sessions focusing on fire behaviour, fire plans and basic firefighting strategies were praised. Of concern, however, was the poor attendance at these sessions. Many people suggested that the programs could be strengthened by:

■■ more regular scheduling

92 ■■ stronger promotion, targeted at new people moving into fire-prone areas Engaging Communities

■■ providing more comprehensive information about different fire behaviours, including information on radiant heat and ember showers

■■ placing more emphasis on the ‘stay and defend’ or ‘leave early’ options so that people are better equipped to make sound decisions

■■ annual checking of fire plans and site visits. Attendance at training sessions was later commented on by Dr John Ferguson of Buxton:

The first thing I learned was that very few people attended them [the CFA information sessions].13

2.46 Roof sprinklers and other sprinkler systems around properties were regarded by many as effective fire suppressants. Some spoke persuasively of the value of diesel pumps or stand-alone solar power units for pumps; private water carts; misters under the eaves; gutter plugs; and back-up generators. Others spoke with conviction about the more fire-resistant capacity of deciduous vegetation compared with native species. The views of Mr Peter Newman of Buxton, Mr P Brown and Dr Ferguson illustrate various opinions about preparing properties for fires:

The sprinkler and having greenery around the house made all the difference.14

If we rebuild, it will be on the basis that we have electric pumps and diesel backup generator, not just one power source.15

Deciduous trees in previous bushfires have produced good shelter … if I had the chance to start from the beginning, the trees would be planted strategically, specifically for that purpose.16

2.47 There were widely held concerns in some communities about water supplies and failing water pressure. Some communities such as Flowerdale and Kinglake West questioned bore water arrangements. The Flowerdale community, in particular, suggested that there was inadequate access to water from King Parrot Creek when it was most needed for firefighting. Other communities spoke of the need for better planning to ensure sufficient and accessible water supplies for tankers. Issues of water supply were confirmed in the evidence of Dr Ferguson and Mr O’Halloran:

In quick succession over about one hour, we had lost electricity, then landlines, then mobile and then town water.17

We had a five and a half horsepower petrol motor on like a billycart that had a pump attached that could be put into the creek. We had pumping rights to the creek.18

2.48 People who belonged to community fireguard groups rated them highly and in the lead up to the fires those who had phone-tree arrangements felt confident about having sufficient back-up support. For those not affected by failed phone coverage, the phone trees were a significant support in making decisions and in securing assistance. Ms Christine Glassford of Reedy Creek and Mr John O’Neill of Steels Creek shared similar views:

It [the community fireguard group] was very good … I felt it was sufficient to enable me to prepare sufficiently, certainly to still be here, but I guess I don’t know what else more you could do anyway.19

The telephone tree was … very good in that it sort of kept the lines of communication clear among the immediate neighbours.20

2.49 Finally, in Horsham, people spoke appreciatively of the council which organised a community practice of its disaster plan in December 2008 and provided its residents with up-to-date phone listings. In addition, the council took heed of the warnings prior to 7 February and ensured that CFA tankers were strategically placed around all high-risk areas, enabling a maximum response time of 11 minutes should fires ignite.

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Fuel reduction

Figure 2.3: Factors in fuel reduction

Number of Communities

0 2 4 6 8 10 12 14

Vegetation clearing – private land

Fuel reduction – public land

Fuel reduction – roadsides

Fuel reduction

Source: Community consultations, March–April 2009

2.50 As figure 2.3 indicates, fuel reduction discussions fell into three major categories of emphasis, with each receiving considerable attention.21 Across all communities these were prominent issues that were articulated with high levels of conviction and contention. 2.51 Specific concerns were raised about the build up of fuel loads on public lands and along roadsides. The Commission heard repeated criticism of the decline in fuel reduction and fuel management programs, such as controlled burning and back burning, conducted by government agencies and local councils. Many argued that the build up of fuel, particularly in state forests and national parks, was the most significant contribution to the fires. Others spoke of roadside fuel acting as ‘wicks’ that drew the fires into townships. 2.52 Added to this concern were widely held views that the buffer zones and fire trail networks on crown land were insufficient and poorly maintained. Some claimed that these impediments compromised the safety of firefighters and severely limited their fire suppression efforts. Similar comments to these of Dr Chris Harvey of Kinglake and Mrs Joan Davey, whose family lived in Kinglake, were often made:

The idea is if you reduce fuel, there is no fire. Bald Spur Road has never, or the mountain either side of it, has never had a fuel reduction burn … The DSE has never been up there to do any burning off … It was metres deep in some places with leaves and debris from 47 years worth of – do we call it negligence? I would call it negligence, but I don’t know whether I’m being fair.22

Roadsides shouldn’t have trees that have the ability to block them. I believe that trees are fine so long as they have not got the ability to fall and block a road.23

2.53 In addition, some participants maintained that tree preservation orders were too prohibitive, as were council regulations about the retention of native vegetation. These issues were contentious, with some favouring radical change, others advocating a hands-off approach, and some arguing for a ‘common sense’ balanced approach to maintaining bushland settings and making homes safe. Views expressed by Mr Ananiev and Ms Glassford illustrate the frustrations that were frequently raised in the consultations:

Fallen trees are not allowed to be touched. Trees on the outside of my property are not allowed to be touched.24

My issue has been that in some instances we have had these dangerous trees or roads reviewed three or four times and each time more trees have been taken.25

94 Engaging Communities

2.54 A final concern to some community members was the issue of absentee landholders and ‘weekenders’ who in some communities showed little or no commitment to fuel reduction programs or standards. Insurance discounts for compliant landowners and tighter monitoring of compliance by councils were suggestions put forward by several communities. As also stated by Mr Newman:

We have got a lot of suburban people in the area that are retired there and they don’t have the same learned knowledge and reactions.26

Emergency management and coordination

Figure 2.4: Issues in emergency management and coordination

Number of Communities

0 2 4 6 8 10 12 14

Evacuation centres/houses

Positive use of aircraft

Not enough use of local knowledge/leadership

Inadequate maps/house signage

Roadblocks (inc. media and looters)

Emergency Management and Coordination

Source: Community consultations, March–April 2009

2.55 Matters associated with resources available to fight the fires were raised but did not feature prominently, with the exception being assistance from the CFA and fire-bombing aircraft — the latter were viewed to be effective in those communities where they were used. There appeared to be tacit agreement that there would rarely be sufficient resources to deal with the multiplicity of fire outbreaks on days like 7 February. 2.56 Any criticism raised in sessions about the CFA was quickly countered by other community members in the same sessions. Across all communities there was widespread praise and appreciation expressed for the CFA and other workers supporting them. The views of Mr Doug Walter of Taggerty, Mr Peter Olorenshaw of Callignee and Mrs Davey reflect widely held opinions:

I would like to be able to get in touch with the fire captains and tell them how very grateful we were.27

[The CFA] are a very selfless organisation and have assisted in clearing debris off the roads, but also the local farming community.28

The families are all very grateful to CFA volunteers and all volunteers.29

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2.57 Roadblocks represented the most frequently mentioned grievance for the majority of communities. People expressed anger and frustration about emergency service personnel denied access to fire-affected areas. Family and friends who were separated from loved ones experienced severe distress. Residents who fled their homes spoke of the stress of being unable to return to care for livestock and protect their homes from spot fires and ember attacks. Others who had stayed spoke of being ‘cut off’ and reluctant to leave their properties for fear of being denied return access. The comment of Mr John Williams of Yarra Glen is representative of one raised many times at the consultations:

I think there certainly needs to be a measure of common sense, a measure of compassion in these roadblocks. 30

2.58 Many people felt that roadblock protocols and regulations were too prohibitive and lacked understanding of some of the fundamental needs of locals to access fresh food, medical assistance, and feed and veterinary care for their livestock. Others argued that roadblocks should be staffed by people with local, up-to-date information, who had discretionary powers to vary regulations and protocols, as the emergency required. Mr D Brown made similar comments:

Neither of the policemen [on a roadblock] were prepared to say what they were doing this for, why they were doing this, what they had been instructed.31

2.59 Community participants in Kinglake, Bendigo, Marysville, Yarra Glen, Flowerdale and Strathewen spoke of the perils of evacuating and of not knowing the location of evacuation centres or fire refuges. These comments were often accompanied by requests for coordinated evacuation plans for people who cannot self-evacuate — in particular elderly people, those without cars and people with a disability. The early evacuation of elderly residents from a Marysville aged care facility was viewed as a good example of a well-executed plan. Uncertainty about the location of fire refuges is reflected in the comment of Mr O’Halloran:

I think it [the Yarra Valley Recreation Reserve] would probably be just one [a fire refuge] that locals know about. I have never been aware of it being an official place.32

2.60 Some people questioned the existence of local council emergency management plans and argued that more was needed to educate residents about such plans. They argued that central fire refuges should be well known and well signposted, both for locals and for tourists visiting the area, and that a coordinated ‘notification’ approach was needed for residents who had chosen to evacuate. It was suggested that fire-resistant signs such as ‘we have left’, posted in a prominent area close to the entrance of properties, would assist emergency workers in checking the safety of residents and properties. 2.61 A number of the communities spoke of roads that changed names multiple times and of the lack of accurate, up-to-date maps that indicated the types of road. Added to this was the failure of many maps to indicate access areas, trails and firebreaks in parks and forests. This was perceived as a significant impediment for fire units and emergency service personnel deployed from outside the local area. A recurring suggestion was that volunteers with sound local knowledge should accompany outside units deployed to the area; alternatively, they should play a greater role in local operational communications. Mr Walter similarly stated:

Through the smoke up Knafl Road we saw the red and blue flashing lights of what was obviously a CFA unit. I ran up to the front gate. They stopped and I was ever so glad to see them. It turned out, on talking to the fire captain, that they were a New South Wales unit that was lost.

… [the fire captain’s] exact words to me were the first casualty in this crisis has been communication, that they had no map and that they had no briefing, and they didn’t know what to expect. So I actually climbed into the command vehicle with him at that point knowing that my wife and Josh were still at the 96 home and showed them where they were trying to go ... 33 Engaging Communities

Recovery efforts

Figure 2.5: Issues with recovery efforts

Number of Communities

0 2 4 6 8 10 12 14

Fences

Grants

Insurance

Lack of coordination

Issues with recovery effort

Source: Community consultations, March–April 2009

2.62 Issues raised about recovery efforts were essentially directed at the immediate post-fire experiences of participants. The timing of the consultations meant that medium- and longer-term recovery issues, such as access to donated funds and government grants, the clearance of blocks and case management arrangements, were only just beginning to surface. 2.63 Most communities acknowledged the generous and sometimes ‘overwhelming’ support from volunteers. They spoke of strengthened community cohesion and resilience and of the many kindnesses extended to them by a host of individuals, businesses, government and community-based agencies. Specific examples of commendation were from Kinglake residents who felt well supported by the people and services available at Whittlesea, and from Marysville residents who were profoundly appreciative of the range of support services provided at Alexandra. Mr Ken Rogers of St Andrews supported this view:

It turned me over. People at one stage just gave us a hundred dollars. Shops were giving us things, or not charging ... They couldn’t do enough. It was hard at times to find things for people to do who wanted to help you.34

2.64 Countering these commendations were grievances about poor coordination of recovery services. Many people observed that there was a lack of clarity about the role of different agencies and the way they should work together. Multiple registration procedures, along with having little or no information about the whereabouts and wellbeing of family, friends or neighbours, exacerbated the stress and trauma for many people. The experience later described by Mr Olorenshaw was not unique:

My herd was inspected twice by veterinarians who had no knowledge or contact with one another and they were doing the same job and the same role.35

2.65 Some people spoke of the need for a single, up-to-date, electronic and centralised database of residents’ details that could be shared among service providers to track locals, synchronise lists of missing persons and monitor access to services and grants. Others spoke of the need for better identification systems such as a bracelet system or an on-the-spot photo identification procedure that enabled photos to be exchanged between evacuation centres and service providers. Mrs Matthews suggested the following in her evidence:

One lady had been told that in fact we had all died. So, I just think in the future, streamlining and training people who are in the process of doing the registrations would be a simple but effective things to do.36 97 2009 Victorian Bushfires Royal Commission—Interim Report

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2.66 Residents of Flowerdale and Hazeldene reported that four days transpired before emergency service personnel arrived. This time lag well exceeded responses in other areas. Nonetheless some communities spoke of there being several days or more before they had access to medical services, fuel, fresh food, power and phone coverage. Delays like those described by Mr Newman illustrate the difficulties:

Water we got back on Tuesday … Thursday we got power back and then we got two bars on the mobile and I have only got a normal mobile, got two bars on Saturday, four bars on Monday so really brilliant.37

2.67 Many people spoke of the need for urgent assistance to repair fences, and of inequities of fencing policies, particularly for people whose properties bordered crown lands. The responsibilities and liabilities of private and public landowners with regard to fencing was a highly contentious issue, causing substantial stress and anxiety for those affected. 2.68 Also touched upon in a number of the consultations were issues of insurance and grants from public relief funds. The issues focused primarily on the equity of eligibility criteria. While acknowledging that it was ‘early days’, some people were concerned about criteria pertaining to insured, under-insured or un-insured property owners. Property owners who did not draw their primary income from the land, and those whose properties were not their principal place of residence, also expressed concern about perceived disparities and inequities. Another recurring concern was about the processes for making claims and applying for grants; many people were fearful that excessive ‘red tape’ would delay respite from the severe financial strain they were experiencing. Ms Sharon McCulloch of Kinglake described the same frustrations:

We needed to comply with certain things to even be open again for insurance purposes, so we needed to have all our fire extinguishers checked, we needed to have our septic tank pumped … we needed to do quite a few things to satisfy them that we were publicly not liable once we re-opened again.38

Buildings and infrastructure

Figure 2.6: Concerns with buildings and infrastructure

Number of Communities

0 2 4 6 8 10 12 14

Building codes and fire rating

Bunkers

Underground powerlines

Buildings/Infrastructure

Source: Community consultations, March–April 2009

2.69 Across the 14 communities, issues raised about building codes and community infrastructure were less predominant than those issues reported under previous themes.

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2.70 People described various building features and infrastructure that they believed would provide them with protection. But many were stunned by the non-discriminatory impact of the fires — some of the most fire-ready homes did not withstand the ferocity of the fires, while others that were less fire-protected were left standing. As suggested by Ms McCulloch in her evidence:

I don’t like saying luck, but it was a bit of luck … if the wind had blown directly at us I don’t think we would have been as fortunate.39

2.71 Few people disputed that building standards for fire protection would need serious review and upgrading. A repeated caveat, however, was that one size does not fit all; fire-prone areas can vary greatly in topography, as can the bushfire risk. The standards need to accommodate these variations. 2.72 Some people spoke of the urban-rural interface of their respective communities and of their ‘lifestyle’ choice to live in bushland settings. They argued that any new developments and reconstruction regulations ought to reflect a sensible balance of competing values — environmental conservation, human safety and property protection. Mrs Matthews reflected on life in the bush as follows:

We love the bush and every time we go back there is a feeling of it being our home.40

2.73 Questions about the merits of bunkers were repeatedly raised. In many instances people expressed an openness to installing bunkers, not just on their own properties but at community centres such as schools. People suggested that an expert engineering investigation was needed so that an Australian standard could be developed. Mr Gobbett later said of bunkers:

It [the bunker] saved our life in this fire. If we didn’t have it, I don’t doubt that we would be dead.41

2.74 As figure 2.6 indicates, another concern raised in some communities was that of power poles. Many argued that power poles should be built from concrete or other fireproof materials. Others argued that powerlines should be relocated underground. Most posited that clearing of fuel loads and vegetation around powerlines had been inadequate. Mr P Brown’s view on powerlines as expressed during the hearings was illustrative of those held by others in some communities:

I believe it is about time we bit the bullet and started undergrounding our power in bushfire areas.42

Community consultations — concluding comments 2.75 As stated at the outset of the consultations, the Commission sought assistance in identifying key issues for further research and investigation, in advance of any formal hearings. This objective was certainly achieved. 2.76 The Commission is extremely grateful to all community participants who provided first-hand accounts of their experiences and views on a wide range of issues. The task of confronting, examining and discussing experiences was at times difficult for people. As emphasised in paragraph 2.35, the commitment to confidentiality has been maintained and the quotes used in this chapter to illustrate the issues raised have come from witnesses at the public hearings, not from attendees at the community consultations. The Commission thanks the attendees and other local community members and organisations who assisted in hosting and supporting the sessions.

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EVIDENCE OF LAY WITNESSES 2.77 An important part of the evidence heard by the Commission during the first block of hearings came from 29 ‘lay witnesses’ — people from all walks of life who were affected in some way by the 2009 bushfires. Having experienced the devastating impact of the bushfires first hand, they were able to provide an account of that impact on them personally, on their families, their neighbours and the communities to which they belong. 2.78 Lay witnesses who appeared before the Commission all lived or worked in areas affected by the 2009 bushfires, or else had loved ones who lived in these areas. A small number of lay witnesses experienced the fires in a professional capacity, though all lay witnesses gave evidence in their personal capacity. Their names and associated transcript references are outlined in Table 2.2. 2.79 The contribution of lay witnesses was extremely valuable, as will be apparent from the frequent references to their evidence in the chapters that follow.

Identification of lay witnesses 2.80 The Commission identified lay witnesses in different ways, including through:

■■ attendance at the community consultations

■■ applications for leave to appear received in March and April

■■ submissions made by members of the public to the Commission

■■ witness statements taken by Victoria Police following the bushfires

■■ referrals from witnesses interviewed

■■ media reports

■■ individuals who contacted the Commission’s enquiry line. 2.81 During the first hearing block, the Commission investigated a number of issues, including warnings, communications, and the ‘stay or go’ policy. Lay witnesses provided information to the Commissioners about these issues by reference to their personal circumstances, their individual fire planning and preparation, and their own experiences on 7 February and immediately following. 2.82 For some, giving evidence before the Commission enabled them to speak for family members who perished in the fires. A number of lay witnesses gave evidence about how the fires affected vulnerable people, such as the elderly, young children and people with disabilities. 2.83 Many lay witnesses told the Commission about their efforts to defend their homes against the fires. Some stayed and defended their homes successfully; others saw their homes burn despite their best efforts; all were able to share their experience to the benefit of the Commission. 2.84 Some witnesses told how they abandoned their plan to stay and defend when they realised the severity of the firestorm. The Commission also heard from lay witnesses about their attempts to find shelter during the fires. 2.85 Other lay witnesses chose to leave rather than stay to defend their homes. Their accounts of how and when they made their decisions to leave their homes have informed the Commission’s understanding of the practical application of the ‘stay or go’ policy. 2.86 Some lay witnesses informed the Commission of their involvement with the CFA, either through being a volunteer, attending community information sessions or becoming involved in a community fireguard group. Several recounted their previous experience of fires in their area, which informed their response to the 2009 bushfires. 2.87 The evidence of almost all of the lay witnesses included vivid descriptions of the fires. Many witnesses also provided photographs and video footage they took during and after the bushfires. Combined with their oral testimony, these photographs and video footage have greatly assisted the Commission in better understanding the spread and severity of the bushfires.

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2.88 Lay witnesses were also given the opportunity to give evidence in relation to other matters of concern to them, including:

■■ their experience with police roadblocks in the aftermath of the bushfires

■■ restrictions on their ability to manage the vegetation around their homes

■■ the adequacy of fuel management in their area

■■ bushfire bunkers

■■ the process of identifying those who perished in the fires

■■ the need for a more coordinated response to the fires. These issues are to be examined in greater detail by the Commission in future hearing blocks.

Evidence of lay witnesses — concluding comments 2.89 The evidence presented by lay witnesses was detailed and varied. It demonstrated the profound effect that living through the 2009 bushfires had on them, their families and their communities. From the evidence of lay witnesses, both the Commission and members of the broader community have been able to gain a better understanding of the devastating effect that the bushfires had on so many people. Lay witnesses also drew on their experiences to offer suggestions as to how things could be done differently in future, all of which have been given careful attention by the Commission. 2.90 The process of identifying, interviewing and calling lay witnesses to give evidence is continuing. In future hearing blocks, the Commission will continue to ask lay witnesses to provide an account of their experience of the fires, while addressing specific topics under investigation. These topics will include building issues, the causes and circumstances of each of the fires, emergency response and recovery, land-use planning and fuel management — all matters within the Commission’s terms of reference.

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Table 2.2: Lay witnesses in the first hearing block, May– July 2009

Name Location Date of appearance Statement Transcript Ms Jesse Odgers Kinglake 12 May 2009 EXHIBIT 10, T189:15–T198:30 WIT.008.001.0001_R Mr Peter Newman Buxton 13 May 2009 EXHIBIT 13, T332:4–T356:2 WIT.009.001.0001_R Mr Brian Patten Upper Plenty 14 May 2009 EXHIBIT 15, T406:2–T429:27 WIT.007.001.0001_R Mr Denis Spooner Strathewen 15 May 2009 EXHIBIT 17, T461:2–T508:28 WIT.011.001.0001_R Mr Ken Rogers St Andrews 18 May 2009 EXHIBIT 20, T603:4–T620:2 WIT.015.001.0001_R Mrs Joan Davey Kinglake43 19 May 2009 EXHIBIT 23, T774:8–T790:15 WIT.019.001.0001_R Dr John Ferguson Buxton 20 May 2009 EXHIBIT 29, T922:23–T956:29 WIT.022.001.0001_R Ms Jillian Kane Long Gully44 21 May 2009 EXHIBIT 34, T1040:6–T1057:12 WIT.017.001.0001_R Mr Daryl Hull Marysville45 25 May 2009 EXHIBIT 39, T1160:9–T1191:19 WIT.030.001.0001_R Ms Christine Glassford Reedy Creek 26 May 2009 EXHIBIT 43, T1319:3–T1348:30 WIT.028.001.0001_R Mr Bevan Gobbett Clonbinane 27 May 2009 EXHIBIT 46, T1491:19–T1505:31 WIT.026.001.0001_R Mr John (David) Brown Strathewen 28 May 2009 EXHIBIT 48, T1635:8–T1657:8 WIT.029.001.0001_R Mr Peter Olorenshaw Callignee 1 June 2009 EXHIBIT 61, T1871:4–T1906:23 WIT.034.001.0001_R Mr Ken Dwight Woods Point, 2 June 2009 EXHIBIT 64, T2058:27–T2093:17 Marysville WIT.037.001.0001_R Dr Chris Harvey Kinglake 3 June 2009 EXHIBIT 67, T2189:5–T2205:1 WIT.036.001.0001_R Mr Christopher Casey Long Gully 4 June 2009 EXHIBIT 70, T2347:19–T2365:28 WIT.035.001.0001_R Ms Sharon McCulloch Kinglake 9 June 2009 Exhibit 73, T2442:3–T2477:7 WIT.043.001.0001_R Mr Doug Walter Taggerty 10 June 2009 EXHIBIT 77, T2581:3–T2602:25 WIT.041.001.0001_R Mr Illiya Ananiev St Andrews 11 June 2009 EXHIBIT 87, T2768:2–T2787:21 WIT.040.001.0001_R Ms Anastasia Scott Marysville 12 June 2009 EXHIBIT 91, T2915:29–T2934:24 WIT.045.001.0001_R Dr Lachlan Fraser Marysville 15 June 2009 EXHIBIT 95, T3046:3–T3065:31 WIT.048.001.0001_R Mr John O’Neill Steels Creek 16 June 2009 EXHIBIT 97, T3190:28–T3218:14 WIT.047.001.0001_R Ms Alice Barber Pheasant Creek 17 June 2009 EXHIBIT 103, T3331:3–T3360:11 WIT.046.001.0001_R Mr Peter Brown St Andrews 18 June 2009 EXHIBIT 108, T3496:6–T3548:19 WIT.053.001.0001_R Mr David O’Halloran Flowerdale 22 June 2009 EXHIBIT 114, T3676:6–T3726:19 WIT.058.001.0001_R Mrs Carol Matthews St Andrews 23 June 2009 EXHIBIT 116, T3771:14–T3807:31 WIT.057.001.0001_R Ms Karen Ward Mudgegonga 24 June 2009 EXHIBIT 121, T4028:3–T4048:1 WIT.052.001.0001_R Mr John Williams Yarra Glen46 25 June 2009 EXHIBIT 125, T4205:4–T4234:9 WIT.055.001.0001_R Ms Jacqueline Hainsworth Kinglake West 29 June 2009 EXHIBIT 134, T4529:4–T4546:31 102 WIT.059.001.0001_R

Note: This list of lay witnesses relates only to the May–July block of hearings. The final report will include a wider representation of witnesses. SUBMISSIONS 3 2009 Victorian Bushfires Royal Commission—Interim Report

3 SUBMISSIONS

This chapter provides an overview of the written submissions received in response to the Commission’s public invitation. Emphasis is placed on those submissions relevant to the topics that have been dealt with in the first block of hearings, namely, warnings, communications and the Prepare, Stay and Defend or Leave Early policy, the ‘stay or go’ policy. The extracts from sample submissions are provided for illustrative purposes. The Commission does not express any views on any of the submissions referred to but comments on their overall value to the Commission’s work.

THE SUBMISSIONS PROCESS 3.1 On 18 March 2009 written submissions were invited from any person or organisation with information relevant to at least one of the Commission’s terms of reference (TOR).1 The Commission’s guidelines stated that submissions could contain factual information, opinions or both, and that observations and recommendations were welcomed on what worked well in relation to the February fires, what did not work well, and what could have been done differently to prevent the tragedies of 7 February. 3.2 There was no set format for submissions, but each author was required to complete a cover sheet to acknowledge that the submission would be treated as a public document, could be published on the Commission’s website, and could be quoted or referenced in reports. 3.3 A small number of individuals and organisations requested that their submission, or parts thereof, be treated as confidential. Requests for confidentiality were few, with reasons given including:

■■ protecting pending patent applications for a commercial product

■■ business owners needing to comply with contractual arrangements

■■ health care workers wishing to protect patient privacy. 3.4 The Commission received over 1260 submissions by 18 May 2009, which was set as the cut-off date for submissions to be considered for the interim report. Some of the submissions focused on one or two topics while others considered a variety of topics. Some authors contributed more than one submission. 3.5 Each submission has been read and reviewed by the Commission. The submissions varied greatly in length and included a range of attachments such as photographs, maps, graphs, books or other printed material, DVDs and CDs. After careful review submissions have been posted on the Commission’s website. 3.6 The Commission continues to receive and review submissions and will share them with the broader community through its website. Those received after 18 May will be considered for the Commission’s further work and its final report. The Commission is not able to personally respond to each author but publicly extends its appreciation to all who have contributed to the Commission’s work through written submissions.

THE Value of submissions 3.7 The submissions provided a pool of valuable resources from which to draw when identifying individuals or organisations with expertise relevant to the Commission’s inquiry. 3.8 The personal stories recounted in some submissions provided the Commission with a means of sourcing people who might wish to give evidence before the Commission as lay witnesses. Twelve of the 29 lay witnesses who gave evidence in the first hearing block (May–July 2009) were identified through the submissions process. 3.9 The submissions also played an important role in enabling the Commission to hear from the broader community. They illustrated the wide range of opinion on some matters and presented valuable insights on critical issues. Some submissions provided insight into complex technical issues, while others alerted the Commission to relevant research or technology that is already available. 3.10 The Commission received many submissions on commercial products. The role of the Commission is not to sponsor, endorse or trial commercial products; the fire authorities undertake this role. Submissions with 104 information about commercial products will be made available to the fire authorities for their further consideration. Submissions

SUBMISSION Demographics 3.11 The Commission received submissions from across Victoria, from people residing in both fire-affected and unaffected areas, from around Australia, and from other countries including New Zealand, Canada, the United States, the United Kingdom, Spain and Slovenia. Authors from the broader international community offered personal thoughts on the fires, words of support and encouragement, academic insights and expertise, and information regarding commercial products such as early warning systems and aerial firefighting hardware. 3.12 A broad spectrum of people and organisations provided submissions and presented an extraordinary range of views, ideas or interests — religious, philosophical, academic, scientific, technical or commercial. 3.13 A significant number of older members of the community contributed submissions. Some authors declared their age, while others recounted personal experiences during earlier historic fires in Australia, such as the 1939 bushfires in Victoria on Black Friday and the 1983 Ash Wednesday bushfires in Victoria and South Australia. There appeared to be fewer submissions by younger people. 3.14 The Commission is aware from its community consultation process that many tourist-related businesses and other businesses were directly affected by the fires through loss of property, staff members, customers and colleagues. However, tourism bodies, related businesses, and other fire-affected businesses were under-represented in the submissions received by 18 May.

Submissions by town and fire 3.15 When submissions were grouped according to one of the 12 fire events within the ambit of the Commission’s inquiry, half related to the impact of the Kilmore East fire and another quarter to the Murrindindi fire.2 Figure 3.1 shows the breakdown of submissions by reference to each fire. 3.16 Some submissions were specific to particular towns or fires, while others were of a more general application. For those submissions that were town specific, the highest numbers pertained to Kinglake and Marysville.

Figure 3.1: Submissions by fire events

Pomborneit – Weerite (0.2%) Beechworth – Mudgegonga (3.3%)

Redesdale (0.8%) Bunyip (4.8%)

Narre Warren (1.6%) Delburn (5.2%) Horsham (1.9%)

Bendigo (2.5%) Churchill (and Jeeralang) (6.0%)

Kilmore East (49.2%)

Coleraine (0.0%) Murrindindi (24.4%)

Source: Submissions received by the Commission by 18 May

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Recurring themes in submissions 3.17 Authors were asked to identify which of the Commission’s TOR their submission addressed. They often covered more than one TOR. 3.18 The second TOR (TOR 2), concerning planning and preparation for bushfires in Victoria, was most often listed by authors. The next most popular TOR concerned the causes and circumstances of the 2009 Victorian bushfires (TOR 1), followed by all aspects of the response to the fires (TOR 3). 3.19 Some issues appeared frequently in the submissions. These included the ‘stay or go’ policy; weather and climate change as a cause of the fires; fuel reduction; roadblocks; bunkers; refuges; the coordination of the response to the fires; and the provision of relief to people affected by the fires. 3.20 Against the background of the Commission’s TOR, the submissions were categorised according to issues that were frequently raised in the community consultations held during March and April 2009 (Chapter 2). Fifteen key topics were identified:

■■ What happened — causes and circumstances of the fires

■■ Emergency management of the fires

■■ Fire detection (including alternative systems)

■■ Warnings

■■ ‘Stay or go’ (including evacuation and fire refuges)

■■ Fire preparedness (including preparing and defending homes and clearing vegetation)

■■ Planning and local government

■■ Fuel reduction and prescribed burning (including vegetation management on public land)

■■ Building and rebuilding

■■ Emergency communications (Triple Zero and other emergency service calls)

■■ Essential services during and after the fires (including power, water and phone coverage)

■■ Economic cost of the fires

■■ Roads (including roadblocks and inaccessibility of roads during and after the fires)

■■ Insurance

■■ Recovery efforts (including relief centres, coordination and Coroner’s Office). 3.21 Of these 15 topics:

■■ Fuel reduction/prescribed burning generated the most submissions (485)

■■ Fire preparedness and warnings both featured in 430 submissions

■■ Fire detection was the least considered topic (61 submissions). 3.22 A significant number of submissions covered more than one key topic and some individuals and organisations made multiple submissions, sometimes on the same topic. 3.23 Figure 3.2 charts the number of submissions for each of the key topics, in descending order of significance.

106 Submissions

Figure 3.2: Submissions to the Commission, organised by key topics

Number of Submissions

0 50 100 150 200 250 300 350 400 450 500 550

Fuel Reduction/DSE/ 485 Prescribed Burning

Fire Preparedness 430

Warnings 430

Planning & Local 340 Government

Stay or Go, 326 Evacuation, Refuges

Emergency Management 310 of the Fires Causes & Circumstances 276

Building/Rebuilding 183

15 Key Issues Economic Cost 156 of the Fires

Recovery Efforts 156

Emergency Communications 140

Essential Services 132

Insurance 65

Roads 64

Fire Detection 61

Source: Submissions received by the Commission by 18 May

3.24 A sample selection of views, comments, offers of assistance and suggestions outlined in the submissions are presented here according to these 15 key topics. The quotations not only provide insight into and detail about each topic, but also serve to illustrate the thoughtful and informative material presented to the Commission.

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Causes and circumstances of the bushfires 3.25 A number of submissions stated that a contributing cause of the fires was climate change and requested that further action be taken to reduce the effects of climate change. The CSIRO noted in its submission that:

Climate change may affect: the occurrence of high-risk fire weather conditions; the characteristics of the natural vegetation which provides fuel for fires; the effectiveness of existing tools, strategies and approaches for managing and controlling bushfires.3

3.26 In many submissions, the extreme weather conditions were identified as a cause of the fires. For example, the Victorian Landcare Council highlighted:

... three crucial facts: 47 degrees temperature (115 Fahrenheit), 120 km/hr winds and relative humidity of 6%. ... That these conditions followed two weeks of >40 degrees heatwave, that in turn followed an unusually wet November–December and lots of late spring–early summer growth, after a decade of drought, made for an explosive tinderbox and an unprecedented Fire Danger Index.4

3.27 Many submission authors attributed the cause of the fires to the build up of fuel. It was suggested by some that there should be an increase in fuel reduction practices as a fire prevention strategy. The Victorian Association of Forest Industries stated that regular forest fuel reduction would:

… result in reduced levels of fuel material that produce burning embers and will reduce both the potential for spotting ahead of the main fire front and the impact on structures in the face of the fire.5

3.28 Some submission authors proposed tougher penalties for arsonists and litterbugs. Other submissions called for the implementation of a monitoring system for known arsonists, to be used on Total Fire Ban days as a deterrent. 3.29 On the issue of powerlines, discontent was expressed about above-ground positioning of powerlines and the use of wooden poles in fire-risk areas. 3.30 A number of submissions from individuals recounted their personal experiences of the fires. This provided the Commission with a basis for understanding the location, ferocity, timing and spread of the fires, and the steps people took to survive.

Emergency management of the fires 3.31 Issues with the coordination among the Country Fire Authority (CFA), the Metropolitan Fire and Emergency Services Board (MFB), and the Department of Sustainability and Environment (DSE) were raised in a number of submissions. Some authors suggested there should be one organisation designated to respond to fires, irrespective of where they start. 3.32 Many submissions stated that CFA volunteers needed more training, support and resources, though in most instances the CFA was congratulated for its efforts. There were many expressions of gratitude and praise for the CFA, such as the following statement on behalf of the Scout Association’s Camp Site ‘Camp Warringal’:

… we have nothing but praise for the CFA and ‘Elvis’ for all their assistance on the day of the fires; without ‘Elvis’ we would have lost a lot more than 100’s of trees and two buildings, had it not been for our committee and the CFA’s vigilance days after putting out the spot fires we probably would have lost the lot.6

Fire detection and alternative warning systems 3.33 A small number of submission authors suggested the use of spatial technologies for fire management. These included satellites using thermal technology to provide fire detection information, and aerial vehicles to gather and relay accurate information instantly. For example, Mr David Gamble of Acheron stated in his submission that, ‘existing “line scan” fire mapping technology is outdated and episodic’. He went on to suggest the use of unmanned aerial vehicles equipped with thermal infra-red imaging equipment to provide real time data.7 108 Submissions

Warnings 3.34 There were 430 submissions that focused on warnings. Many authors stated that official warnings were not received or were sent too late to be of assistance to residents of individual towns. Mrs Renee Visentin of Kinglake wrote:

[The] entire official warning system that people relied on failed on the day.8

3.35 A few submissions presented suggestions about ways in which warnings should be released. For example, the Victorian Council of Social Services argued that:

… emergency warning systems need to communicate effectively and in a timely manner with the whole community … they need to be delivered in multiple formats to ensure that people with a range of disabilities ... including mobility difficulties, are able to make appropriate choices about evacuation.9

Similarly, the Disability Emergency Advocacy Group noted in its submission that emergency warning systems need to:

… reach people with visual or hearing impairments, and those who do not understand English.10

3.36 Some submissions commented on the provision of warnings via SMS, sirens, and television:

■■ The Ferny Creek Bushfire Alert Committee stressed in its submission that:

… reliance on any single information source is fraught with danger because any and all information sources will fail.11

This submission emphasised the value of incorporating sirens into community alert systems, coupled with appropriate community education as to what the siren means.

■■ Nillumbik Climate Action Now suggested the use of:

… a targeted communication system similar to Western Australia, where people under threat from fire are called by telephone and told to evacuate and given information regarding safe exit points and areas to evacuate.12

■■ Mr Shane Moore of Traralgon proposed that:

… in times of emergency, all broadcasters (radio and television) be obliged to announce at regular intervals or by means of a scrolling/displayed notice (for television) of the frequencies on which emergency broadcasts are being made. This should be the case, especially for those broadcasters (mostly commercial broadcasters) who would not normally be willing to suspend their normal service to provide emergency services broadcasting, although the federal minister has the power to direct any broadcaster to oblige to satisfying the needs of emergency services organisations wishing to communicate with the population.13

■■ The Mount Pleasant Community Fireguard Group, and Mr Max Garner, Leader of 9437 Fireguard Group, discussed in their submissions the trial of an automated telephone polling system that enables all telephone numbers registered in a telephone tree to be connected to an alert message within a few minutes. This system is linked to the Research CFA fire station, which enables the fire captain there to activate North Warrandyte and Mount Pleasant Community Fireguard telephone trees in the event of a fire in the area.14 3.37 Some submissions presented the view that there was a lack of common sense shown by some residents in fire-affected areas, and that these residents did not take responsibility for themselves. Mr Stuart Strachan of Callignee wrote:

… one of the best support networks is the community itself and staying indoors on a potentially disastrous day does not support or contribute to the local community.15 109 2009 Victorian Bushfires Royal Commission—Interim Report

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3.38 Many noted that the warnings given in the days leading up to 7 February were sufficient. For example, Mr David Baker-Gabb of St Andrews wrote:

[My] family was well warned of the impending severe wildfire weather in the three days before 7 February by a range of authorities from the Premier down. Consequently I took the whole of Friday 6 February off work to ‘fine tune’ our fire preparations. I suggest that the level of warning was adequate for our family’s needs.16

3.39 Others considered the general warnings about 7 February to be adequate, though specific warnings were lacking. Mr Stan Larner of Buxton stated:

Despite this obvious threat of fire to the Buxton community, there had been no official warning given that Buxton [itself] was under threat.17

3.40 There were suggestions from some that an explanation of the anticipated fire risk beyond Total Fire Ban day would make warnings more effective and allow people to better implement their fire plans. These submission authors sought a classification system of fire intensity beyond the current ‘Low’, ‘Moderate’, ‘High’, ‘Very High’ and ‘Extreme’. It was also suggested that there should be an explanation of the Forest Fire Danger Index and Grass Fire Danger Index, or a numerical rating like that used for cyclone warnings. 3.41 Some submission authors took issue with the quality of the information available via the CFA and DSE websites, the Victorian Bushfire Information Line (VBIL) and 774 ABC Radio. Submissions noted the lack of timely information on the CFA and DSE websites, as well as problems with the layout of the information. Others were unable to access these websites due to local area network failures. Mr Geoffrey Raftery of Strathewen stated that often when he tried to check fire update pages on the internet, he received the message, ‘server timed out’.18 3.42 Some submissions noted that operators taking telephone calls at VBIL lacked local knowledge and were unable to supply up-to-date information on the status of the fires. Mrs Bronwyn McLaren of St Andrews wrote:

Training needs to include the bushfire info line being aware of maps and locations. So many times after Black Saturday, for further outbreaks, we would ring up to find out if we were under threat. We would tell the operator on the bushfire info hotline that we were in St Andrews and they had no idea where we were. They would try to give us info for Gippsland, so clearly they had no idea of our location and what fires we needed to be aware of.19

3.43 Submissions recorded both an appreciation for and a dissatisfaction with the coverage of the fires on 774 ABC Radio. Some stated that some of the information broadcast was out-of-date or incorrect. Others suggested the use of local radio and foreign language stations to broadcast emergency information, in conjunction with 774 ABC Radio, particularly in areas where there is no ABC reception. The National Ethnic and Multicultural Broadcaster’s Council submitted that:

… community radio can play a vital role during any emergency. Community radio has the distinct advantage of having local knowledge, understanding the local geography and the people that live in the community.20

3.44 The naming of fires by fire agencies, based on the point of origin of the fire, gave people a false sense of where the fire actually was. This comment applied to all warnings and information, whether delivered via websites, VBIL or 774 ABC Radio. Mr Mark Stephenson of Bundoora wrote:

Fire information on the CFA website refers to the point of origin of a fire … Thus the Kilmore complex fire remained with that name, despite the fact that the fire had moved a considerable distance from its origin and was threatening townships some considerable distance away from the point of origin. The naming protocol, in my view, provided false information of the status of the fire, particularly in relation to its location.21 110 Submissions

Stay or go, evacuation and refuges 3.45 There were 326 submissions that addressed the ‘stay or go’ policy, relocation and fire refuges. Various submissions indicated that there was confusion, misinformation or a lack of information regarding what the ‘stay or go’ policy means, in particular as to what ‘leave early’ means. Ms Tammy Lobato MP, Member for Gembrook, stated:

… [many] people thought that ‘leave early’ meant leaving before a fire actually arrived at a township.22

3.46 The main issue people raised in relation to the policy was the difficulty in understanding what it meant in practice — when is the right time to go and where do you go if you are unable to leave the area? The United Firefighters Union of Australia questioned:

… [how] can a member of the community with no firefighting background know about how to plan an evacuation when a threat is imminent, and when it is appropriate and safe to leave?23

3.47 Some submissions focused on the use of household and community fire refuges. Mr Geoffrey Mortimer and Mrs Nancy Mortimer of St Andrews spoke of a house design that included a fire-resistant pantry as a bushfire shelter that:

... ultimately saved the lives of 5 people and a dog when utilised in the Black Saturday fire.24

3.48 The submission from the Yackandandah Fire Brigade stated that:

... policies regarding community emergency refuges needs [sic] to be reviewed so that such areas can be designated and maintained for both residents and visitors.25

3.49 A number of people expressed a desire that they have the right to decide whether to stay. A smaller number thought that the introduction of forced evacuations would save lives; some people suggested that there be mandatory evacuations only on Total Fire Ban days with a particularly high fire danger index rating. 3.50 Other submission authors commented on a perceived degree of apathy in the community. These authors stated that residents needed to take more responsibility for their own safety. Some submissions noted the problems that arose when people with an inadequate or no ‘stay’ plan did not have enough warning to be able to leave safely.

Fire preparedness 3.51 A large number of submissions reflected dissatisfaction with current council rules limiting the removal of trees, shrubs and dead wood from private property. Many of the authors sought regulations that allowed landowners to prepare their properties for the fire season. The Victorian National Parks Association stated that:

… [laws] regulating the removal of native vegetation on private land are an important element of biodiversity protection in Victoria. Reasonable exemptions should be available for landowners to undertake fire protection measures.26

3.52 The need for individuals to fire proof their own homes was noted by Mrs Lynlee Tozer of St Andrews, who submitted that:

… [more] homes are made unsafe due to general household build-up and domestic gardens, or from lack of preparedness by ensuring a home is impenetrable to embers, than they are from any other cause … my home was one such dwelling that was not sufficiently prepared prior to Black Saturday.27

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3.53 Many of the submissions that reported personal accounts of the fires, and how residents prepared their homes, properties and families for bushfires, made reference to tanks, pumps and pipes. For example, Mr Terence McManus of Frankston wrote:

... I was concerned that the water tank bought for the purpose of fighting fires was plastic. It is a basic common fact that plastic melts in high temperatures, let alone the enormous temperatures resulting from severe fire events. In the same vein, plastic or PVC fittings, such as the piping along the guttering designed to keep water in that guttering, will also melt. The pump purchased to pump the water to the piped guttering system was underpowered for the job and worse, had a plastic fuel tank and was petrol powered. The LP gas tank for domestic use within the brick veneer home was placed directly next to an exterior wall.28

3.54 A few submissions referred to preparations for future fires. For example, Mr Drew Adamson of Yarra Glen stated:

… [watering] systems should be installed on all roof tops with metal pipe to ensure that they survive the heat intensity, or be built into the roof frame with metal sprayer sprinklers, on the top and sides. An external watering system should be set up a distance away from the house with heat sensors.29

3.55 The need for more and improved fire education was often mentioned in submissions, as was the usefulness of CFA meetings, Community Fireguard training and phone trees to communicate with others and warn them of approaching fires. The voluntary nature of training for the bulk of CFA members was expressed as a concern, as was the fact that current training is only suited to ‘normal’ fires. Some submissions reported the view that such training is unsuitable for particularly intense fires and leaves people unprepared and unable to make informed choices about their safety during extreme bushfires.

Planning and local government 3.56 A large number of submissions reflected dissatisfaction with local council policies about the need for permits to remove trees, the restrictions on vegetation clearing, and the favouring of native versus European flora. A large number of submissions advocated a change in local council regulations to allow people to clear to a safe distance around their homes. Mr Liam Sheahan of Reedy Creek wrote:

There needs to be serious revision of the planning laws, particularly relating to the removal of native vegetation. More credence should be given to local knowledge and landholders should be able to manage their own property without being bullied and victimised by local government.30

3.57 A small number of submissions described a concern that there could be extensive vegetation removal if further clearing was allowed. Also, the amenity of their local areas would be reduced by extensive fuel reduction practices on private property. Mr Tim Connell and Ms Anna Bunbury of Kinglake stated:

[We] are extremely concerned regarding the apparent swiftness with which native vegetation controls are being progressed ... [and] that these will not be given sufficient and measured consideration to the detriment of future communities and ecological values.31

3.58 Other submissions on this topic highlighted concerns regarding insufficient green waste collection; the extent of existing native tree-planting programs; councils’ fuel reduction burns; and the perceived reluctance of councils to take responsibility for vegetation clearing and fuel reduction. For example, the submission from Mr Geoff Bruckard of Warburton noted that:

… local residents … should be encouraged to dump green waste in council recycling facilities from where it can be recycled into mulch. The current prohibitive costs of dumping such waste will inevitably lead to such waste not being removed from properties, it being dumped in the bush or being burnt in a non-environmentally friendly way which increases the risks of bushfires.32

112 Submissions

Fuel reduction, DSE, prescribed burning 3.59 Generally submissions on this topic raised concerns about the effects of prescribed burning on flora, fauna and on climate change. Many submissions called for further investigation and evidence about the effectiveness of fuel reduction, and its effect on flora and fauna. Equally, there were many submissions stating that the benefits were obvious. Ms Jenny Lau of Briar Hill called for a multi-faceted approach:

Prescribed burning will be a necessary component of most fire risk management plans but the community cannot rely on prescribed burning as the only solution to the increased risk of wildfire predicted under climate change scenarios.33

3.60 Many submission authors advocated the use of fuel reduction burns. The submission of the Department of Environment and Conservation, Western Australia stated:

... there is no doubt that wildfires burning in low fuel levels cause significantly less environmental damage than fires burning in heavy, long unburnt fuels.34

3.61 Other authors opposed an increase in the current levels of prescribed burning. Dr Patrick Baker, of the Australian Centre for Biodiversity, Monash University, stated that:

… [changes] to fire management practices, such as the widespread adoption of high-frequency prescribed burning, have the potential to further endanger ... the native biodiversity.35

3.62 A few submissions, including one from the Victorian Farmers Federation, called for the reintroduction of cattle grazing in parks, particularly in the High Country (Victorian Alps), as a means of reducing fuel loads in crown land areas.36 3.63 Some authors demonstrated an interest in the different methods of prescribed burning such as cool burning, mosaic burning, and fire-stick or indigenous burning, with some providing a comparative analysis of their advantages and disadvantages. They also called for the use of evidence-based fuel reduction techniques. Many authors on this topic also claimed that scheduled prescribed burning had not been undertaken by DSE, and that not enough burning is scheduled. 3.64 The issue of roadside clearing produced a variety of responses in submissions. Some sought extensive clearing of roadside vegetation while others advocated no clearing where roadsides have been declared native flora and fauna reserves. The South Gippsland Conservation Society Inc. stated that roadsides and rail trails:

... provide very important links or habitat corridors between areas of native vegetation in parks and reserves.37

3.65 Conversely, the Eureka Project’s submission noted that roadside reservations posed risks as fuel levels increased:

… road reservations are increasingly becoming fire-wicks with the propensity to join rather than separate fire activity.38

Building and Rebuilding 3.66 Many submissions reflected dissatisfaction with a perceived lack of information regarding materials, designs and recommendations for building fireproof or fire-resistant housing and bunkers. Submissions on this topic emphasised the need for easy-to-access government recommendations about materials and designs for building fireproof or fire-resistant housing and bunkers (including easy access for people without the internet). BlueScope Steel in its submission noted that:

... not only is the prevention of ember ingress and the use of non-combustible building materials important in the dwelling design, but also other aspects such as ensuring radiation barriers and separation from other ignition sources within the dwelling landscape.39 113 2009 Victorian Bushfires Royal Commission—Interim Report

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3.67 Others raised as an issue the high cost of building fire-resistant homes, or retro-fitting houses with fire-resistant features. This is acknowledged in the submission from the Housing Industry Association, which stated:

[There] are a vast array of provisions for bushfire management, but there are an equal number of requirements in respect to native vegetation. These sometimes competing provisions need to be viewed in a holistic fashion to ensure that the costs and benefits of each are appropriately balanced.40

3.68 In light of the rebuilding process and the forthcoming fire season, various submissions raised the need for regulations regarding refuges and bunkers so that people could modify their fire plans and any rebuilding on their properties could include these. The Australian Institute of Building Surveyors submitted that:

... building standards must facilitate and maximise the ability to evacuate safely and offer every opportunity to save lives.41

Emergency communications 3.69 A number of submissions outlined problems with Triple Zero calls — in particular, the length of time callers were placed on hold, and callers’ inability to get through to fire or other emergency services. As described by Dr Hania Lada of Kinglake:

We called 000, which was so overwhelmed it took many minutes before we could talk to anyone. This was useless.42

3.70 Problems with radio transmissions, particularly in the mountain areas, were also raised as an issue. Recommendations were proposed regarding the usefulness of UHF radios to communicate and CFA scanners to obtain information about fire spread. Mrs Sandra Kerkvliet of Smiths Gully relied on her scanner to gain information about the fires:

Every waking moment over that next month, the scanner became my annoying best friend, proving to be the one constant source of accurate local information I could rely on while the fires continued. The scanner was of more practical use than we could ever have imagined.43

3.71 Several submission authors also commented on a failure of mobile phone reception. They noted that emergency coverage was dependant on location. For example, Ambulance First Response Team from Kinglake stated that:

... radio communications, ABC reception and mobile telephone coverage in the Kinglake ranges have long been prone to black spots where there is no coverage.44

Essential services during and after the fires 3.72 The loss of power, water and phones, and delays in reconnecting these services featured in a significant number of submissions. Ms Fiona Wallace of Mont Albert North, in her submission recounting her experience on 7 February, stated:

… [the] importance of communication infrastructure that can withstand fires cannot be over-estimated.45

3.73 Delays in reconnecting essential services had an adverse impact on those who stayed to protect their homes and their ability to defend them. Mrs Susan Marstaellar, of Heathcote Junction, who stayed to defend on 7 February, wrote that she had:

... no power, no mobile or land line phone coverage and no access to food or water until late Sunday, which made it difficult to feed the fire fighters.46

114 Submissions

3.74 However, a couple of submission authors were complimentary of the speed at which essential services were reconnected in the circumstances. For example, Mr Kenneth MacGowan of Coldstream wrote:

... thanks go to the various authorities responsible for restoration of utilities. Our power was reconnected within a week, phone lines restored, water tank cleaned out by two weeks and 5000L of water provided, and I have registered with Grokon [sic] for the Government provided clean-up.47

3.75 A number of submission authors called for the power and telephone lines to be underground and, where they had to be above ground, suggested that power poles should not be wooden. As outlined in the One Tree Hill Ferny Creek Residents’ submissions:

During every serious emergency (fire or storm), the power goes down. In some cases, electricity cables cause fires. With increased reliance on power and phone cables, not least for planned safety communications, it is time to put them underground.48

Economic cost of the fires 3.76 Submissions referred to the economic costs of the loss of buildings, and the impact on farming and business ventures. The economic costs on farming included the loss of livestock and fencing. In addition to the direct costs of fire damage to business premises and assets, a small number of submissions mentioned the economic cost to businesses caused by a reduction in residents and tourists in the fire-affected areas. The Insurance Council of Australia stated:

... as of 30 April 2009, members of the Insurance Council have received approximately 10,020 general insurance claims as a result of the bushfires. The approximate value of these claims received, including residential, commercial, industrial and farming losses, is $1.2 billion.49

Roads 3.77 Many people expressed dissatisfaction with roadblocks, the state of roads and roadside vegetation. Some complained about police at roadblocks requiring proof of residence before allowing them to pass; this was difficult as many residents did not have identification. The process was said by some to have become easier where identification wrist bands were issued. The submission of the Mount Taylor Fire Brigade noted that:

... the police roadblock policy for fire-affected areas caused significant frustration for locals who successfully stayed and defended their assets but needed to travel outside the roadblock to access essential supplies.50

3.78 The roadblocks were particularly frustrating for locals when it became apparent that the media had been given access. Submissions from locals also expressed frustration that many of the roadblocks were ineffective because it was often possible, by using back roads, to avoid the roadblocks, and for this reason they were simply a waste of time. Some complained that the attitude of people operating roadblocks was unhelpful and sometimes callous in the circumstances. Mr Geoffrey Biggs of Toolangi stated:

Police members on road blocks were given little or no information by superiors and didn’t know the localities they were in and quite often showed very little common sense in these situations.51

3.79 Roadblocks also prevented supplies and services getting through to some residents in fire-affected areas. In some cases this included veterinary services for animals, as described by Mrs Judy Johnston of Narbethong:

… even though DPI had notified the Alexandra Vet that he was needed, he was not allowed past the Police roadblock. It was 6 days before any horses could receive veterinary treatment. One had burns to her eyes, nose, mouth, chest, legs, teats and tail area!52

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3.80 Other submission authors, such as Dr Renee Paulet of Hazelwood North, were ultimately successful in getting veterinarians through roadblocks to treat their animals.

Our vet agreed to meet us at the Loy Yang roadblock to see if we would be able to gain access to our property to treat the horse and remove him from the property. Thankfully, the police on both the roadblocks allowed us through and we were able to catch, treat and sedate our horse and load him on the float.53

3.81 A few submission authors noted that roadblocks had a beneficial role in keeping tourists and looters out of fire-affected communities. For example, Mr Edward and Mrs Diana Cherry of Marysville, although critical of the fact that the residents of Marysville were locked out of the town for seven weeks, stated that:

Of course the Police were correct in keeping sight-seers out of the town during those early weeks.54

Many of the submissions addressed concerns regarding limited access along roads caused by trees falling on the roads, dead-end streets and single-lane streets. Some authors voiced concern at the significant vegetation along the verges of roads, creating fuel for fire, while others considered that these verges should be retained. Mr Helmut and Mrs Kim Widrich of Calignee wrote:

Overhanging trees and dense vegetation close to roads have long been a concern to us. Escape via the road on Black Saturday was not an option … Dense vegetation and accumulated fallen trees and branches made the road on which we live a death trap for residents.55

Insurance 3.82 The majority of submissions about insurance issues related to dissatisfaction with the Fire Service Levy being part of voluntary insurance. The National Insurance Brokers Association (NIBA) noted in its submission that the Fire Service Levy is imposed on insurance companies for policies of insurance on Victorian property and is then passed on to policy-holders. According to NIBA, the Fire Service Levy raises 75 per cent of the cost of funding the MFB and the CFA. Submissions suggested that to make the fire levy fair, it should form part of every homeowner’s rates and this would increase the amount of funding available to the CFA. CGU stated:

… there is a need to expand the funding base because the broader community benefits from fire-fighting services, not just the insured.56

3.83 Suncorp stated that:

... the current system of levies is inequitable due to the rate of non-insurance.57

3.84 Submissions from entities within the insurance industry highlighted problems with the degree of under-insurance and non-insurance. According to NIBA:

... almost 30 per cent of the houses destroyed by the recent fires carried no insurance at all and many more were underinsured.58

3.85 The Royal Automobile Club of Victoria (RACV) stated in its submission that:

... the Fire Services Levy is a major contributor to non-insurance and under-insurance.59

3.86 Some submissions suggested a reduction in the cost of house insurance for people who took steps to fireproof their homes. The Institute of Actuaries of Australia provided an example:

... [the] incentive within the insurance industry is the charging of lower premiums in cyclone regions for houses built to appropriate building standards.60

116 Submissions

Recovery effort 3.87 The lack of coordination and organisation of recovery measures featured in a number of submissions. There was a general sense that the recovery effort did not start immediately, leaving residents to organise their own recovery centres. A large number of submission authors directly affected by the fires mentioned the frustration at having to retell their stories to different entities. The Yarra Glen Community Fire Relief Centre submission stated that many survivors:

... are frustrated by the amount of form filing to be done.61

3.88 Some submissions described problems with resources at recovery centres, including practical requirements such as hand-washing facilities being overlooked, or difficulties in getting a caseworker. 3.89 Many submission authors wrote that the community-based relief centres had been of assistance to residents in fire-affected areas. For example, Mr Rainier and Mrs Ann Verlaan of Callignee wrote that:

The support and assistance we received from the Traralgon South community via the Relief Centre that was set up there was not short of amazing.62

3.90 A few submissions referred to the importance of counselling services for those in fire-affected areas. Ms Jenny Beales of Kinglake stated:

... [in my] view, the work of the agencies that coordinated the disaster relief in our community during the aftermath of the fires was, on the whole, excellent ... Many of the agency staff who arrived in the first few days were highly trained in disaster management, with many having worked in the Queensland cyclones and in Bali, and their skills and training were evident. Counselling services Berry Street, Mitchell Community Health Services and DHS provided many counsellors to assist people cope with the enormous trauma they had suffered.63

3.91 The need for ongoing support services to assist people in fire-affected areas to recover from the trauma of 7 February was also mentioned. Ms Roslyn Shannon of Kinglake wrote:

While many services were provided in the first two week[s] ... [if] my experience is anything to go by then it is now that the realisation and shock are beginning to take effect. Counsellors and people to help get through the maze of red tape and to offer help are needed now … I have returned to work as I want some normalcy in my life. Everywhere I look is burnt and my street has been almost obliterated. Every landmark I knew has disappeared. We may have survived but our lives burnt down.64

3.92 The physical and emotional toll on people who survived the fires was evident in many submissions. Mrs Pamela Clune of Wollert recounted the difficulties she and her husband Colin faced after he suffered significant burns while fighting fires as a CFA volunteer. She described the experience of:

… trying to limit the emotional effect on our children and grandchildren, extended family and friends … Eight weeks passed before I found my own personal space to allow myself to deal with the reality of ‘Our CFA Black Saturday’ journey. To let the tension of holding on relax, and allow suppressed emotions to flow. Together we hope we have limited the risk of hidden, long term, emotional trauma that we are aware could occur.65

3.93 Another issue raised in some submissions by people who had lost relatives in the fires was the lack of sufficient and timely communication from the Coroner’s Office.

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3.94 A number of submissions raised concerns about how donated money was distributed and requested that this information be publicly available. Other submissions noted the generosity of the broader community. For example, Ms Linda Fries of Hurstbridge wrote:

In the aftermath the good and kind people gave so abundantly, it moved me to tears and warmed my heart to know that so many would care.66

3.95 Finally, the impact of the fires on animals and the inadequacy of recovery efforts in relation to them was mentioned in a few submissions. Animal Aid stated:

Veterinary response for large animals was unacceptably slow in some areas, with animals waiting for many days for humane euthanasia whilst suffering from burns and smoke inhalation. This is cruel. For a disaster of this scale, involving many large animals and wildlife that could not be evacuated, future emergency responses must include the dispatch of an appropriate number of people qualified to perform humane euthanasia.67

CONCLUDING COMMENTS 3.96 The Commission is very grateful for the many thoughtful, informative and constructive submissions it has received. The submissions have fostered discussion and inquiry on relevant topics and have assisted the Commission in identifying information, experts and lay witnesses for further examination and consideration. The contribution made by authors of submissions is, and will continue to be, an extremely important one. 3.97 The Commission continues to receive and review submissions from individuals and organisations in the local and broader communities. In preparation for the next block of hearings (beginning 24 August), the Commission, through its website, called for further submissions on the key topic of building. As the Commission’s inquiry progresses and other key topics are examined in detail, the Commission will make further calls for topic-specific submissions. These further submissions, together with those already received, will be considered in the Commission’s ongoing work and final report. 3.98 The selection of submissions referred to in this chapter provides a ‘snapshot’ of the various views, comments, concerns and suggestions expressed in the submissions received by 18 May 2009. All submissions can be viewed on the Commission’s website.

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Timely and accurate warnings may save lives. It is this possibility that has motivated the Commission’s lengthy examination of bushfire warnings issued in February 2009 and of what constitutes effective warnings. This chapter first considers definitional matters relating to warnings and the bushfire information and education that has been available in Victoria. It moves to an overview of the recommendations on warnings from recent inquiries, before considering what constitutes good warnings. The chapter then considers the warnings and information issued in Victoria prior to and on 7 February and the way in which the community received and understood this material. Finally, triggers and signals, sirens, and a telephony-based emergency warning system are considered.

BUSHFIRE INFORMATION, WARNINGS AND TRIGGERS 4.1 There is a significant difference between the provision of general information about bushfires and specific warnings to alert the public of a particular threat. Ongoing information provided to the community about bushfires prepares the community and educates them on the appropriate steps to take if a warning is issued. In contrast, a bushfire warning is specific advice about an imminent event. Such a warning should propel the community into action in response to a specific threat — ideally, armed with the information and education that has prepared them to respond. 4.2 The evidence before the Commission has demonstrated that the community depends on (and has come to expect) detailed and high-quality information prior to, during and after bushfires. In addition, the community is entitled to expect to receive timely and accurate bushfire warnings whenever possible, based on the intelligence available to the control agencies (further discussion in Chapter 10). Though they are distinct concepts, the successful provision of information and warnings are inextricably linked. 4.3 In relation to the provision of information about bushfires, the Emergency Services Commissioner, Mr Bruce Esplin, made the following comments when asked about the best time for the effective provision of bushfire information:

In my judgment … it is in the years, the months and the weeks and even the days before the fire season in this case even starts. This is when the good work is done. That is where people … can do their planning away from the immediate threat of fire and come to a considered decision about what is the best plan for them as individuals, as a family ...

I think it is very easy to see a campaign as being something that has effect in one year, but in my judgment, and certainly in my experience, campaigns such as this have a cumulative effect over time and what you do in any one year, it is not a very high chance that it will have a profound effect or a profound risk reduction, it is the impact over time that will make the difference.1

4.4 The success of specific bushfire warnings partly depends on the standard of the information and education provided to the community prior to its issue. In some instances, specific bushfire warnings — and use of ‘triggers’ such as the Standard Emergency Warning Signal (SEWS) and sirens — will be less effective in the absence of high quality information and education campaigns that increase a community’s preparedness to meet the threat and its understanding of how to respond to a warning. 4.5 It is also clear that on receipt of bushfire warnings, people often seek further information and advice. For example, after receiving a specific bushfire warning, people often want or need further information from sources like 774 ABC Radio, agency websites or the Victorian Bushfire Information Line (VBIL). It emerged during the hearings that on 7 February people were sometimes unable to access the information they needed to respond to the warnings they had received. In other cases, it was clear that in the absence of timely warnings, the public turned to other sources of information for assistance. This placed pressure on the agencies providing that information, and was a source of great frustration and stress for those seeking, but unable to obtain, information and advice. Victoria’s information and warning systems operated under great stress on 7 February. The systems broke down in a number of respects. The question of information is addressed in more detail in Chapter 5.

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4.6 The content of warnings is separate from the mode of disseminating warnings. The content of warnings raises considerations of drafting and construction, while the dissemination of warnings is about the means and modes by which warnings are communicated to the public. This includes existing modes of communication, such as radio broadcasts and web pages, and new and emerging technology, including Twitter and telephony-based warning systems. 4.7 SEWS (further described at paragraph 4.188) and sirens are generally not warnings. Rather, they are triggers, signals alerting the listener to the fact that a warning is to follow. They are a means of attracting attention and prompting the audience to listen carefully for a warning and/or to search out more information. Such triggers and alerts are important, and have a role in the suite of responses that should be available to deal with bushfire threat.

BUSHFIRE INFORMATION AND EDUCATION IN VICTORIA 4.8 The publication of information about bushfires and materials designed to educate the Victorian community about bushfire risk has received considerable attention. 4.9 A Fire Communications Taskforce was established in August 2005 by the Department of Justice to undertake a whole of government approach to community education and communication about fires. This Taskforce coordinates communication activities and plans. It has overseen the implementation of a number of flagship projects, and monitors the success of its approaches.2 4.10 The State Government and the Country Fire Authority (CFA) have sponsored a number of high-quality campaigns to deliver key messages to the community about the risk of fire, including campaigns known as Fire Ready Victoria and Living with Fire.3 Those campaigns are explained in publications including:

■■ Fire Ready Victoria Strategy 2004–20074

■■ Living in the Bush: Bushfire Survival Plan Workbook2nd ed (2008)5

■■ Fire Safety Victoria 20066

■■ Living with Fire: Victoria’s Bushfire Strategy 20087

■■ Living with Fire: A Community Engagement Framework 2008–2012.8 4.11 Information and education programs provided by the State and the work of the Community Fireguard program have been instrumental in delivering messages about bushfire preparedness. These education programs are ongoing, and are an important part of the context in which key messages and advice are delivered in Victoria. It is clear that the CFA and the State have given considerable thought and effort to ensuring that, as far as possible, the community is well educated and prepared about fire risk before it receives any particular bushfire warning. This is discussed in more detail in Chapter 5. 4.12 Prior to 7 February 2009 the State Government devoted unprecedented efforts and resources to informing the community about the fire risks Victoria faced (paragraphs 4.81 to 4.92). That campaign clearly had benefits, but it could not, on its own, translate ‘levels of awareness and preparedness’ into universal successful risk minimisation on the day of the fires. Indeed, no campaign will have universal success. All campaigns are dependent for their effectiveness on the quality of information, the modes of dissemination and the willingness and capacity of people to hear, understand and act on the message. As discussed in the Introduction, this is a shared responsibility between government and the people. 4.13 This chapter takes lessons learned on the content and process of warnings presented to the Commission so far and makes recommendations for the next fire season. This report does not analyse the effectiveness of warnings across all the fires. Chapter 1 includes information about initial and critical warnings issued for each fire and Chapter 9 analyses warnings for the Kilmore East fire. Further evidence on warnings will be heard by the Commission in future hearings.

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BUSHFIRE WARNINGS: THE WELL-TRODDEN PATH 4.14 The review and analysis of warnings and their mode of delivery is not new. Successive inquiries, reviews and reports have considered bushfire warnings. Some have focused on warning content and construction, others on delivery systems. 4.15 Some matters highlighted in these reports have received government support and been implemented. Others, in particular the national adoption of standard bushfire warnings and the development of a telephony-based warning system, received insufficient attention in the years after their recommendation.

1984 Report on Ash Wednesday 4.16 The 1984 inquiry into the 1983 Ash Wednesday fires produced a report,On Bushfire Disaster Preparedness and Response in Victoria.9 That report noted the difference between warnings that simply raise general awareness and specific warnings about particular fires:

… fire threat indicators which ushered in the 1982/1983 season served as a serious underscoring of the extreme risk facing authorities and communities alike. Whilst it is difficult to generalise with accuracy, it would appear that these indicators did help to enhance levels of awareness and preparedness. Whether this, in turn, had any significant effect on the disastrous circumstances of 16 February, is another matter.10

4.17 The Ash Wednesday report went on to address warning and information systems generally. It emphasised the importance of maximum warning lead time, accurate meteorological information, standardisation and clarity of warnings. It also explored the methods of providing information, such as special messages or warnings that alert people to switch to a designated system, such as the ABC. It found that greater use should be made of local TV and radio stations and that ‘Special fire warning sirens should be located at police and fire stations; also, church bells should be utilised’.11 4.18 The goal that warnings be standardised and their meaning rendered ‘clear and unambiguous’ was not fully achieved by 7 February. While sirens and church bells received specific attention in the report, the evidence before this Commission is that use of sirens was contrary to CFA policy on 7 February (further discussion at paragraph 4.224). 4.19 The report emphasised the importance of informing the community about warning systems, and advising people about how to respond to them. It also recommended that ‘new systems which offer possibilities of enhancing warning capability should be examined’.12 4.20 These comments appear just as relevant today as when they were published in 1984. While new systems were indeed examined and kept under review in the years since 1984, the available technology for a telephony-based warning system was not used or introduced prior to the February 2009 fires. This represents a missed opportunity, and is addressed in more detail below.

2002 COAG Report 4.21 In 2002, the Council of Australian Governments (COAG) commissioned a review of Australia’s approach to dealing with natural disasters. The review was carried out by a high level group of officials representing all levels of government. The product of that review was a report titled, Natural Disasters in Australia — Reforming Mitigation, Relief and Recovery Arrangements.13 4.22 The report concluded that current arrangements ‘could be improved to ensure that Australia has a world class national framework for disaster management’.14 Significantly, the report recommended what it described as ‘a paradigm shift to disaster mitigation’. It recommended the implementation of a Disaster Mitigation Australia Package, which would include funding for programs such as disaster warning systems and community awareness and readiness measures.15

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4.23 The report contained a number of recommendations, three of which are summarised below:

■■ there should be legislative obligations on all broadcasters to broadcast natural disaster warnings to the public via radio and television (Recommendation 26)

■■ guidelines should be prepared for best practice in the development of local area emergency warning systems (Recommendation 27)

■■ post disaster assessments should routinely review the effectiveness of warning systems (Recommendation 28).16 4.24 The Victorian Government has entered into a Memorandum of Understanding (MOU) with the ABC, which appears to reflect part of the aims of Recommendation 26. Otherwise, the above recommendations were referred to the Australian Emergency Management Committee (AEMC) (a standing committee of the Ministerial Council for Police and Emergency Management — Emergency Management). An AEMC working group undertook to identify ‘the requirements for a nationally consistent emergency warning system’. Other initiatives such as the establishment of the National Forum on Emergency Warnings to the Community were undertaken. However, work on the development of a national telephony-based warning system did not come to fruition for a number of years.17

2004 COAG report 4.25 The question of warnings was again considered by the COAG National Inquiry on Bushfire Mitigation and Management of 31 March 2004 (the 2004 COAG report).18 This inquiry recommended that the content of bushfire threat warnings should be nationally consistent, and that SEWS should be used. 4.26 The features of a warning system emphasised in the 2004 COAG report are: a) A warning system should involve use of ‘a consistent warning signal’ at the beginning of the advice in circumstances where lives are at risk or there is a major threat to property to attract the attention of those who should be alerted to the warning that follows. b) A bushfire warning should provide information about the location, size and intensity of a bushfire threat. c) A warning should inform the listener as to the expected movement of the fire front and should identify the communities at threat. d) A good warning advises communities on the appropriate action to take.19 4.27 As discussed further in this chapter, some of the warnings on 7 February were deficient with regard to matters raised in paragraph 4.26 b, c and d — and SEWS was not used at all. 4.28 Recommendation 8.5 of the 2004 COAG report endorsed the recommendations on warning systems from the 2002 COAG report and further recommended that all fire ban advice and bushfire warnings should be used consistently (including SEWS) where lives or property are threatened. The 2004 COAG report also called for the introduction of a nationally uniform bushfire warning system.20 Finally, it recommended that the structure of warnings should be based on the findings of the Bushfire Cooperative Research Centre’s (Bushfire CRC) project ‘Communicating Risk to Communities and Others’. 4.29 The 2004 COAG report also indicated some logistical concerns about the use of SEWS. In particular, it noted that due to its infrequent use in southern Australia, television and radio stations ‘have difficulty locating the signal when they need to play it and the public is largely unaware of its significance. Reluctance to use the signal when local communities are threatened by bushfire has led to the signal being virtually ineffective as a national warning measure’.21 It advocated the regular use of SEWS during periods of bushfire threat. 4.30 COAG’s findings and recommendations were sound and have been justified in light of the evidence before the Commission. It is regrettable that a nationally consistent approach to bushfire warnings has not been developed, and that SEWS fell into disuse in Victoria prior to 7 February 2009. This is discussed in more detail at paragraphs 4.189–4.205.

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2005 Catastrophic Disasters Report 4.31 In October 2005 the report, Catastrophic Disasters Emergency Management Capability Working Group — Review of Australia’s Ability to Respond to and Recover from Catastrophic Disasters was prepared by the Catastrophic Disasters Emergency Management Capability Working Group, chaired by Mr Tony Pearce, then Director of Emergency Management and Security of the Office of the Emergency Services Commissioner (OESC) in Victoria.22 4.32 The 2002 COAG report had recommended the creation of the Working Group that then prepared the 2005 report. It found that ‘whilst existing State/Territory and national emergency management arrangements are robust … Australia is currently not as prepared as it should be to manage the consequences of a catastrophic disaster impacting the country’.23 4.33 The Working Group modelled four hypothetical scenarios to assist in identifying the likely impact of catastrophic events: a cyclone impacting on Cairns, a major earthquake impacting the wheat-belt of Western Australia and the City of Perth, a tsunami impacting on the mid New South Wales coast and an influenza pandemic.24 The report found that ‘there is an overwhelming national need for the development of appropriate, effective and timely community information and warning systems’. It also emphasised the desirability of a national approach, and the potentially counter-productive consequences of disparate systems being developed in isolation.25 4.34 It is disappointing that what was identified in October 2005 as an ‘overwhelming national need’ for a national warning system, was not the subject of agreement by the states and territories until April 2009. It is also a matter of concern that the 2005 Catastrophic Disasters report, which revealed significant areas for improvement in Australia’s capacity to respond to natural disasters, was not made public until summonsed and tendered in the Commission’s hearings.26 One of the clear lessons from the fires of 7 February and from the substantial body of material on natural disaster and warning systems generally, is that the community, governments and emergency services benefit from the free flow of information. The decision not to release this important report for a number of years did nothing to increase community preparedness to meet the challenges posed by natural disasters.

2006 Fire agencies’ internal review 4.35 In 2006, the CFA and the Department of Sustainability and Environment (DSE) commissioned Mr John Schauble to conduct a review of information processes during fire incidents, including the issue of provision of warnings to the community during fires: Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media During Fire Incidents — Preliminary Findings.27 4.36 This review involved a series of debriefs and interviews with CFA and DSE personnel engaged in the information management process. It focused on the work of the Information Units in Information Management Teams in the fire services. The report noted:

… the bar has been raised’ in terms of both how rapidly information about developing events is released to the general community and how specific that information should be. It is no longer sufficient to report that a large fire is burning in a general location. There is now an expectation on the community’s part that timely and useful information regarding predicted spread into specific locations, including particular streets, will be made available in time for potential-affected citizens to make decisions.28

WHAT MAKES A GOOD BUSHFIRE WARNING? 4.37 The Commission received expert advice on what constitutes an effective warning in written submissions and in oral evidence.29 Other key documents on this topic include:

■■ 2005 and 2009 Australasian Fire and Emergency Service Authorities Council (AFAC) position papers30

■■ 2008 Australian Government advice Emergency Warnings — Choosing your Words31

■■ Material relating to the Common Alerting Protocol (CAP).32 124 Warnings

4.38 There is a high level of consistency between these key documents and the expert advice received by the Commission. The State has committed to implementing improvements in bushfire warnings for the forthcoming fire season.33 This guidance highlights that the content of a warning should be driven by its aim. In this context, Professor Handmer, Innovation Professor in Risk and Sustainability and Director of the Centre for Risk and Community Safety at RMIT University, set out the features of a good warning.34 In particular, it should let people know what they should or should not do to protect themselves, empower them to respond appropriately, be ‘people centred’ and be based on local needs and expectations.35 4.39 In oral evidence, Professor Handmer added that the purpose of a warning is to ‘provide a signal for some action’.36 He noted that it is important to ensure that people realise that the warning relates to their personal situation.37 4.40 Professor Handmer also suggested that messages should set out the expected timing and severity of the event, say what is likely to happen and when it will occur, indicate how people should act and identify the source of the message (which should be one that is trusted as credible by those at risk).38 He noted the phenomenon of people seeking to confirm and discuss warnings in their personal networks.39 He said that language should be vivid, rather than vague or abstract; messages should be positive, rather than negative (that is, they should advocate what to do); and they should invite sociability (for example, by recommending that people check on their neighbours) because people like to ‘do something’.40 4.41 Urgent messages should contain locally specific information.41 Professor Handmer recommended that messages should include information about the degree of severity of the fire, or the predicted event.

… the severity message is to help people gain an appreciation of what is coming and to help them make an appropriate decision 42

4.42 He made the following further suggestions for improvements to existing materials:

■■ consideration should be given to having another level of fire danger for particularly extreme conditions43

■■ high-risk areas and vulnerable groups should be targeted for more personalised messages and bushfire-related education44

■■ commercial media needs to become part of the fire and emergency management system45

■■ informal networks could be used more to disseminate warnings, and to add locally specific information to the message46

■■ to be useful, warnings need to provide those at risk with enough time to take protective action.47 4.43 Mr Alan Rhodes, Manager Community Safety Research and Evaluation for the CFA, referred to the research of two American experts, well known in the field, Mr Dennis Mileti and Mr John Sorensen. He set out their view that for a warning to be effective, it must:

■■ describe the precise nature of the threat and how it poses a danger to the public

■■ communicate the exact location of the threat

■■ provide guidance as to the specific actions the public should undertake

■■ specify the time when the hazard is likely to impact

■■ state the agency which is giving the warning (multiple sources are preferable).48

These statements provide sound guidance as to what constitutes a good warning. 4.44 Many of the matters explored in the evidence of Professor Handmer are strikingly similar to the views of the Emergency Services Commissioner, Mr Bruce Esplin. The OESC has produced a number of significant reports in relation to warning systems, emergency management and emergency events in Victoria.49 The Commission commends the work of Mr Esplin’s office and its contribution to the development of the learning and research in the area, in particular its work on the Community Information and Warning System: The Report of Trial and Evaluation (2006).50

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4.45 In evidence, when asked what constitutes a ‘good warning’, Mr Esplin said the following:

I have formed a view in that regard and the first thing is that the warning has to be delivered to a community that has been prepared to receive the warning and to know (a), hopefully where to access information and what to do when they get that information. A good warning is simple; it is probably locally relevant information delivered by locally credible sources.51

4.46 It is also useful to consider the work of the American expert, Mr Sorensen. In his article, Hazard Warning Systems: Review of 20 Years of Progress, Mr Sorensen referred to six warning myths that ‘all too often constrain the effectiveness of warning systems when implemented’.52 He describes the six myths: (1) the myth of ‘public panic’: Mr Sorensen says that social scientists have shown this is not the case, except in situations affected by closed physical space and an immediate and clear source of death where escape routes are not available to everyone affected. (2) the second myth Mr Sorensen cites is that ‘officials are usually worried about overwhelming people with too much information’: in his opinion, the public ‘rarely, if ever’ receives too much information during an emergency. (3) Mr Sorensen refers to the concern about raising ‘false alarms’: he notes that the likelihood of people responding to warnings is not diminished by what has been labelled the ‘cry wolf’ syndrome — so long as the basis of the false alarm is understood. (4) the belief on the part of authorities that a single spokesperson is good practice when disseminating emergency information: indeed, to the contrary, says Mr Sorensen, the public needs information from a variety of sources. (5) it is a common belief that people will take action immediately on receipt of a warning: however, most people ‘simply do not’ do so, says Mr Sorensen. (6) the sixth myth is that officials often think people will follow all recommendations made in a warning, but research shows people will not blindly follow instructions, unless the basis for the instruction is clear and that basis makes ‘common sense’.53 4.47 The myths described by Mr Sorensen appear to have underpinned some of the development of our current bushfire warning systems. The challenging of these myths assists in assessing the system with fresh eyes. An improved understanding of the way in which people react to warnings assists in crafting better warnings.

THE WARNING POSITION ADOPTED BY AFAC 4.48 In 2005, AFAC prepared a draft position paper on bushfire information and warnings.54 The paper was last modified on 24 April 2007, but remained in draft form.55 The AFAC paper is described as being ‘In Response to Recommendation 8.5 from the COAG Report on Bushfire Mitigation and Management’.56 4.49 The 2005 AFAC paper emphasised the importance that messages should use plain language and should address the following questions:

■■ What is the risk?

■■ Where is the threat now?

■■ Where is the threat expected to move to next?

■■ What are the immediate risks faced by people in the threat area?

■■ What are the public advised to do about those risks?

■■ What are the response agencies doing about the situation?57

4.50 It indicates that bushfire information and warning messages should also include:

■■ clear information about the area of risk

■■ where a specific location is provided, information about the general location — local place names should not be used unless supplemented with general location details 126 ■■ the time and date that the message was issued, including the length of time that the message is current.58 Warnings

4.51 Though this 2005 paper has been superseded, it expressed a number of sound principles, drawing on the work of COAG in 2004, and it constitutes a useful guide to a clear approach to the construction of bushfire warnings. 4.52 The call for clearer content in warnings was reiterated in a subsequent AFAC draft paper titled A National Systems Approach to Community Warnings: Discussion Paper Draft Version 2.0 (May 2009).59 This paper proposes a systems approach to warnings incorporating four elements:

■■ preparing the community

■■ situational awareness

■■ message construction and dissemination

■■ appropriate action taken. 4.53 This 2009 AFAC paper advocates a consistent national approach given the transient nature of the population and the fact that ‘emergencies have no regard for jurisdictional boundaries’.60 The paper observes that the ‘most crucial aspect of the warnings system is the continued development of community survivability strategies that are in place well before any emergency event occurs’.61 4.54 The second element, ‘situational awareness’, refers to the information and awareness that resides in individuals, communities, industry and the emergency services. The paper notes that individuals and emergency service organisations all receive information from a range of sources, formal and informal. Based on that information, organisations decide to warn, and individuals to act — but these actions may not align (for example, people may act prior to the warning). This is not necessarily a problem, as:

No matter how the information gets to someone, the challenge is to make sure the information is able to be corroborated through the authoritative source, is meaningful and people are confident they know what to do when they receive it.62

4.55 The evidence before the Commission tends to confirm that while emergency services are monitoring natural disasters, gathering intelligence and considering issuing official warnings, many (but not all) in the community are likely to be responding to the environmental cues and informal sources of information available to them. On receipt of an official warning, people commonly seek corroboration from other sources, and further information about the appropriate response. 4.56 The 2009 AFAC paper also notes that there is no consistent Australian standard for message construction, or protocol for triggering a warning and calls on COAG to adopt the use of the CAP as the basis for messaging in Australia and to set a timeframe for its implementation by emergency agencies.63 4.57 Finally, the AFAC paper notes studies that demonstrated the significant association between community education and higher levels of household preparedness and the taking of appropriate protective action.64 This is certainly consistent with the evidence before this Commission.

Best practice IN BUSHFIRE WARNINGS: Choosing Your Words 4.58 In 2008, the Commonwealth Attorney-General’s Department released Emergency Warnings — Choosing Your Words.65 This document is a valuable guide to best practice in drafting warnings. Its content is practical and clear. The paper set out a number of guiding principles. It counselled against making assumptions about the audience, noting that warnings will need to reach a broad audience and that any message needs to be appropriate for those at home, at work, in the car or visiting the area.66 4.59 The paper noted that an emergency warning is a ‘dialogue with the community, not a command situation’. It promoted seeking cooperation with a suggested action, not compliance with an order: ‘This is best achieved by giving people information that convinces them that a particular course of action is the best one to take’.67

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4.60 In describing the way in which people generally respond to warnings, the paper suggested that this is a process and not a single step. People generally follow a certain thought process before deciding to respond, starting with receiving a message, believing its credibility, confirming it, personalising it, determining what action is required and ending with determining whether the action is feasible.68 4.61 Professor Handmer agreed that the advice in Choosing Your Words is sound.69 Ms Jillian Edwards, Manager Strategy and Knowledge, AFAC, said that it was ‘a very good piece of work that provides a lot of insight into some of the language that could be used to elicit certain reactions from people’.70 Mr Pearce, now Director General of Emergency Management Australia, agreed it was provided to agencies to guide them in best practice.71 Mr Rhodes accepted that CFA messages could benefit from some of the paper’s suggestions.72 4.62 Choosing Your Words provides excellent practical guidance as to the best method of drafting and constructing a clear and useful bushfire warning. There is general support among the parties for the proposition that the content of bushfire warnings should be based on the principles set out in Choosing Your Words.73 The State indicated in its submissions that it would, before the next fire season, refine fire messages based upon the Choosing Your Words publication.74

The Common Alerting Protocol IN BUSHFIRE WARNINGS 4.63 There is evidence before the Commission concerning the development of a protocol and standard digital format for expressing the content of warnings, known as CAP. 4.64 CAP was designed in the United States by emergency managers and technology experts and ultimately adopted there in April 2004 by the Organisation for the Advancement of Structured Information Standards (OASIS). Use of CAP is mandated in the United States.75 It is now being introduced in other countries including Italy, Canada, Indonesia and Japan.76 4.65 The use of CAP permits a consistent warning message to be disseminated simultaneously over different media (for example, internet, SMS, landlines, email).77 Once adopted, CAP can be incorporated into any number of technology applications.78 It has been described as a ‘write it once’ tool. 4.66 As Ms Edwards explained, CAP is two things:

It is a simple but general template for the consistent construction of messages, using standard classifications and terminology.

It stipulates a digital format for making the constructed message readable by any machine.79

4.67 The benefits of the adoption of CAP have been described as including:

■■ efficiency and minimisation of confusion during emergencies

■■ reduction of costs and operational complexity by eliminating the need for multiple custom software interfaces to the many warning sources and dissemination systems involved in all hazards warning

■■ facilitation of movement towards coordinated warning messages over multiple delivery systems

■■ distribution of authoritative alert messages to those who need them in a timely and effective way, ultimately reducing damage and loss of life

■■ capability of conversion to and from the ‘native’ formats to all kinds of sensor and alerting technologies, forming a basis for technology independent of national and international alerts and warnings.80 4.68 In April 2008, AFAC formally adopted the position that its member agencies will use the OASIS Common Alerting Protocol, V1.1, or its derivative, as the standard alerting protocol for handling the essential content of alert warning messages.81 4.69 In its 2009 draft paper A National Systems Approach to Community Warnings, AFAC suggested that a ‘standards based, all media, all hazards public warning strategic framework makes for a more effective solution and more efficient use of resources’.82 The paper went on to note that the OASIS CAP provides a suitable basis for messaging format, with some adjustments for Australian content and terminology.83 128 Warnings

4.70 The introduction of CAP would assist in simplifying bushfire warnings in Victoria, and would contribute to what should ultimately be a nationally uniform approach. The written submissions of AFAC endorsed the adoption of CAP.84 The State undertook in its written submissions to adopt CAP in the next fire season.85

RECOMMENDATION 4.1

The State ensure that bushfire warnings issued in Victoria:

■■ are founded on the principle of maximising the potential to save human lives;

■■ embody the principles encapsulated in Recommendation 8.5 of the Council of Australian Governments report the National Inquiry on Bushfire Mitigation and Management (2004);

■■ embody the principles endorsed in the Australasian Fire and Emergency Service Authorities Council Draft Discussion Paper, A National Systems Approach to Community Warning (May 2009); and

■■ incorporate the use of the Common Alerting Protocol, as adapted for the Australian context.

BUSHFIRE WARNINGS: THE SYSTEM IN VICTORIA ON 7 FEBRUARY 4.71 Before examining the evidence on bushfire warnings issued on 7 February it is important to understand the system for disseminating bushfire warnings in Victoria in effect on that day.

The procedure set out in the Emergency Management Manual 4.72 The Emergency Management Manual Victoria (the Manual) states that:

Warnings should be used under specific circumstances where community action is necessary to protect lives, property or the environment. Upon the request of a control agency to issue a warning, it is the responsibility of the emergency response co-ordinator to ensure that it is issued both to agencies and the potentially affected community. The content and format of the warning must be simple, arresting, brief, suited to the needs of the affected community and be worded in accordance with advice from the control agency … Warning methods could include loud hailers, telephones, door knocks, radio or television announcements or local community networks.

For emergencies of major community significance, the warning should be authorised by an emergency response co-ordinator in consultation with the control agency. 86

4.73 While some of this text cannot be faulted — such as the first sentence — other parts of it are outdated and confusing, such as the statement about loud hailers and door knocks. The text does not refer to websites, yet there is clear evidence that many in the community rely on the fire agencies’ websites to obtain bushfire warnings. When referring to the issuing of warnings, the two apparently simple statements about who issues warnings in different circumstances mask the considerable complexity about who is responsible for issuing warnings in Victoria during fires (Chapter 9). Finally, the evidence before the Commission demonstrates that many bushfire warnings issued on 7 February were not simple and suited to the needs of the affected community. The particular shortcomings evident in relation to the content of the CFA’s awareness, alert and urgent threat messages are discussed in more detail below, and summarised at paragraphs 4.163–4.164. 4.74 The degree to which current policies and protocols on warnings are, in many respects, divorced from the reality of what occurred on 7 February is troubling. If the Manual is to be useful to emergency services it should contain information that reflects current best practice.

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Dissemination of BUSHFIRE warnings by the fire agencies 4.75 The evidence before the Commission demonstrates that there were generally two types of material made available to the public in early February 2009 concerning the bushfire threat in Victoria. First, general information (including weather and fire risk predictions) was disseminated prior to 7 February. This information (which is dealt with in more detail from paragraph 4.82) focussed principally on the risk of fire and the conditions facing Victoria throughout the fire season, particularly during the heatwave between late January and early February. 4.76 Secondly, there were the specific bushfire warnings for each of the fires issued in one of three categories — awareness, alert, urgent threat — prepared by the CFA or DSE using pre-existing templates. The information units in each Incident Management Team created information releases at the incident level. The information releases were provided to the Integrated Emergency Coordination Centre (iECC), Regional Emergency Coordination Centres, the ABC and local media agencies for broadcast, and to the VBIL. When the iECC information unit received these messages from the IMT, they were generally uploaded onto the CFA or DSE websites, albeit with some delay.87 4.77 The evidence reveals that the CFA and DSE websites were a key source of information for the community and that many people relied on the internet as their principal source of information.88 Broadcasts by the ABC, in its role as the emergency broadcaster, were also critical in the flow of information to the public.89 The role of the ABC is addressed in more detail below. 4.78 Mr Rees explained that the CFA has developed standard form information releases to describe fire situations. Three levels or ‘grades’ of message are created. The standard information releases for fire situations were presented in his witness statement.90

Table 4.1: Current CFA types of information releases for fire situations

Title of Message Description Review Time

Awareness Message To be issued when a fire first commences, when there is Within four hours of issue – Initial Advice not currently a threat to life or property but local interest depending on conditions. may be generating. Alert Message To be issued when a heightened level of awareness is Within two hours of issue, required by people and communities in close proximity to depending on conditions. a fire. There is still no direct threat, but there is the potential for direct impact should conditions change or escalate. May include a time parameter within message if known. It is important not to over exaggerate the risk so that people in the area do not feel unnecessarily threatened. Urgent Threat Message To be issued when direct impact from a bushfire is imminent. Within 30 minutes of issue, depending on conditions.

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) [201] 91

RADIO Broadcasts by the ABC — the ‘emergency broadcaster’ 4.79 On 4 February 2004, the ABC entered into an MOU with the State of Victoria pursuant to which the ABC has undertaken to broadcast information and warnings provided to it by relevant emergency services organisations during an emergency.92

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4.80 Emergency messages are provided by the emergency services to the ABC via a special hotline number staffed by the ABC 24 hours a day. Local radio Victoria broadcasts the messages immediately and then regularly repeats them every 15 minutes until the threat message is downgraded by the emergency organisation that issued the alert. The messages can be broadcast on 774 ABC Radio Melbourne, the regional ABC local radio network in Victoria, a specific Victorian local radio station or the whole Victorian radio network.93 Ms Samantha Stayner, Acting Program Director 774 ABC Radio, gave evidence about the process followed by the ABC to meet its obligations under the MOU and in relation to the events of 7 February, during which the ABC devoted significant resources and effort to covering the fires.94 This is discussed further below.

BUSHFIRE INFORMATION DISSEMINATED PRIOR TO 7 FEBRUARY 4.81 A significant body of information about bushfires was made available to the public during the 2008–09 bushfire season. There was also intensive coverage of weather forecasts, fire danger predictions and information about the risk of bushfire during the period from October 2008 onwards. Dissemination of this sort of material is vital to maintaining the community’s knowledge about the risk of fire. 4.82 During the 2008–09 bushfire season, senior government figures made key announcements about the high risk faced by Victoria during the season. The approach adopted to these messages was laudable. Significant resources and time were devoted to ensuring that Victorians were aware of the risk during the summer months.95 The campaigns reflected a sound emphasis on improving community preparedness. 4.83 For example, on 27 October 2008, the Premier, the Minister for Police and Emergency Services and the Chief Fire Officers of each of the CFA, DSE and the Metropolitan Fire and Services Board announced the beginning of the 2008–09 bushfire season. The announcement emphasised the need for preparedness, the significant investment of State resources in fire response, and the high-risk outlook for the 2008–09 bushfire season.96 4.84 Major announcements, media releases, press conferences and events aimed at alerting the community to the extreme fire risk took place throughout November and December 2008, and January 2009. There was intense media coverage of the issue from late January through early February 2009.97 On 4 February, Mr Esplin met with the Chair of the Fire Communications Taskforce, Ms Louise Martin, Director Strategic Communications, Department of Justice, and Ms Amber Brodecky, Manager Media and Community Relations, OESC. In light of the weather forecast, they agreed on the need to urgently renew the FireReady advertising campaign. A decision was made to immediately resume and extend that advertising campaign.98 This was a timely and commendable decision. 4.85 Announcements were made by senior members of the government and the emergency services. For example:

■■ 30 January at a press conference the Premier urged Victorians ‘to be vigilant’ and he said: ‘we are right on the edge today’.99

■■ 2 February the Premier said ‘this is not over yet’.100

■■ 4 February: a media release (titled Fire Services Warn of Continuing Fire Threat) was jointly issued by the CFA, DSE and the Metropolitan Fire and Emergency Services Board, warning of the continuing fire threat and extreme weather forecast for Friday and Saturday.101

■■ 4 February the Premier was reported in the Herald Sun saying that the State was ‘set to burn’ with or without the extreme heat.102 The Premier also said that the CFA warned people to ‘be alert and do not get caught out when a bushfire strikes’.103

■■ 5 February: a press conference was held at the iECC. A number of media releases were issued by the CFA and DSE for the event, titled Victoria’s fire agencies and police warn of extreme danger,104 This is the weekend to be bushfire alert105 and High Fire Danger Saturday 7 February.106

■■ 5 February the Premier was quoted in the media saying: ‘Everything is just absolutely tinder dry 107 and we don’t even need the high temperatures now for high fire alerts’. 131 2009 Victorian Bushfires Royal Commission—Interim Report

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■■ 5 February: the CFA’s Chief Officer and DSE Chief Fire Officer were on ABC statewide radio. They referred to the ‘unprecedented fire weather’, the fact that, ‘Saturday appears to be worse in terms of weather forecast terms, than the 16th of February 1983’. In his interview, Mr Rees noted in particular that people might form the view: ‘given where the situation is, I’m going to make the decision not to be there — that is a very valid decision’. Mr Ewan Waller, Chief Fire Officer, DSE, noted that people should ‘get mentally prepared as well as physically prepared for a very, very, very difficult day’. He also stated that fire ‘could be anywhere in Victoria’. Mr Rees noted the concern that fires in these sort of conditions ‘can pop up really quickly and unless you’re vigilant, and alert and looking about you may not even get that warning’.108

■■ 6 February: further media releases were issued, for example: Campers urged to stay home during extreme conditions;109 Extreme Fire Threat;110 Extreme Fire Weather Warning;111 Avoid all unnecessary travel tomorrow;112 and High Fire Danger Saturday 7 February.113

■■ 6 February: during the press conference at Ballarat, the Premier said: ‘The worst day ever in the history of this State’…‘I can’t stress this enough, I mean I know the Chief Fire Officer has been out and he said it will be as bad as you can get and he is not exaggerating’.114

■■ 6 February: Mr Rees said we would see ‘weather that perhaps we have never had in the State of Victoria in respect of fire danger’.115 He also released a podcast which was available online at www.cfa.vic.gov.au in which he provided a series of statements about the weather, the state of the fuel and the legitimacy of leaving property. He said ‘we would rather be talking about lost houses than lost lives’.116

■■ 7 February: Mr Esplin was interviewed on ABC Radio at 11:15am, where he said, among other comments: ‘These fires can come and go in the space of an afternoon and do untold damage and that’s what happened in Ash Wednesday in 1983 — rapid onset, fast moving into built up areas and the human toll was huge and we don’t want that today’.117 4.86 This narrative indicates that a great deal of information on bushfires and the risk of bushfires was broadcast in Victoria throughout the 2008–09 bushfire season, and particularly in early February 2009. This material was generally of a high quality, attracted significant media attention and achieved high media ‘penetration’.118 Professor Handmer expressed the view that the use of a person such as the Premier to disseminate messages is very useful and likely to carry high credibility.119 4.87 Mr Esplin remarked:

I haven’t seen a situation where as many warnings were delivered in that period of time, in such a period of time. Warnings that were stark and clear and unequivocal about the level of risk.120

4.88 After the fires, the OESC commissioned an independent media analysis of the radio, television and print coverage for the period 4–7 February.121 The media analysis confirms that terminology related to fire predictions and the dire weather forecasts, such as ‘warnings’, ‘heatwave’ and ‘bushfire’ were used repeatedly in the lead up to 7 February.122 4.89 Professor Handmer stated that the ad hoc high-level ‘warnings’ from people such as the Premier, the Chief Fire Officers and the Emergency Services Commissioner were ‘very clear not only about the risk in physical terms, but also the types of people who might be most vulnerable and the sorts of things that perhaps people could do’.123 4.90 The message delivered in the days leading up to 7 February were direct in their meaning. The words of the Premier, the Chief Fire Officers and the Emergency Services Commissioner showed foresight. Each of them was honest, forthright and explicit in the information and advice they gave. There is no doubt that each went to great lengths to disseminate the message that Victoria was facing an extreme fire risk. 4.91 These messages no doubt contributed to many Victorians’ preparedness and, possibly, were responsible for saving the lives of some who heeded those words and left bushfire prone areas prior to 7 February and/or undertook additional preparations for the bushfire threat.

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4.92 However, it is also clear that for many Victorians these general awareness messages and advice were not sufficient to alert them to the threat caused by any particular bushfire, nor were they translated into a ‘call to action’ in all cases. Such statements in the media prepare the community only to the extent that individuals respond, prepare and listen for specific bushfire warnings which may follow. This can in part be explained by the evidence of Professor Douglas Paton, Chair, School of Psychology, University of Tasmania, who discussed the various factors (individual, social and structural) that influence a person’s level of bushfire preparedness.124

BUSHFIRE WARNINGS ON 7 FEBRUARY 4.93 An outline of the specific warnings issued on 7 February is provided in Chapter 1. This section provides a broader discussion about different types of warnings. The Commission will hear further evidence on the warnings given for each major fire in future hearings. 4.94 Mr Rhodes stated that the methods the CFA uses to disseminate information include:

■■ information releases, which are uploaded to the CFA website (www.cfa.vic.gov.au), read aloud on ABC Radio, and provided to the VBIL, so that they can be used to respond to public enquiries

■■ a hotline number established with ABC Radio, so that a designated CFA officer can contact the control room direct to broadcast urgent threat messages

■■ the VBIL, which is a free call number the public can call to obtain information about current fire threats, preparedness advice and also recovery information

■■ community meetings held during fire threats that provide community-specific warning information and advice

■■ information releases provided to local radio stations by regional offices and Incident Control Centres before they have been sent through to the iECC

■■ community fireguard telephone trees, which work by one member contacting two or more other members when they become aware of a threat, who in turn contact other telephone tree members and so on

■■ local community members with access to scanners that can monitor CFA radio communications to pick up information direct from the fire ground.125 4.95 There is evidence before the Commission about each of these methods of information dissemination. It emerged that on 7 February agency websites and ABC broadcasts were the most common sources of information and warnings about bushfires for most Victorians, though other sources played a complementary role.

THE CFA and DSE websites 4.96 On 7 February the CFA and DSE issued warnings for a large number of fires. The pressure on the agencies’ staff and volunteers was extreme and all those involved were forced to cope with a rapidly evolving situation and threats posed by multiple emergencies. At times, there were obvious limitations on their capacity to supply information on fires. Mr Waller noted the following:

It was extremely difficult to provide accurate information as all fires were moving extremely quickly and spotting long distances. Fires moved rapidly into difficult terrain where it is difficult to track progress and is dangerous to access. There was intensive short distance spotting. Surveillance was also restricted as at times planes could not fly with the strong winds, or could not safely approach the smoke plume and infra red scanning was not possible. Ground observation was also limited because [sic] the concern for safety. Incoming reports on fires from the public had to be quickly verified before possible inclusion in messaging on where a fire front may be.126

4.97 Mr Rees produced a copy of all bushfire warning messages posted to the CFA website on 7 and 8 February.127 Mr Waller produced a detailed compilation of all the information and warnings issued by DSE on 7 February, including the information posted on the DSE website and sent to the ABC.128 133 2009 Victorian Bushfires Royal Commission—Interim Report

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4.98 This demonstrates that a very large number of awareness, alert and urgent threat messages were posted to the CFA and DSE websites throughout the day. Information contained in the awareness, alert and urgent threat messages was conveyed to the ABC and to commercial media for broadcast. It was also supplied to the VBIL to be used by staff providing information to the public.129

Warnings broadcast by the ABC 4.99 Consistent with the MOU, many bushfire warnings were broadcast by the ABC on 7 February. After the usual midday news bulletin, local radio Victoria began its scheduled grandstand sports broadcast but interrupted this at about 12:30pm to broadcast fire-related information. As information about the number of bushfires burning in various parts of Victoria was received, and the growing seriousness of the situation became apparent, Victorian local radio management decided to cancel scheduled programming and switch to continuous rolling coverage of the bushfires.130 4.100 During the day, much of the content broadcast on local radio Victoria was sourced from 774 ABC Radio Melbourne. In some areas, local ABC radio stations made local broadcasts at some stages of the day.131 4.101 The information concerning bushfires received by the ABC came from multiple sources:

■■ telephone calls from representatives of emergency services made on the hotline directly to 774 ABC Radio Melbourne production studio in Southbank and to regional radio stations and directly to ABC local radio staff

■■ emails from the fire agencies and Victoria Police

■■ ABC staff monitoring the DSE and CFA websites: on the afternoon of 7 February a person in the Ballarat studio was rostered to monitor the messages being posted on the agencies’ websites and as appropriate to read those messages on air on 774 ABC Radio Melbourne

■■ direct conversations between CFA and DSE staff and ABC personnel located at the iECC

■■ ABC staff speaking directly to Incident Controllers by telephone, and sometimes the Incident Controllers being interviewed on air

■■ telephone calls with representatives of the Bureau of Meteorology

■■ telephone calls, SMS messages and emails from members of the general public.132 4.102 There are in evidence transcripts of the 774 ABC Radio broadcasts on 7 February.133 Additional audio files and transcripts of ABC Central Victoria Radio, ABC Gippsland Radio, ABC Western Victoria Radio, 3AW and ABC local radio were also tendered.134 In addition, a chart setting out the first mention of warnings for the Kilmore East and Murrindindi fires was tendered.135 4.103 It is clear from this material that bushfire awareness, alert and urgent threat messages were read multiple times throughout the day. ‘On the spot’ coverage was provided throughout the day. Interviews were conducted with representatives of the emergency services, callers from the public provided information and reporters on the ground provided additional coverage. 4.104 An extremely high volume of calls was received by ABC Radio on the afternoon of 7 February. The Melbourne Southbank studio received just over 6000 calls. In comparison, on an ordinary day it expects to receive approximately 800 calls.136 4.105 Ms Stayner said calls to the ABC were being made simultaneously and continuously on multiple lines. Producers and editorial staff were answering calls for over 10 hours commencing at about midday on 7 February.137 The events of the afternoon presented a ‘very challenging situation even for experienced staff’.138 Some members of the public called in a distressed state seeking information, which presented difficulties for ABC staff.139 The public increasingly called the studio looking for specific information and reporting problems with the VBIL.140 Some callers rang back repeatedly and became increasingly frustrated.141 4.106 In addition to the information broadcast on ABC Radio:

■■ ABC television broadcasts on 7 February carried ‘crawlers’ which advised viewers that there were fires burning throughout Victoria and that they should listen to their ABC local radio for further information. 134 The first crawler went to air at 1:45pm and they continued regularly until nearly 10:00pm on 7 February.142 Warnings

■■ Information was published on the 774 ABC Radio Melbourne Twitter account from about 12:30pm on 7 February until the early hours of the following morning.143 The information published on the Twitter account came from information already broadcast by the ABC, the CFA website and information on the ABC news site.144 4.107 The ABC played a vital role on 7 February in informing and warning the community. The efforts of its staff are commended. The level of public trust in and reliance on the ABC is evident. However, in a number of key instances the information provided by the ABC was out of date, or inaccurate — or there was simply no information that particular communities were under threat. The ABC was reliant on accurate and timely advice from the emergency services, and when this was not available, the quality of information relayed by the ABC was inevitably compromised. The specific circumstances around warnings for the Kilmore East fire are discussed in Chapter 9. The Commission will hear further evidence for each major fire in future hearings.

Commercial media 4.108 The commercial media also played a role in alerting the community to bushfire warnings. A compilation of media clips (including commercial TV news bulletins) was played during the hearing.145 These clips graphically illustrated the level of attention that the bushfire risk gained in the commercial media on 7 February. 4.109 There is scope for increasing the involvement and profile of the commercial media in emergency broadcasting. As Mr Rees noted, the MOU between the ABC and the emergency services agencies acknowledges that ABC local radio broadcast to a maximum of about 25–30 per cent of Victorians at peak listening times, and a smaller number outside those hours.146 Attention needs to be paid to reaching those who are not within the ABC’s audience. 4.110 Mr Grant Johnstone, General Manager of ACE Radio Traralgon stations TRFM and Gold 1242, gave evidence.147 ACE Radio is Victoria’s largest regional commercial radio network. It operates 13 AM and FM radio stations throughout Victoria. Mr Johnstone noted that ACE Radio and other commercial radio networks are not recognised officially as emergency broadcasters.148 However, ACE Radio follows the procedures contained in the Commercial Radio Australia Limited codes of practice and guidelines for broadcasts of emergency information.149 Pursuant to those guidelines, ACE Radio broadcasts emergency information. ACE Radio broadcast the warning messages it received on 7 February and undertook substantial efforts to obtain information directly from Incident Controllers to supplement that information. 4.111 ACE Radio’s system for broadcasting emergency service announcements relies heavily on the emergency services directly contacting ACE Radio by telephone, fax or email and on ACE Radio staff being able to speak to emergency service personnel directly when the need arises.150 4.112 Mr Johnstone noted, however, that there are two major consequences of ACE Radio not having the status of the emergency broadcaster: (1) Incident Controllers and others charged with dissemination of information do not automatically and routinely provide emergency information to commercial regional radio networks. As a result, the information available for broadcast is more limited than it should be. (2) Commercial broadcasters are not promoted in the mind of the public as ‘emergency broadcasters’.151 4.113 Mr Johnstone expressed the firm view that all radio networks that are prepared to broadcast emergency service information during bushfires and other emergencies, and to maintain appropriate standards when doing so, should enjoy equal access to the emergency service information to maximise public accessibility. He noted that ACE Radio would be prepared to enter into an undertaking with the relevant authorities to guarantee the extent and integrity of its emergency information broadcasts in a similar way to the MOU that presently exists between the ABC and Victorian emergency services organisations.152 He said:

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It is something that I particularly feel quite passionate about; that all broadcasters should be given an equal footing and all broadcasters should be given equal access to the information … it would be impossible to say that everybody was listening to the ABC on February 7. Given the volume of calls that we received on that night, I would suggest that that’s not the case. Therefore all radio stations … in a given area should be given equal access to the information.153

4.114 Efforts should be made to pursue this willingness of commercial radio interests to enter into arrangements and commitments similar to those with the ABC. 4.115 The State indicated in its submissions that the OESC has already decided to negotiate with commercial broadcasters who wish to act as emergency broadcasters and thereby ‘extend the reach of warnings delivered by radio and beyond the audience of the ABC’.154 This development is welcomed. However, the Commission notes that success in extending the emergency broadcaster network will require commitment by the parties on an ongoing basis.

HOW DID THE COMMUNITY RECEIVE AND UNDERSTAND THE WARNINGS on 7 february? 4.116 Evidence previously described in this chapter confirmed that a large volume of warnings was issued in various forms and at different times during 7 February. The Commission has also paid careful attention to the content, accuracy and timelines of the warnings, the detail of their accessibility to the communities directly affected by the fires, and to the nature of their general dissemination.

Interim report of the Bushfire CRC 4.117 The Bushfire CRC has produced an interim report on its investigation into the fires: Victorian 2009 Bushfire Research Response Interim Report (June 2009).155 That report included a detailed study of human behaviour and community safety.156 The themes that emerged included the existence of low levels of awareness prior to 7 February, criticisms of some of the sources of information relied on by the community and concerns about an absence of timely warnings. 4.118 The report’s findings were based on preliminary analysis of 201 (or approximately one third) of the interviews conducted by the research team.157 The researchers’ preliminary analysis of the material indicated that a minority of those interviewed (about one in five) spoke of some level of awareness of heightened risk of fire predicted for 7 February, although it was noted that not all interviewees were asked specifically about this.158 Very few of those interviewed indicated that the forecast and warnings had resulted in them changing their behaviour prior to 7 February. The report noted that:

The most frequent outcome of the early predictions and warnings was to raise general, non specific concern about the possibility of fire, and to probably promote a ‘wait and see on the day’ response. Only a small minority of residents of at risk communities appear to have interpreted the warnings as having implications for their personal safety and the security of their property resulting in either earlier action to prepare their property for a defence, or a decision to be elsewhere.159

4.119 Most interviewees reported receiving information via the radio on 7 February. Very few made references to specific and useful information having being broadcast.160 The report noted that for many interviewed, the lack of timely information about developing threats to communities such as St Andrews, Strathewen, Kinglake, Kinglake West, Narbethong and Marysville, especially late in the day when fire activity was rapidly increasing, may have contributed to people being surprised by the sudden impact of the fires. Because those communities were not identified as being under threat, many residents appear to have assumed they were unlikely to be threatened.161 4.120 Many interviewees reported seeking information from the CFA and DSE websites and were critical of those sites.162 Particularly in Bendigo and Marysville, those interviewed also indicated that direct verbal warnings from police officers and CFA and SES volunteers were very important in enabling residents to evacuate 136 safely.163 The report concluded: Warnings

In summary, for many of those interviewed, environmental cues as to the risk of fire (smoke, flames, embers) served a useful function in alerting them to a developing threat, and in many instances prompting an active search for more information, or a decision to take active steps to evacuate or to initiate defence. These environmental cues took on special significance in the reported absence of specific warnings via the media and agency websites about imminent threat to many of the affected communities. However, environmental cues, especially remote cues such as smoke, are ambiguous and are likely to add to uncertainty in the absence of accurate, specific, and timely information for residents about developing fire threats. By way of concluding, vigilance by residents for environmental cues on Total Fire Ban Days cannot always be relied upon.164 analysis of a SPECIFIC BUSHFIRE WARNING ISSUED ON 7 FEBRUARY 4.121 Professor Handmer was asked to comment on the effectiveness of the bushfire warning messages issued during the fires.165 In particular, he was asked to comment on bushfire warnings placed on the CFA website on 7 February. One of these warnings is replicated below.

Table 4.2: Alert Message for the Saunders Rd, Kilmore East fire, 2:20pm

Review Effective Effective News Message Authorised date/ From To Title Type Message by time

7/02/2009 7/02/2009 Saunders Alert Incident Information: A grass fire is burning SDO Gregg (null) 14:25 14:40 Rd, Message 3 kilometres east of Kilmore, near Saunders Patterson Kilmore for fire at Road (VicRoads Map reference 417 C4). East fire, Kilmore It is burning in a south easterly direction. 2.20pm East This fire is not currently posing a threat to communities, however the communities of Kilmore East, Wandong and Clonbinane need to be aware of this fire. This fire has now jumped the Hume Highway and significant spotting has occurred. The fire is impacting on the outskirts of the Wandong township. Estimated size is over 600 hectares. Core Advice: People in the area need to remain alert as there may not be a warning should conditions change unexpectedly. Continue to listen to ABC or local radio for updates on this fire. Be prepared to activate your bushfire survival plan if necessary. Decide now if you are going to stay or go. Remember that it is very dangerous to leave late with a fire in the area. Road use in the area will be extremely hazardous due to low visibility from smoke. Watch out for fallen trees, power lines, abandoned cars, wildlife and emergency services vehicles. If you plan to stay, remember to seek shelter from radiant heat. Should the fire reach your property, close all doors and windows and stay inside the house while the fire passes. Remain alert, extinguish any small fires and if necessary, move outside to burnt ground once the fire has passed. Drink plenty of fluids to avoid dehydration. For information on fires in Victoria and general fire safety advice, please contact the Victorian Bushfire Information Line (VBIL) on freecall 1800 240 667. Callers who are deaf, hard of hearing, or have a speech/communication impairment may call textphone/telewriter (TTY) on 1800 122 969. Information is also available at www.dse.vic.gov.au/fires 137

Source: Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0530–0531166 2009 Victorian Bushfires Royal Commission—Interim Report

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4.122 In relation to this message, Professor Handmer made the following points:

■■ Layout: subheadings are present but hard to find, people have to read the whole statement carefully to find what they might want.

■■ Content and wording: This is an alert message, but the timeframe it is relevant for is only 15 minutes. This appears inconsistent with the message ‘the fire is not currently posing a threat to communities’, and the statement that the fire ‘is impacting’ on the outskirts of the Wandong township. He concludes that ‘much of that message is generic in all the alert messages but it is quite confusing, more than quite confusing’.167 4.123 The confusion caused by a message which states both that, ‘this fire is not currently posing a threat to communities’ and that ‘the fire is impacting on the outskirts of the Wandong township’ is particularly problematic. Mr Rhodes accepted that this rendered the message ‘contradictory’.168 4.124 The reference to a fire being 600 hectares in size is not, on its own, particularly informative to most members of the public, unless accompanied by an indication of the severity and speed of the fire. The reference to a VicRoads map (which appears in this warning, but not all those posted on the CFA website) may be very useful to those travelling, but other information describing the location and predicted spread of the fire is likely to be more useful to residents who are in their homes when they receive the warning. 4.125 In the context of an exploration of these mixed messages, Mr Esplin stated that he was aware the CFA and DSE were already reviewing the language in the messages.169 The terminology, design and content of the messages indeed needs urgent review. 4.126 A real problem with this message, and others like it, is the failure to indicate the severity of the approaching fire, and the failure to refer explicitly to the window of time until the fire reaches Wandong and other communities. 4.127 When asked to comment on urgent threat messages, Mr Esplin said such a message should not be regarded as a warning to leave. He asserted that it is rather ‘the last bit of information for a community that has prepared itself to stay and defend its property’. He said ‘If you get an urgent alert message [sic], it is to help those people who are planning to stay and defend their properties and it should not be seen as a trigger to flee, which all the research at that stage had highlighted was the most dangerous option to you’.170 4.128 This suggests that urgent threat warnings carry meaning only for those who have determined to stay and defend their properties. However, it is clear that many in the community decide to leave when threatened by fire and that for some, an urgent threat message is the first indication they receive of fire in their area. Such messages must be crafted with this reality in mind.

LAY WITNESSES VIEWS ON THE WARNINGS 4.129 Lay witnesses provided useful evidence about warnings relevant to their communities. A number of those who gave evidence did not hear specific bushfire warnings for their community. Some did not receive a warning because a timely warning was not disseminated for their community. Some were unable to receive warnings as their homes had lost power by the critical time. Others did not actively seek warnings or ‘missed’ specific warnings, because they were engaged in other activities, or were preparing their homes or focusing on other communication sources when the warning was disseminated. Some heard warnings, but found them inadequate in their description of the speed and severity of the fire. 4.130 Many of those who gave evidence before the Commission expressed grief, anger and frustration about the fact that they or their family members did not receive timely or accurate (or in some cases any) warnings sufficient to enable them to take steps to protect themselves and their families. 4.131 Witnesses drew on various sources for information and warnings. Dr Lachlan Fraser of Marysville was aware of the weather forecast. He saw smoke at about 3:30pm on the afternoon of 7 February and then sought information from the VBIL, which confirmed that there was a fire at the Murrindindi Mill. He listened to commercial radio rather than the ABC.171

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4.132 Mr John O’Neill of Steels Creek listened to the commercial stations and 774 ABC Radio. He monitored the CFA website. His family also made use of a telephone tree in their area.172 Ms Alice Barber of Pheasant Creek heard on the television and radio about fires in Kilmore East.173 4.133 Mr Peter Olorenshaw of Calignee was aware of the severe weather and fire risk. In particular, he listened to the ABC and monitored the Bureau of Meteorology website. Mr Olorenshaw is the leading Senior Constable attached to the Latrobe Traffic Management Unit. In that capacity he attended Red Hill Road where fire was already burning, and he and his partner drove to a number of homes and personally advised residents of the approaching fire.174

REACTIONS TO THE INFORMATION BROADCAST PRIOR TO 7 FEBRUARY 4.134 Some lay witnesses reported their reactions to the information concerning the weather predictions for the weekend disseminated in the days before the fire. Ms Jesse Odgers of Kinglake left her home at lunchtime on Friday 6 February having heard that ‘conditions would be worse than that of Ash Wednesday’.175 Ms Odgers said:

There are two parts to my decision, that it was a risk on the Saturday and that was the weather forecast. I have never heard before in my life a weather forecast that stated that conditions would be worse than that of Ash Wednesday and together with that and the forecast for extreme winds, temperatures in the low to mid forties and so that is one part of the external information; and the second part of that information was my physical experience of where I lived ... seeing the leaves drop from the trees, I had never seen that before in my life and I thought that was another extreme indicator that something was very wrong.176

4.135 Mr Peter Newman of Buxton said:

All that week the weather forecasts had got progressively worse, and they started dynamite, anyway, and they said Saturday is going to be the worst on record … You can’t get any plainer than that they said this is going to be the worse day on record. On that day we got to 48 degrees and 4 per cent humidity I was told. You can’t get any worse than that. 177

4.136 Mr Brian Patten of Upper Plenty said: ‘I was well aware that Saturday was going to be a big day for fires or a dangerous day for fires’.178 Mr Ken Rogers of St Andrews was aware that 7 February had been declared a day of Total Fire Ban and regarded this as ‘an indication’ and had undertaken various preparations but was nevertheless expecting to hear a specific warning.179 Mr Rogers said:

We understood that it was going to be a pretty bloody day and with a high risk of fire and to be ready for it. Also, it should be remembered, after 4 days, after [sic] 43, the place was tinder dry. It was obviously a very high risk of fire, but I think, you never really think it’s going to happen to you. They always seem to happen to other people. They always had in the past anyway.180

4.137 Dr John Ferguson of Buxton was aware of weather predictions to the effect that it was to be ‘potentially the worst bushfire day in Victoria’s history’. Dr Ferguson was listening to ABC Radio, but did not hear the warning message for Marysville and Buxton at 5:34pm, as by then the power had gone off at his home. He noted, however, that by that time he could see the smoke in the sky and it was obvious the fire was coming.181

Waiting for a trigger 4.138 A common theme among lay witnesses was that they expected to receive information about whether the fire had reached certain areas or towns, which they regarded as an indication that the fire was ‘in their area’. Some of those witnesses were then overtaken by the speed of the fire when it reached their homes. For example, Mr Denis Spooner of Strathewen and his family were waiting for an indication that the fire was in or near Whittlesea.182 Ultimately, the family left their home, but became separated.183 Sadly, Mr Spooner’s wife and adult son died in the fire. 4.139 Ms Jacqueline Hainsworth of Kinglake West, heard the warning from the Premier on the Friday.184 But she anticipated that the trigger for her to leave would be news of a bushfire anywhere in her area including Whittlesea, Mount Disappointment, Humevale, Strathewen, St Andrews or Kinglake, rather than declaration 139 of a Total Fire Ban day.185 2009 Victorian Bushfires Royal Commission—Interim Report

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4.140 Mr Illiya Ananiev of St Andrews said his family was relying on a ‘trigger’ from the internet or the CFA scanner. Mr Ananiev was aware of the high fire danger, but his first awareness of a fire in his area was being showered by blackened sticks in his family swimming pool. At that time, the only information on the website was that a Kilmore fire was ‘going’ and Mr Ananiev was not concerned by this information. In the end his family had to evacuate at the very last minute.186 4.141 Mr Bevan Gobbett of Clonbinane planned to commence his preparations when he received word that a fire had started in his shire. Mr Gobbett was first notified by a friend that a fire had started in Kilmore East. He accepted that due to a family function on that day he had not heard or seen some of the earlier warnings. Mr Gobbett had access to a CFA scanner, and the CFA and DSE websites, but found that the substantive web pages were inaccessible. He also listened to ABC Radio.187 4.142 Mrs Joan Davey was aware that her son and daughter-in-law from Kinglake were making preparations while monitoring the CFA website and looking for information about fires in their area. The fire consumed the family home and tragically took the lives of the young family, including Mrs Davey’s two grandchildren.188

Informal sources AND visual cues 4.143 Some who gave evidence were not aware of a fire until they saw smoke in the area — for example, Mr Daryl Hull working in Marysville.189 Others first heard of fire in their area from friends and family.190 Others heard information on CFA scanners — or later expressed the wish that they had been able to do so.191 4.144 Mr Christopher Casey of Long Gully heard nothing about the fires as he was listening to a commercial radio station. His first indication was noticing smoke in the distance. Ultimately Mr Casey went out into his local area and was advised by a police officer of the need to evacuate.192 4.145 Ms Sharon McCulloch of Kinglake was aware that the weather conditions leading up to 7 February were as bad or worse than Ash Wednesday, but the first indication she had that the fire was approaching was when she saw smoke and was informed by a relative. She did not hear any warnings for Kinglake on ABC Radio during the brief period she listened to it.193 4.146 Mr Douglas Walter of Taggerty had been listening to 774 ABC Radio and heard notification of a fire in Kilmore that was moving quickly. However, the first indication he had of the progress of the fire was his direct observations of the smoke.194 4.147 Mr David O’Halloran and his family monitored ABC Radio and the DSE and CFA websites. He did not hear a warning for his town of Flowerdale, although he accepted that a warning was broadcast on the ABC shortly after ten past six. He heard from a neighbour that fire was approaching Kinglake.195 4.148 Ms Anastasia Scott of Marysville was aware of the forecast weather. But her first indication that a fire had started at the Murrindindi Mill came from a phone call from a friend. She also received advice personally from a DSE employee who happened to live nearby.196 4.149 Ms Christine Glassford of Reedy Creek was aware of the weather forecasts and knew it was going to be very hot. Ms Glassford’s first information concerning the fire was when she noticed smoke; she then checked that information on the CFA website but it did not appear to match her observations.197

Lack of timely warnings 4.150 Chapter 1 describes the main fires on 7 February and contains information on the provision of warnings. For a number of the fires there is a serious time lag from the point of activation of emergency services to the provision of information, alert and warning messages to the community. The Commission will hear further evidence on the timeliness and accuracy of the warnings given for each major fire in future hearings. 4.151 Mr David Brown of Strathewen was aware of the predictions for fire risk for Saturday 7 February. He said that they were waiting for a trigger, that is an indication a fire was in their vicinity. The fire that came upon them had started over four hours before it reached them.198 Mr D Brown said:

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I cannot understand how if the two senior officers with the command responsibility for the CFA on the one hand and DSE on the other were prepared to go public a week or so later in the press and make the statements they did about how certain they were where this fire was going to come out, that a warning was not given to the community that was in the path of that fire. I cannot understand it.199

4.152 Mrs Carol Matthews of St Andrews knew that her children were monitoring the CFA website while undertaking careful preparatory steps for the approach of possible fires. There was no reference in the material available to her children to fire approaching or reaching the town of St Andrews. Mrs Matthews listened to 774 ABC Radio herself and could hear no mention of St Andrews being in the path of the fire. 200 The fire approached the family home rapidly, and tragically took the life of her son.

Views about the content of the warnings 4.153 A number of witnesses expressed concerns about the way in which information was conveyed to the public, and suggested improvements. 4.154 For example Dr Christopher Harvey of Kinglake was aware of the weather predictions for 7 February. 201 But in his view, there were shortcomings in the way in which the extreme fire danger was conveyed to the community:

We needed more. My dead neighbours, my deceased neighbours, my friends, we needed more information. An extreme fire danger day to us is a day to be vigilant. That is as far as I would describe that.202

4.155 Dr Harvey called, in particular, for more information about the fire danger index, noting that this would have to be accompanied by an education program.203 4.156 Mr D Brown explained that his wife listened to the radio all day and monitored the CFA website. They became aware that there was a fire in Kilmore East early in the afternoon, but were surprised by the speed by which it came to their property.204 Mr D Brown also stated that information about the fire danger index would have helped people understand the severity of the fire. He said:

I think it would have been a very graphic way of demonstrating the level of potential risk. When you have an index that normally runs from 0-100 as its top end and it was registering 328, that is a very graphic illustration of the seriousness of the potential event and I think that would have been quite easy for people to understand and I think … it would have caused us to think a lot harder about the potential risk the Kilmore East fire, once we learnt about it on the afternoon of the Saturday, represented to us.205

4.157 Mr Peter Brown of St Andrews became aware of the Kilmore East fire via an ABC Radio broadcast. He said they only heard ‘snippets of information’ about the Kilmore East fire on the radio and had to ‘wade through everybody else’s fires before we would get a little snippet about our fire’. A broadcast heard on ABC Radio at about 4:00pm informed him that there was a fire in the Clonbinane area, which was advancing slowly with a south-westerly change already coming through. This caused him to believe the fire would be pushed to the north-east, away from his valley:206

I had a strong belief that the information that I was receiving was accurate. I put it quite bluntly that I would rather receive no warning at all than a warning that is patently inaccurate because, rightly or wrongly, you pace your day to what information you’re hearing.207

4.158 Mr P Brown also called for use of plain language:

I feel that when language like ‘held within containment lines’… what are they? The euphemisms for ‘held within containment lines’ is, ‘oh, we’ve got it under control’… what does that mean? ... I think we have to be absolutely blunt that, once these fires are out of control, they are out of control and unless you have some form of backup plan on your property for life preservation you should get out.208

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4.159 Ms Karen Ward of Mudgegonga was aware of the weather forecast and predictions. She heard a message on ABC Radio in the evening, which was helpful because ‘it let us know that it was going to be us that was directly affected’. Ms Ward also sought more information about warnings and suggested it would be useful if fire was rated so it was clear if the approaching fire is going to be extreme.209 4.160 Mr John Williams of Yarra Glen noted that on Friday ‘the tempo of the warnings certainly increased’ and recalled seeing the warning given by the Premier.210 He took this as a trigger to commence preparations to defend the winery. He said, however, that the warnings he heard on ABC Radio were difficult to understand:

There were warnings issued from time to time in a very sort of performance type language, ‘a warning is issued to the people of such and such that you may be about to endure an ember attack,’ this sort of language, and I had to concentrate very carefully on each one of these messages just to see to whom it did apply. If I missed the beginning of the statement, the rest of it was of no consequence whatsoever. These messages went on, very lengthy, using up a lot of valuable time and I kept mumbling to myself, ‘get on with it, give a short, pithy messages that are up to date.’ They were out of date. I can see more going on here than what’s being told over the radio.211

4.161 He emphasised the need for short messages and suggested the following model:

‘A message for the people of Timbuktu. A message is issued at 1:35pm. You may be enduring an ember attack within the next hour. This is a message for Timbuktu timed at 1:35pm’, and then move onto the next one.212

4.162 Ms Jillian Kane of Bendigo, gave evidence on the death of her disabled brother in Long Gully. She noted that given his vulnerability he, and those like him, require ‘a more effective warning system’ and advance notice to be able to arrange to relocate.213

conclusions on the construction and content of BUSHFIRE warnings 4.163 Changes should be made to the content of bushfire warnings. Many of the warnings used by the fire agencies on 7 February were deficient in the following respects:

■■ many warnings did not indicate the likely severity of the fire; this is a significant shortcoming

■■ the warnings rarely identified the window of time during which the fire was predicted to reach certain towns or communities; this information is vital to the community

■■ some warnings were imprecise in their description of the location of a particular fire or the direction in which the fire was spreading; again, this information is important to those preparing to meet the threat

■■ the advice in many warnings was lengthy and confusing, sometimes even contradictory; it was difficult to identify the important information

■■ the terminology used in some warnings was vague and euphemistic; it did not serve to grab the audience’s attention. 4.164 On the particular language to be used in bushfire warnings, as Mr Rees agrees, terms like ‘going’ and ‘out of control’ — though they have meaning to fire specialists — fail to convey sufficient meaning to the public.214 In his evidence, Mr Lawson agreed that the use of a term such as ‘extremely dangerous bushfire’ would be in keeping with the desire to use plain language.215 Mr Pearce agreed that using the term ‘severe’ would improve communication about the severity of fires.216 Terms which convey clearly the severity and intensity of bushfires should be used.

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RECOMMENDATION 4.2

The State ensure that the content of bushfire warnings issued in Victoria reflects the principles set out in the Commonwealth policy paper Emergency Warnings — Choosing Your Words (2008). In particular, all bushfire warnings issued in Victoria must use clear language, avoid euphemisms, and contain explicit information in relation to:

■■ the severity, location, predicted direction and likely time of impact of bushfires on specific communities and locations; and

■■ the predicted severity of impact of the bushfire and whether a specific fire poses a threat to human life.

TOWARDS A LONGER TERM APPROACH — A NEW CATEGORISATION SYSTEM 4.165 A number of witnesses who appeared before the Commission said that it may be desirable to develop a clearer means of communicating the severity of a bushfire to the public. Some witnesses proposed drawing on the ‘category one, category two’ terminology used in cyclone warnings. For example, Mr P Brown suggested an improved system of fire danger rating:

… you could have a total fire ban season and you could train people up on the type of equipment that can be used on any given day, and then what happens is you rate everyday during the fire season from a 1 through to a 5. You can have it such that, as you move through it, the response from the fire authority can go from being at a 1, where the fire can be contained within a given time and so the community can have confidence that it is actually within a scale that the fire authorities can control, right through to a 5, where straightaway we know that, when the fire occurs, unless it is under control within the first ten minutes to a quarter of an hour, it’s now out of control … the community needs to know that.217

4.166 Similarly, Mr Ananiev suggested, ‘All we are looking for is a category 1, 2, 3, or 5, and maybe a colour, red, yellow, green, to mix in with it’. When asked about use of the terminology ‘extremely dangerous’, he said ‘For me it would be category 1. One red’.218 4.167 Ms Glassford said she found the information on ABC Radio confusing:

I would have probably personally preferred to have heard that the fire was in a particular location and the direction it was heading rather than hearing about what towns were under threat. I think that probably reflects the fact that I’m not really close to a particular town … I know a lot of people who were leaving late that day. I think also just knowing where it was and the direction it was heading may have aided them in choosing the direction to escape the fire.219

4.168 Dr Harvey agreed:

You know you can’t be calling it a very extreme fire day, you can’t use that sort of language, it just doesn’t mean a thing. Numbers mean things to people.220

4.169 Professor Handmer drew comparisons with other warning systems used for natural disasters. He explained that in relation to cyclones, there is a categorisation system ranging, ‘from 1 or 2, very low impact, to 5, extreme cyclone’. He explained further the benefits of cyclone warnings, while noting that cyclones are easier than bushfires to ‘detect, track and issue warnings for’.221 4.170 There are important differences between floods, cyclones and fires, and different challenges are raised in relation to warning systems for each. However, a more readily understood ‘severity scale’ to be used when grading bushfires would assist the community in responding to bushfire warnings.

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4.171 The AFAC 2009 draft paper, A National Systems Approach to Community Warnings, recommended that categorisation levels should be developed for other emergencies, and in particular that the use of the fire danger index should be reconsidered, incorporating the experiences of dealing with cyclones.222 Such an approach has benefits and may be capable of more starkly bringing to the attention of the public the severe risks attached to some fires. 4.172 In a related context, a number of witnesses spoke of the difficulty of conveying the severity of extreme fires by reference to the current fire danger index scale. This matter is discussed in more detail below in Chapter 5. 4.173 In relation to the possible introduction of a numerical system of grading severity of fires, Professor Handmer said that it may require some years of education but people would understand it, so long as it was accompanied by an appropriate education awareness program.223

RECOMMENDATION 4.3

The State commission research into the development of a new fire severity scale that denotes the risk posed by dangerous and extremely dangerous bushfires (similar to the cyclone categories 1 to 5).

LESSONS FROM THE 2005 WANGARY FIRES AND PROJECT PHOENIX 4.174 In January 2005, the Wangary fire on the Eyre Peninsula in South Australia resulted in the deaths of nine people and the destruction of 93 homes. After the Wangary fire, Mr Andrew Lawson was appointed as the Country Fire Service of South Australia (CFS) Liaison Officer to the Coronial Investigation Team and to assist those conducting an independent review into the same fire.224 4.175 Mr Lawson is currently Deputy Chief Fire Officer of the CFS. He is also a member of the AFAC Operations Strategy Group and the Urban Strategy Group. Mr Lawson has extensive experience in all areas of the fire industry, including operational firefighting, fire planning and mapping, administration, management and policy development.225 4.176 Mr Lawson gave evidence effectively ‘wearing two hats’. He attested to his experience dealing with the aftermath of the Wangary fires and the implementation of a new bushfire warning system in South Australia. He also gave evidence in his capacity as a member of AFAC’s Operations Strategy Group and as principal author of the 2005 AFAC draft paper discussed at paragraph 4.48. 4.177 Mr Lawson explained that as a result of the Wangary fires, the CFS immediately commenced an extensive ‘lessons learnt’ process known as Project Phoenix. The aims of that project included identifying and implementing improvements prior to the 2005–06 fire danger season.226 One such improvement was the introduction of a new bushfire warning system. 4.178 In January 2005, the CFS was using four levels of bushfire warnings. Part of the learning of Project Phoenix was that there was widespread confusion about the numbering system and the meaning of each phase in the system.227 The CFS has since simplified the warning system to two levels, comprising bushfire information messages and bushfire warnings. The new system is now known as the CFS Bushfire Information and Warning System.228 4.179 Bushfire information messages inform the community about a bushfire that is burning or ‘going’, and may be threatening, but does not necessarily demand urgent action by the community. Bushfire information messages may also include information and advice on the state of a more distant bushfire.229

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4.180 The second stage, the bushfire warning message, warns the community that a major bushfire is burning out of control under high to extreme conditions and is a threat to public safety. A significant threat to life exists, and the community needs to respond immediately to ensure their safety and survival. In South Australia, a bushfire warning message is accompanied by use of SEWS.230 4.181 Compared with the Victorian bushfire warnings, the South Australian regime involves less dense text, and more explicit reference to a ‘threat to public safety’. Mr Lawson explained that the construction of the South Australian messages takes into account the COAG recommendation of 2004. He said ‘we believe that it is most important that the community understand what the risk is in as simple and as plain terms as possible’.231 4.182 Professor Handmer was asked to consider the South Australian warning examples for comparison. He said the South Australian examples were clear and straightforward and that the wording was ‘better practice’ in how it describes the fire and locality.232

The South Australian one is a bit more punchy. I often think a lot of CFA material is very sound but perhaps it is directed more for people who like to read a lot of material — it is not a criticism; I like to read a lot of material — whereas the South Australian one is minimalist and it would be seen, I think, as good practice in warnings to try to just head in that direction that’s all.233

4.183 When issued, CFS warning messages are displayed on the CFS website, broadcast on ABC Radio and 5AA (a commercial radio station) and sent to subscribers who opt in to receive CFS messages via email and fax stream.234 4.184 Mr Lawson explained that the CFS has an MOU with the ABC and the commercial radio station 5AA. Those radio stations have undertaken to read on air a bushfire warning message immediately, regardless of their programming commitments and to repeat it every 15 minutes thereafter. Each bushfire warning message is preceded by SEWS.235 4.185 South Australia implemented changes to its warning system very rapidly following the January 2005 fires. The new system was in place by May 2005. Mr Lawson explained that ‘we had to do something prior to the 2005–06 fire season’.236 He indicated that it would be difficult for a new system to be introduced in Victoria by October or November this year but that this should nonetheless be undertaken.237 4.186 The State of Victoria’s submissions note that steps are ‘already being taken’ to ensure changes to warnings will be implemented by next fire season.238 4.187 Use of a two-part system of warnings, instead of the three used in Victoria, has appeal as a simpler approach that is likely to be more easily understood by the public. The first level is essentially an information or alert message of the existence of a fire, which does not necessarily require any action to be taken by the public, other than to keep it under notice. The second level encourages urgent action, such as to activate a pre- determined fire plan. The level of threat can range from low to high depending upon the language used. The Choosing Your Words publication provides a hierarchy of terms to match the assessed degree of risk, urgency and need for action.

RECOMMENDATION 4.4

The State ensure bushfire warnings in Victoria are confined to two categories or stages:

■■ Bushfire Information — a message providing information to the community on a bushfire that is ‘going’ and has the potential to threaten public safety; and

■■ Bushfire Warning — a warning to the community about any dangerous or extremely dangerous bushfire, particularly one that is burning out of control and poses a threat to human life.

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RETHINKING THE Standard emergency warning signal 4.188 As noted in paragraph 4.7, SEWS is not a warning. It is a distinctive alert tone or signal broadcast prior to warnings for major emergencies. It is designed to ‘alert listeners or viewers of radio or television that an official emergency announcement is about to be made concerning an actual or potential emergency which has the potential to affect them’.239 4.189 The use of SEWS is not referred to in the Emergency Management Manual Victoria, but a protocol is set out in a document titled SEWS Guidelines for its Use in Victoria (October 2006).240 The current protocol for the use of SEWS requires the control agency to request the police to authorise its use.241 4.190 SEWS was not used in Victoria on 7 February. There were no discussions with the Chief Commissioner of Victoria Police about the use of SEWS on the day.242 4.191 The Commonwealth had been considering a ‘relaunch’ of SEWS; however, it ceased that work in anticipation of the findings of this Commission.243 4.192 There is evidence of a clear reticence on the part of the emergency services in Victoria to use SEWS. The signal has not been regularly used in Victoria, because of concerns about its so called ‘overuse’ and the emergency services’ view that its use may cause confusion.244 This appeared, in part, to be derived from reviews of past fires. For example, Mr Rees said:

Although the decision to use SEWS rests with an Incident Controller, the current practice within the CFA is not to utilise SEWS. This is because whilst SEWS remains available for use, the current process of graduated warnings is considered more sophisticated. That view has been reached on the basis of both anecdotal evidence and reviews conducted following fires in 2006–07.245

4.193 In evidence, Mr Rees expressed the view that SEWS does not have a place if there are multiple fires,246 and expressed concern that if SEWS had been used on 7 February prior to each urgent threat message on the ABC, it would have been played 510 times on the day. 4.194 There was criticism about the use of SEWS following the 2005–06 fires in the report Debrief Outcomes Significant Victorian Fires December 2005 and January 2006, Review by Ross Smith 12 July 2006. In particular, the report was critical of the risk of ‘SEWS overload’. It also noted that messages were broadcast late, and that SEWS messages must be initiated well before the anticipated fire impact.247 4.195 It is obvious that SEWS has little utility if broadcast too late. However, a criticism about the late use of SEWS does not justify a conclusion that SEWS should not be used at all or that the mere use of SEWS has the capacity to confuse the listener. Mr Esplin agreed that there were no reports following the 2005–06 fires of dangerous or late evacuations or death that could be traced back to use or misuse of SEWS.248 4.196 Further consideration was given to use of SEWS in the report Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media During Fire Incidents – Preliminary Findings (July 2006) (CFA/DSE Review of Information Flows).249 This review suggested that the use of SEWS during 2006 fires was inconsistent and sometimes inappropriate. It was overused to the degree that the public were ‘sick of it’. The consensus in the debriefs was that SEWS messages had become counter-productive.250 4.197 The use of SEWS must be consistent. This could be achieved by adopting appropriate protocols, such as one that the signal would be used to precede the proposed bushfire warning messages that relate to fires of a particular severity — namely those which are ‘extremely dangerous’ and those that pose a threat to human life. 4.198 The CFA/DSE Review of Information Flows report contains a curious comment. It states that, ‘other than performing the role of an initial notification, SEWS in this context may arguably have become obsolete’.251 However, the only appropriate role for SEWS is just that — as a signal, or what the review refers to as the ‘initial notification’. When seen in the correct light, SEWS does have an important and useful role to play, as has been demonstrated in South Australia.

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4.199 The South Australian CFS uses SEWS whenever lives are at threat or when a fire is burning out of control on a very high to extreme fire danger day.252 SEWS precedes each bushfire warning message. Mr Lawson explained that an education program was implemented prior to the re-introduction of SEWS. He was asked whether, since the changes to the warning system were introduced in May 2005, the CFS had received feedback about the use of SEWS, including any suggestions of irritation, confusion or panic. Mr Lawson indicated the following:

We have received feedback from very small numbers of communities saying that it raises their level of awareness unduly, that we have used the signal when the fire didn’t pose the threat that they believed it should have as a result of using the warning, but we continued to use the SEWS warning.253

4.200 When asked why the CFS continues to use the warning in the face of such criticism, Mr Lawson stated the following:

We take that view that we have made that decision to use the SEWS, and until we have strong evidence to the contrary that suggests it does in fact provide confusion to the community, then we will continue to use the SEWS.254

4.201 Professor Handmer suggests that SEWS can be useful: ‘warnings to me operate in a competitive environment often with everything else people are doing or listening to, and there is often, not always, but often needs to be some way of cutting through all the haze and the idea of SEWS is to do that’.255 Mr Esplin said that he would prefer SEWS to remain available as a tool for the control agencies to use ‘if they believe it will materially assist the delivery of messaging to the community’.256 4.202 The State and the ABC expressed concerns during the hearing that the introduction of a protocol for the use of SEWS may lead to irritation or confusion in the community.257 However, it has been possible to overcome these issues in South Australia, as Mr Lawson outlined, by disaggregating the broadcasting network and issuing warning and information messages to specific communities through the regional radio system.258 4.203 The concerns expressed about the use of SEWS may be addressed by various means, including adopting a sensible approach to a new protocol for its use. This could include:

■■ grouping bushfire warnings that require the use of SEWS

■■ reducing the length of time SEWS is played when used multiple times

■■ disaggregating ABC broadcasts on occasions when multiple fires are threatening different parts of the State

■■ arrangements concerning the number of times particular warnings are repeated. 4.204 Professor Handmer indicated that, in his view, SEWS could be introduced to the Victorian community before the next fire season.259 4.205 In light of this discussion, it appears likely that a reintroduction of SEWS, accompanied by appropriate education, could indeed be achieved prior to the next fire season. Of course, its reintroduction must be accompanied by education on its purpose.260 Further, any concerns about the effects of overuse of SEWS could be addressed by the ABC, CFA and DSE implementing a protocol for a streamlined process for the use of SEWS on ABC Radio and television.

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RECOMMENDATION 4.5

The State ensure that the Standard Emergency Warning Signal (SEWS) be used in Victoria to precede each bushfire warning or group of warnings for bushfires that are dangerous or extremely dangerous, particularly for a fire that is burning out of control and poses a threat to human life, subject to appropriate limits on the maximum frequency of use.

RECOMMENDATION 4.6

The State invite commercial operators to enter into a Memorandum of Understanding (MOU), similar to its MOU with the ABC, on the dissemination of bushfire warning messages and the use of the Standard Emergency Warning Signal by those operators.

THE USE OF SIRENS AS A BUSHFIRE WARNING 4.206 Sirens are intended as a signal to those in the vicinity to seek further information or take protective action according to procedures established in the minds of those hearing the siren.261 When understood correctly (that is, as a trigger used against the background of an existing procedure for correct response) it is clear that a siren may have a useful role as part of an overall system of bushfire warnings. 4.207 CFA policy is that sirens are not to be used for warning the public.262 Mr Rhodes expressed the view that sirens have many limitations.263 He confirmed that the CFA does not advocate the use of sirens.264 4.208 The Commission has heard evidence on the use of sirens in some communities in Victoria and South Australia. Whether the use of a siren is appropriate as a fire danger warning depends on local circumstances, including a developed community appreciation of its function. There is scope to investigate and develop the use of sirens in communities that would benefit from such an alert system. In addition, sirens may be useful outdoors, particularly for travellers and campers.265 4.209 A small number of lay witnesses who gave evidence before the Commission referred to the use of sirens. For example, Mr Hull and Dr Fraser spoke of hearing the siren in Marysville sound briefly, but Mr Hull thought it was a false alarm, given how quickly it stopped.266 Dr Fraser heard something, but it was not a ‘wail’ and did not appear to indicate that there was a fire in the area.267 Ms Barber was waiting to hear the CFA siren in Kinglake West, but it did not sound.268

Ferny creek — a local solution 4.210 There is compelling evidence before the Commission of the manner in which a siren may be developed for use by a town to serve its local needs and purposes. In 2001, the OESC facilitated the trial of a siren in Ferny Creek. That process gave rise to a written report, The Ferny Creek Fire Alert Siren Evaluation Report — Office of the Emergency Services Commissioner (2001).269 4.211 The Ferny Creek fire alert siren trial was initiated following the recommendations of the State Coroner’s inquest into the deaths of three people during the Ferny Creek fire on 21 January 1997.270 A number of residents expressed concern that the CFA fire siren could not be heard in their location and, as a result, they had received little or no warning of the impending fire. This concern prompted a group of residents to lobby all levels of government for the installation of a CFA-type siren that was audible to all residents in an identified area in Ferny Creek.271 4.212 The Ferny Creek trial was conducted by a working group of representatives from the CFA, Victoria Police, Shire of Yarra Ranges, the OESC and three community resident representatives.272 The report noted that the process of reaching consensus about use of a siren involved a ‘shift from antagonism to acceptance’, and 148 that ‘it is also an example of the emergency services having the courage to move outside their comfort zone and actively contribute to the trial of a system about which they have strong reservations’.273 Warnings

4.213 The CFA’s opposition to the use of sirens is recorded in the report.274 In this context, the report noted that statewide CFA messaging does not always suit local issues: ‘It does not consider people such as recreational bushwalkers who may not have any warning about an approaching bushfire and those residents (children and older people) who are not aware of safety procedures or who are not able to leave their homes on days of total fire ban’.275 4.214 It appears that the tension referred to above, which may exist between the statewide bushfire preparedness policy and local interest in early warning systems that suit a particular community, continues to plague the development of local solutions. One of the lessons from February 2009 is that greater weight ought to be given to communities’ desires to fashion warning systems appropriate to their location and their needs. 4.215 Mr Esplin described the Ferny Creek siren in the following way:

They are a unique community in the sense of, firstly, their preparedness for fire; secondly in their accepting that they have chosen to live in a place in the State that is particularly beautiful most of the time but particularly high risk in a very small percentage of time. They accepted that risk and understood that they had a responsibility to take steps themselves to protect themselves and their community. They were prepared to take on responsibility for the siren which they have done and maintained to this time.276

4.216 The community in Ferny Creek use their siren as a ‘contribution to promoting appropriate bushfire survival behaviour’. It is not promoted as a trigger to evacuate, but rather it prompts residents to ‘access further sources of information’277 and to activate defensive actions. 4.217 The progress of the Ferny Creek fire alert siren was further considered in a subsequent evaluation report: Community Alerting For Bushfire — A Local Solution For a Local Need: The Ferny Creek Fire Alert Siren Follow-up Evaluation 2002 conducted by the OESC.278 The follow-up evaluation confirmed that the fire alert siren is now ‘an established element within bushfire preparedness planning and response. The fire alert siren is one link in a chain of communication being used and accessed by community residents’.279 4.218 The evaluation noted that a belief remains in the emergency management sector that sirens encourage residents to unsafely leave their homes if a bushfire threatens. The evaluation has in fact shown that, with appropriate community education and communication ‘the role of the alert siren can be incorporated into appropriate and safe planning and decision making’.280 4.219 This example provides robust evidence that a siren can be part of a successful program for bushfire preparedness and that, if properly understood and implemented, a protocol for the use of a siren does not undermine statewide policies such as ‘stay or go’, which is further discussed in Chapter 7. The success of the project is the result of considerable effort and goodwill on the part of the community, the local CFA and the OESC.

THE USE OF SIRENS IN Boolarra 4.220 The Commission heard evidence from Mr Lou Sigmund on the use of a CFA siren in the town of Boolarra on 30 January 2009, when the town was impacted by the Delburn fires. This evidence provides a vivid example of how a siren might be used in a particular community and its capacity to save lives. 4.221 Mr Sigmund, who lives in Boolarra, has been a CFA Group Officer responsible for eight brigades in the Morwell Group. He has been a volunteer fire fighter for the CFA since 1998. He has fire-fighting qualifications and fought in a number of major fires. He was Operations Officer for the Ashfords Road fire (part of the Delburn fires) between 28 and 30 January 2009.281 4.222 Mr Sigmund gave a detailed account of his efforts while fighting the fires near Boolarra and about his role in deciding to sound the siren. 282 The idea of sounding the siren came about at a community meeting on 30 January 2009, at which Mr Sigmund had expressed his strong view (contrary to advice from a CFA representative) that the town was in imminent danger of being overrun by the fire.283 Mr Sigmund then told the meeting that once the ember attacks started ‘we will set the sirens’.284

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4.223 The CFA siren was activated in Boolarra shortly after 1:00pm that day. A large number of people evacuated the town. The main street was described as filled with caravans, boats and horse floats hooked up to cars heading for Churchill.285 4.224 Mr Sigmund’s direction to use the siren was contrary to CFA policy. Mr Sigmund was aware of the policy against use of the brigade siren and he was chastised for its use.286 He attested that he had received ‘nothing but positive feedback from townspeople. They have written letters; rung me and given me nothing but support for the actions I took’.287 4.225 Mr Sigmund, by his own account, acted on the spur of the moment.288 He accepted that his decision carried risks and that if the fire had come from another direction, he might have been sending people into danger.289 In this context, Mr Sigmund expressed the view that the ‘stay or go’ policy is impossible for ordinary people to apply, because there are no trigger points to allow the average resident to make a judgement as to their safety.290 He said: ‘that is why at the meeting we decided to give them a trigger in the form of a siren’.291 4.226 Twenty nine houses were lost in the fires at Boolarra but no-one died.292 Despite the siren being used in a manner that is contrary to CFA policy, it appears to have served a useful purpose in warning townsfolk to leave. Many appear to have acted on that trigger. 4.227 Mr Rhodes expressed serious reservations about the use of sirens, but he did note that the siren worked in Boolarra on that occasion because its use was defined at the community meeting and the residents understood its use.293 4.228 In addition, Mr Lawson gave evidence that sirens are used in South Australia to alert the community to the activity of the fire service. The South Australian CFS encourages local brigades to engage with their communities and to use sirens for purposes determined by the community in consultation with the brigade.294 Some brigades use sirens to alert the community to fire, others do not. Mr Lawson said: ‘We leave it to the brigade to make that decision with the community’.295

USE OF SIRENS AND REFUGES 4.229 There is also evidence before the Commission concerning the use of sirens in a number of communities in conjunction with the use of refuges. One such community is Walhalla. The town of Walhalla uses the Long Tunnel Mine as a refuge. 296 The use of this refuge is described in more detail in Chapter 8. Woods Point also has an established procedure for the use of a siren in conjunction with its refuge.297 4.230 The Commission also heard evidence about the use of a police car siren as a means of getting people’s attention in Marysville.298

Support for a new approach TO THE USE OF SIRENS 4.231 Mr Esplin accepted in evidence that individual communities who support the use of sirens as a means of taking action to preserve lives and property should be supported by agencies in doing so.299 Mr Rees also accepted that the use of sirens should be reconsidered.300 4.232 There is potential for more communities to attempt a comparable approach as that in use in Ferny Creek, Walhalla or Woods Point. Not all communities will want to institute a local alert siren. Some communities will determine to use their siren in different ways for different purposes. The option to pursue local solutions, including sirens, should be part of Municipal Emergency Response Plans and should also be given more prominence and assistance in the education campaigns and advice concerning bushfire preparedness. As Mr Esplin notes in relation to the Ferny Creek fire alert siren:

The community should not be just a passive recipient of services; it should be an active participant in developing safety strategies that it knows how to apply and is willing to apply, and applies, and it is involved in a partnership with the emergency services and with local government … and it is my philosophy that where such a tripartite partnership can be recreated, the safety outcomes are maximised, but risk is mitigated to the greatest extent.301

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4.233 Sirens are one of a number of options that might be deployed in some areas to ensure the community is alerted to the need to be ready to receive warnings, search out further information, take defensive actions or prepare to implement a protocol for a local refuge.

RECOMMENDATION 4.7

The Office of the Emergency Services Commissioner and the CFA develop guidelines for the use of sirens in communities that decide to use a siren as part of their response to bushfires.

A TELEPHONY-BASED EMERGENCY WARNING SYSTEM 4.234 The evidence before the Commission establishes that the principal modes of warning the community about the threat of fire on 7 February were broadcasts on ABC Radio and messages displayed on the CFA and DSE websites. 4.235 However, the evidence also shows that members of the community often sought out more than one source of information. Sources such as the VBIL, commercial media, CFA scanners, Twitter sites, phone calls and text messages from friends or family were also important sources of information and warnings. Others formed their own views based on their own observations of events as they unfolded. 4.236 Employing multiple modes to disseminate warnings is desirable to ensure the widest possible audience is reached and to guard against the risk of failure of any one mode. Technology in particular has a role to play but should not be solely relied upon. 4.237 This section considers the new technology, in particular a telephony-based warning system, that is available to disseminate warnings.

TRIALlING A nATIONAL EMERGENCY WARNING SYSTEM 4.238 In 2005, the OESC — in partnership with Telstra, ABC Radio, DSE, Victoria’s emergency services, the Shires of Yarra Ranges and Northern Grampians and the communities of Mt Evelyn, Stawell and Halls Gap — ran a successful trial of an opt-in landline telephony-based community warning system known as CIWS: see the report Community Information and Warning System — The Report of the Trial and Evaluation Office of the Emergency Services Commissioner Report 2006.302 The report stated that:

The purpose of a public warning system is to help minimise the impact or perceive threat of emergencies on affected communities by providing timely and accurate information to assist people and organisations to make decisions about their own safety.303

4.239 At the time of the trial there were restrictions on Telstra’s use of the Integrated Public Number Database (IPND). The IPND is an industry-wide database of all listed and unlisted public telephone numbers. It was established in 1998 and is managed by Telstra under the terms of its carrier licence condition. As a result, it was necessary to seek participating residents’ permission to use their telephone numbers and property addresses to develop the CIWS trial database.304 The report indicated that the CIWS Trial and Evaluation was informed by key national and international research. 4.240 The report concluded:

The evaluation findings strongly demonstrated that the majority of the participating residents understood the link between receiving the telephone message and immediately accessing ABC Radio as the secondary information source. There was also a strong response to continue using the telephone to access other sources of information (such as a telephone hotline).305

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4.241 The Victorian trial of CIWS was a clear success. There were high hopes that the success could be built on and a national telephony-based warning system could be implemented. Regrettably, these hopes did not bear fruit until 2009. 4.242 Since the 2005 trial, Victoria’s position has been that a national community information and warning system should be implemented. Victoria has advocated this position repeatedly and forcefully at the highest level.306 4.243 For a national warning system to be implemented, a number of matters had to be resolved:

■■ Amendments to the Telecommunications Act 1997 (Cth) to enable access to the IPND for the purpose of issuing warnings were required.307 There was considerable debate about the need for legislative amendments. For example, Telstra argued initially that they were not required. The Commonwealth disagreed and in the end amendments were made.308

■■ Agreement reached among the states and territories as to the model of warning system to be implemented (for example, whether it be opt-in or compulsory).

■■ Funding for the establishment of the warning system needed to be secured. 4.244 The chronology of events that unfolded after 2005 indicates that although steps were taken by governments, sufficient priority and urgency was not given to implementing a national warning system. 4.245 It is not possible to set out every meeting, item of correspondence, event, review and paper that occurred or was produced between 2005 and 2009 on this issue. Suffice to say that despite political will from the Victorian Government and a lot of bureaucratic activity, progress was slow and debate was protracted.309 4.246 The end result was that:

■■ On 23 February, legislative amendments were introduced to permit disclosure of data in the IPND in certain circumstances. The amendment now permits IPND information to be disclosed in the event of an emergency or when an emergency is considered likely. The Telecommunications Amendment (Integrated Public Number Database) Bill 2009, which was hastened as a result of the Victorian bushfires, received Royal Assent on 26 March 2009.310

■■ On 23 February, a press release was issued announcing $11.3 million of Commonwealth funding to contribute to the development of the warning system.311

■■ On 20 March, a tender was released for the construction of a database known as the Location Based Number Store, to provide a warning delivery mechanism to the states and territories. Funding for the development of the Location Based Number Store database and the first four years of operation is to be drawn from the $11.3 million Commonwealth contribution announced in February 2009.312

■■ On 30 April, it was announced that COAG had agreed to develop a national telephone emergency warning system. Further, the Prime Minister and the Attorney-General announced the Commonwealth investment of up to $15 million to assist the states and territories in establishing the national system.313 4.247 The new national telephone emergency warning system will be operated by the states and territories, and will be developed following an open tender process. The system will send emergency warning alerts by recorded voice and text to landline and mobile phones based on an owner’s billing address. A proposed second stage, sending warnings based on the location of a mobile (rather than its billing address) will be the subject of further research.314 4.248 It now appears that the first stage of the warning system is capable of being implemented by October 2009.315 4.249 Victoria is managing the call for tenders for the proposed national Emergency Warning System. On Tuesday 14 July 2009, the Victorian Premier issued a media release Brumby releases national emergency warning system tender ahead of bushfire season.316 The selective tender apparently involves two major telecommunication providers, Optus and Telstra. Mr Brumby is quoted in the release as saying:

With the first milestone in the procurement process complete, we are on track to ensure this critical system is in place in October.317 152 Warnings

4.250 The Commission is encouraged by reports that this project is currently ‘on track’ but, the Commission remains cautious given the projects history. The Commission will hear further evidence on the progress of this project during future hearings.

THE USE OF SMS ON 2 MARCH 2009 4.251 Another ‘post fire’ event is worth mentioning in this context. On 2 March, Victoria Police and the OESC decided to issue a mass warning message via SMS to warn of predicted severe weather.318 The message was in the following terms:

Msg from Vic Police: Extreme weather in Vic expected Mon night & Tues. High wind & fire risk. Listen to local ABC radio for emergency updates. Do not reply to this message.

4.252 The message did not rely on the amendments to the Telecommunications Act 1997 (Cth), as it was sent before they came into force. Approximately 2.07 million SMS messages were sent out over a number of hours to Telstra mobile phone customers.319 4.253 Due to time constraints, it was not possible to geo-code Victorian mobiles, that is, to allow warning messages to be sent to all mobiles located in a defined area at the time of the transmission. As a result, some Tasmanian customers received the SMS message. This was known prior to the message being sent, and efforts were made to minimise any confusion that might have resulted.320 4.254 A review of this event revealed a high rate of recall by recipients and ‘success’ in the message delivery.321 The apparent success of the 2 March SMS message (and the fact that the capacity to send such messages has existed for some time) underscores the utility of a telephony-based warning system.

Source: AAP Image 153 2009 Victorian Bushfires Royal Commission—Interim Report

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A MULTI-MODE APPROACH TO EMERGENCY WARNINGS 4.255 The implementation of the first phase of the new telephony-based warning system appears to be proceeding in a timely fashion, and, as noted, the State Government has announced it believes it will be in place by October 2009. The Commission commends the leadership role adopted by Victoria in the implementation of the system and the considerable work undertaken by Telstra in the development of the technology. 4.256 If, by September 2009, it appears unlikely that the first phase of the system will be operational throughout Australia, steps should be taken to ensure that the system is, nevertheless, operational in bushfire prone parts of Victoria as soon as practicable thereafter, and ideally in time for the 2009–10 bushfire season. 4.257 The introduction of the second stage of the system should be investigated and implemented as a matter of urgency. This stage will offer improvements, including the capacity to issue a warning of an emergency to visitors to an area who have access to mobile telephones. 4.258 The introduction of a new national telephone emergency warning system should not replace, but rather supplement, other modes of disseminating warnings, including unofficial messages. Multiple message dissemination modes are essential, as any single mode is unlikely to reach everyone, and in a crisis some dissemination modes can fail.322 Mr Esplin said:

Well, firstly I would say that no one warning system will or is likely to capture all the community that needs to be in receipt of that particular warning, but warning messages go from as simple as a megaphone to a doorknocking, to use of the mass electronic media or, if time permits, it could be the print media, SMS messaging, emails. The new technology is providing more and more opportunities to get that message, that crucial message to more and more people.323

RECOMMENDATION 4.8

The Australian Government, Council of Australian Governments and the State determine whether it is technically possible to implement the second phase of the national telephony-based warning system (that is, the delivery of warning messages to mobile phones based on the physical location of a handset at the time of the emergency) with a view to implementation for the 2009–10 bushfire season.

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The community seeks information about fire risk from a range of sources. Current means of communicating with and informing the public do not always satisfy the community’s needs and do not always cope with the levels of demand. This chapter is concerned with information: the content, sources and means of the dissemination of bushfire information to the public. It deals with three discrete areas in which the provision of information to the community might be improved: the fire danger index and fire danger ratings; websites; and the Victorian Bushfire Information Line.

revisiting the fdi and the fire danger rating 5.1 The McArthur Forest Fire Danger Index (FFDI) and the Grassland Fire Danger Index (GFDI) are used by fire services to assess ‘the difficulty of controlling or suppressing a wildfire’.1 These indices are calculated by reference to fuel characteristics and weather in order to generate a numerical index. 5.2 The FFDI and the GFDI indicate expected fire danger and are regularly calculated by the Bureau of Meteorology (BoM) for the use of fire agencies.2 5.3 The FFDI is calculated using the ‘inputs’ of drought, recent precipitation levels, temperature, relative humidity and wind speed. The FFDI is calculated on the basis of a normative fuel load.3 5.4 The GFDI is calculated using the ‘inputs’ of curing or fuel moisture, temperature, relative humidity and wind speed.4

Table 5.1: The FFDI and GFDI fire danger ratings

Ratings FFDI5 GFDI6

Low danger rating 0–4 0–2 Moderate danger rating 5–11 3–7 High danger rating 12–23 8–19 Very High danger rating 24–49 20–49 Extreme danger rating 50+ 50+

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.2], [237.5]7

5.5 The FFDI and the GFDI are together referred to as the fire danger index (FDI). The FDI was originally calculated on a scale of 0 to 100. As can be seen from Table 5.1, the fire danger rating of ‘Extreme’ corresponds to an FDI of 50 and above. The scales are effectively ‘capped’ at 100, though higher values are possible.8 As Dr Mark Williams, Regional Director, Victorian Regional Office of the BoM explained, the FDI was originally only designed to ‘go up to’ 100. Computing models now allow the FDI to exceed this.9 5.6 The declaration of a Total Fire Ban (TFB) day is a separate, though related, process.10 The Country Fire Authority (CFA) (following consultation with the BoM) generally declares a TFB for a day on which the forecast FDI exceeds 50.11 The declaration of a TFB is guided by, but not rigidly tied to, the FDI.12 The declaration of a TFB triggers statutory controls on activities that use heat and fire.13 5.7 Witnesses referred to the difficulty that arises because all days on which the FDI exceeds 50 are described as ‘Extreme’ fire danger days, yet there is a significant difference between a day with an FDI of 50, and a day on which the FDI is above 100 or even 200.14 Fire danger ratings do not distinguish between FDI values of 50, 200 or 300. The original work underpinning the development of the FDI has not been validated beyond the value of 100.15 5.8 The FDI forecast for 7 February 2009 exceeded 100 for most locations in Victoria.16 Accordingly, the fire danger rating for the day was ‘Extreme’, but in the view of many lay witnesses, this failed to convey the especially extreme nature of the fire danger risk for that day.17 156 Information

Table 5.2: Fire danger indices forecast for 7 February 2009

Location Forest Fire Danger Index Grass Fire Danger Index

Walpeup 148 190 Swan Hill Airport 159 210 Horsham Airport 137 178 Stawell 133 195 Ballarat Airport 185 330 Hamilton Airport 128 186 Mortlake 102 133 Bendigo Airport 142 186 Shepparton Airport 127 167 Mangalore Airport 131 171 Geelong Airport 129 167 Coldstream 142 186 Tullamarine 164 175 Dunns Hill 136 159 Wonthaggi 79 110 Albury-Wodonga 100 93 Wangaratta Airport 100 95 Hunters Hill 86 102 Latrobe Valley 133 175 East Sale Airport 112 129 Mount Moornapa 125 163 Orbost 84 29 Gelantipy 95 173 Falls Creek 56 126

FFDI/GFDI between 0–50 FFDI/GFDI between 101–150 FFDI/GFDI between 51–100 FFDI/GFDI above 151

Source: Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 006918

Note: The locations are listed generally from west to east of the state.

5.9 Expert witnesses expressed interest in reviewing the FDI, the language of the fire danger ratings or developing some other index to predict the potential for a fire to cause damage. For example, Dr Williams accepted that it was time to revise the FDI for indices greater than 100. He said that it was ‘clearly a research project that would have to be done with all the parties involved’. He proposed that the Bushfire Cooperative Research Centre (Bushfire CRC) might be involved in such work.19 5.10 Professor John Handmer, Innovation Professor in Risk and Sustainability and Director of the Centre for Risk and Community Safety at RMIT University, suggested that we need to find a way of reflecting a gradation above 50 or even above 100: ‘Some extreme level. At the moment I think we don’t have a way of institutionalising responses for a very extreme fire risk’.20 He said that further research and work was required by the fire behaviour specialists to devise a scale to deal with very extreme fires.21 157 2009 Victorian Bushfires Royal Commission—Interim Report

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5.11 Expert witnesses agreed that current FDI scales provide insufficient information on the severity of fires, and they highlighted the importance of revisiting the FDI and the related fire danger ratings.22 The indices and ratings need to be enhanced to reflect a meaningful set of numbers and language to express fire danger ratings above the present FDI 50+ (Extreme) category. This would assist in informing and educating the community about the graduated degree of risk on days when the FDI exceeds 50. 5.12 A revised FDI that retains its purpose as an operational tool, indicating the level of fire risk and the difficulty of suppression, could also provide the community with a more objective indicator of potential fire intensity. 5.13 The Commonwealth agreed that research should be undertaken to explore the option of including an additional fire danger rating beyond ‘Extreme’.23 The Commonwealth noted, however, that this would require careful consideration because, presently, FDI values above 100 are not supported by fire suppression research. This is accepted, and it is assumed that the validity of values over 100 would be considered in the proposed research. 5.14 In its written submissions, the State also supported this proposal. It suggested it would, however, await the outcomes of a reconsideration of the FFDI and GFDI being undertaken by the Australasian Fire and Emergency Service Authorities Council (AFAC) before implementing any Commission recommendations on this issue.24 The work of AFAC, to which reference was made by Ms Jillian Edwards, pertains to a new approach to bushfire warnings, dealt with in Chapter 4 of this report.25 5.15 In supporting the proposed recommendation AFAC suggested that it, the Bushfire CRC and the BoM be included in the parties that could explore the options for revisiting the fire danger ratings.26 Given that the Bushfire CRC, the CSIRO and a number of universities are potential recipients of research funds for this work, the Commission makes no recommendation on which body should be invited to undertake this research.

RECOMMENDATION 5.1

The Australasian Fire and Emergency Service Authorities Council and the Bureau of Meteorology collaborate with researchers to explore options for the fire danger indices and fire danger ratings including:

■■ an additional fire danger rating beyond ‘Extreme’;

■■ adjusting the existing fire danger ratings to correspond to higher Fire Danger Index values; and

■■ developing a revised fire severity scale for use in bushfire warnings based on new fire danger ratings.

Making the FDI Available to the Public 5.16 The BoM issues the FDI every afternoon for a selection of locations in each forecast district. When a rating of 50 or more is forecast at two or more locations, the BoM issues a Fire Weather Warning for that district after consulting with the CFA and the Department of Sustainability and Environment (DSE).27 5.17 The BoM makes the FDI available to the public, but only in the fire weather forecasts posted to the BoM website on the afternoon before the day in question.28 The FDI is not included in the general weather forecasts posted on the BoM website or in material distributed to the media. Dr Williams accepted that if people knew where to look they could have accessed information about the FDI late on Friday, 6 February 2009 on the BoM website, but there was no general broadcast by the BoM of the FDI for 7 February.29 5.18 Dr Williams was asked whether there was any reason why the FFDI and GFDI could not be provided with future general forecasts issued by the BoM.

Well, that’s an interesting question. It could be. I guess my concern is that I don’t know how well they would be understood. People like numbers and obviously the higher the number, the more extreme the fire danger index is. It is there for the 24 hour forecast so I suppose they could be made available for longer periods. We calculate them routinely, we do them every day.30 158 Information

5.19 It does appear to be the case, as Dr Williams puts it, that ‘people like numbers’. The BoM is an extraordinarily popular site — one of the most popular in Australia.31 The site received 75 million hits on 7 February, which compares with a daily average number of approximately 44 million hits.32 This provides some indication of the level of public interest in the weather forecasts and fire information the BoM is able to provide. 5.20 A number of lay witnesses expressed a desire to have the FDI published more widely and for it to be more readily available. Typical of these views was Ms Jesse Odgers of Kinglake, who said:

I feel the information is absolutely essential and I would like to educate myself more as to better understand what those indexes mean because they are going to assist me in making a more informed choice about when to leave. It assists me in that somebody external to me who is educated and experienced in fire is going to be able to give me an external assessment as to the danger other than a broad message such as that it is a total fire ban day or it is a day of extreme fire danger. So the more information that we can receive the more informed we will be and the more informed choices we can make.33

5.21 Mr Ken Rogers of St Andrews noted that he was surprised after the fires to learn that a fire severity index exists and felt that information about such an index would have helped him to decide whether to stay or go.34 Mr David Brown of Strathewen also expressed a desire to have had access to the information that the FDI was forecast to be in excess of 100 in his area.35 He said that it would be a very graphic way of demonstrating the level of potential risk:

When you have an index that normally runs from nought to 100 as its top end and it was registering 328, that is a very graphic illustration of the seriousness of the potential event and I think that would have been quite easy for people to understand …36

5.22 Dr Chris Harvey of Kinglake expressed a similar view that the FDI should be more readily available to the public, and accompanied by education about its meaning.37 5.23 Ms Karen Ward of Mudgegonga also said that had she ‘known how high the fire danger index was for that day,’ she would have left as soon as she knew of a fire in the area, because she would have known ‘how bad the fire was going to be’.38 5.24 It therefore appears that in times of fire threat, the public has a strong desire for fire knowledge and information. It appears likely that there are as many in the community who prefer to have access to FDI figures, as there are those who find language such as high or extreme helpful and it would, therefore, assist the public to have ready access to the FDI. 5.25 When asked whether there was any reason why the FDI is not provided to the community by the CFA with the other information provided about bushfires, Mr Russell Rees, Chief Officer, CFA, responded:

Only in the sense that to understand those figures ... you need to understand what they mean so there needs to be an educative process and the language of low, moderate to extreme, high extreme is the language that is considered best to explain that scenario. If we move to explain those numbers it is a bit like using the UV index. If I say, ‘the UV index today is 35’ what does that mean to you and I? But if I said, ‘it is extreme today’, the chances are we would take action and put sunscreen on.39

5.26 But Mr Rees accepted that if one provided the FDI in conjunction with ‘the words as well’ this ‘would be fine’.40 5.27 In relation to Mr Rees’ concerns that some may not understand the index figures, it is expected that the FDI would be provided in combination with the fire danger rating descriptors. In short, the numbers and words would be provided together. Of course, it is also desirable that information be available to the public about the meaning of both these resources. 5.28 The FDI should be placed in easily accessible publicly available material, along with the fire danger rating, to increase the prospect that the message is understood by the widest possible sector of the community, including those who ‘like numbers’ and those who find language more comprehensible.

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5.29 In their submissions, Counsel Assisting proposed that the FDI ought to be published and more readily available to the community to assist individuals to assess the level of bushfire risk on particular days.41 5.30 The State agreed in principle with this recommendation, but said it did not intend to implement it until it had had the opportunity to examine the outcome of AFAC’s consideration of this issue.42 The Commonwealth supported the proposed recommendation, but indicated it wanted to consult with the fire agencies before deciding on the best way of providing the FDI to the public.43 AFAC endorsed the proposed recommendation, but called for an accompanying national public education campaign.44 5.31 This is a simple matter, but one worthy of immediate action, to ensure that the FDI is readily available to the public. Drawing on the comments of Mr Rees, it would be desirable for the FDI and the revised fire danger rating to be as well publicised and as well known as the UV rating. To that end, the FDI should be included in fire weather warnings and general weather forecasts to promote the visibility of this tool in predicting fire danger.

RECOMMENDATION 5.2

The Bureau of Meteorology include the Forest Fire Danger Index and the Grass Fire Danger Index in its fire weather warnings and general weather forecasts on its website and in material distributed to the media.

Building A Single, multi-agency bushfire information website for Victoria 5.32 The CFA and DSE maintain separate websites. Mr Rees explained that the State Information Desk at the Integrated Emergency Coordination Centre (iECC) currently publishes information on the CFA website, based on information received from Incident Control Centres (ICCs) in the field.45 Mr Ewan Waller, Chief Fire Officer, DSE, described the DSE website as providing ‘rapid access to critical incident updates, map based information, warnings and other related information’. He said the DSE website had evolved to meet ‘rapidly increasing public demand’.46 5.33 Members of the public rely on fire agency websites for accurate and up-to-date information about fires in their area. A number of lay witnesses attested to seeking information from websites.47 On 7 February, ABC staff also monitored the CFA and DSE websites as one of the sources of information available to them.48 The Victorian Bushfire Information Line (VBIL) staff also relied on the websites.49 5.34 The public reliance on websites was reflected in the interviews analysed for the purposes of the Bushfire CRC Victorian 2009 Bushfire Research Response Interim Report (June 2009). The preliminary analysis in that interim report noted that, ‘many interviewees sought information from the CFA and DSE websites ... There were no positive references to the websites. There were several negative evaluations of both websites’. Information on the sites lagged behind fire events.50 5.35 Professor Handmer provided expert opinion on the use of websites to gain information about fire risk and location. He expressed the view that ‘web based material has become the primary source of information in our society, both official and unofficial’.51 He noted, however, that websites are often unreliable under heavy demand.52 Professor Handmer stated that the public should have access to one website with the relevant information but, to reduce overload, there may be more than one site with identical content.53 5.36 Several witnesses agreed with the need for a single website. For example, Mr Alexander Caughey, Community Education Coordinator for the CFA, agreed there should be one site.54 5.37 Ms Kathryn Venters, Manager of Customer Service at DSE (based at the VBIL Customer Service Centre), also expressed the view that VBIL staff find it confusing to have to consult two agency websites, and said it would be a great advantage to have a single website.55 160 Information

5.38 Counsel Assisting has proposed the development of a single, multi-agency website to publish bushfire information in Victoria. This need was identified some time ago in the July 2006 report, Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media During Fire Incidents — Preliminary Findings (the Joint CFA/DSE Information Review) where the following findings and recommendations were made:

Along with the VBIL, the websites are a powerful tool for the dissemination of accurate and timely information directly to the community. The growing importance of the website can be measured by the fact that CFA’s website was recording in excess of 100 new users per minute during peak times in January 2006. The CFA’s website eventually encountered serious overloading to the point where it could not be accessed at some times. This created credibility problems; having created an expectation that information will be available it is imperative that this can be met …

It would appear that there is a degree of duplication in the website presentations of both agencies. These sites have evolved over time to serve different purposes. They continue to serve a multitude of purposes and are aimed at multiple audiences.

It also seems clear that there will be increasing demand for web-based information. Given the efficiency of such distribution and its capacity to deal with routine as well as urgent messages and information, the further development of web-based information should be treated as a priority … the prospect of permitting for web updates from IMT [Incident Management Team] or RECC [Regional Emergency Coordination Centre] level is worthy of consideration.

Recommendation: Ensure websites have sufficient technical capacity to deal with public demand during peak periods.

Recommendation: That the possibility of web messages being authorised or uploaded from IMT or RECC level be examined.

Recommendation: That the creation of a single, multi-agency bushfire information website for Victoria be considered.56

5.39 The findings and recommendations made above are strikingly similar to those now recommended. In particular, concerns about website capacity, the speed with which material is posted to the site and the desirability of a single website all received detailed and careful attention in the Joint CFA/DSE Information Review. When asked why the recommendation on a single website had not been implemented since July 2006, Mr Rees said:

… I can’t answer you why not except to say that it was a project that was started following a review in 06–07 to create one website. Whether it failed due to a lack of funding, the clear objective we had was that we in CFA reached a view that ... two changes needed to happen as we moved forward towards this one website. The first was that the CFA adopted the CAP [Common Alerting Protocol] as part of the AFAC recommendation ... the other thing we were looking forward to was the standardisation of message through the electronic telephone type message system. So we were looking to make the change all at once. I think the one website is a weakness. It is simply a case that we haven’t got there yet.57

5.40 These comments do not fully explain the failure to implement the single website by February 2009. 5.41 Mr Rees said in his statement that the CFA and DSE were presently engaged in a project designed to develop ‘one website for the display of fire emergency information. It is envisaged the website will provide a simple summary of the information from the CFA and DSE websites on a single map of Victoria using common terminology to describe the fires’.58 Mr Waller also referred to a current project to have ‘one website and I would very much welcome that, and a very quick website’.59 5.42 The State accepted the proposed recommendation for a single website, but in its written submissions proposed that the CFA would be promoted as the official bushfire website, with the DSE site remaining available to ‘ease capacity constraints’ and for individuals who wish to continue using that site. To ensure consistency, the State proposed that behind the scenes there would be a single website with single data entry and ‘same time’ uploads to both the CFA and DSE websites.60 This suggestion of a principal and subsidiary website is arguably a little different from the evidence already given by Mr Rees concerning the project he attested was underway. 161 2009 Victorian Bushfires Royal Commission—Interim Report

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5.43 In any event, the development and promotion of a single multi-agency website is essential. If the DSE site simply mirrors the CFA site and is provided to ease demand, this appears sensible, assuming identical information is posted and updated to both sites simultaneously. But the continued maintenance of separate sites, with the potential for separate information, is unlikely to be as useful. 5.44 The creation of a single website would enable information dissemination and receipt to be streamlined, would eliminate confusion, and would prevent possibly contradictory information being placed on more than one site. Further, the promotion of a ‘one stop shop’ website is likely to relieve demand on other services, including the VBIL and even Triple Zero. 5.45 Ultimately, consideration should also be given to the creation of one ‘brand’ for bushfire information and warnings. There is potential confusion in the use of both the CFA and the VBIL as sources of bushfire warnings and information. But for the purposes of the interim report, the recommendation concerns only the creation of a single multi-agency portal which would permit a single data entry point to be used to upload the same bushfire information to multiple websites at once, in time for the next bushfire season.

RECOMMENDATION 5.3

The State ensure that a single, multi-agency portal for bushfire information be established that uploads information simultaneously to both CFA and DSE websites.

EXTREME DEMAND and delays in posting information on Agency WEbsites 5.46 The agencies’ websites experienced difficulties on 7 February. There is evidence of delays in information being posted to the CFA and DSE websites, particularly for the Kilmore East fire, and of information being double-handled. The delays associated with the Kilmore East fire are addressed in more detail in Chapter 9. 5.47 Ms Samantha Stayner, Acting Program Director, 774 ABC Radio, noted that on 7 February the CFA and DSE websites often lagged behind information the ABC was receiving from the emergency services.61 5.48 To reduce delays in the posting of information onto websites, there should be capacity for ICCs to upload bushfire information and bushfire warnings directly to the new single multi-agency website. This would reduce the need to disseminate material. If this approach is adopted, in combination with sensible protocols, it is likely to increase the speed with which such material can be publicly displayed. The Joint CFA/DSE Information Review also suggested this. 5.49 In its written submissions, the State indicated that it is exploring the technical capacity required for ICCs to upload data to the website.62 This is a very positive development. 5.50 It appears that the agencies’ websites also slowed down due to the extreme levels of demand.63 Professor Handmer referred to ways of reducing the risk of the website malfunctioning or ceasing to function on days of extreme demand. These included using different display modes so more users can access the site quickly — for example, placing some of the key information on fixed rather than interactive pages, which reduces the time taken to deal with particular queries.64 Graphics and logos can also ‘slow down’ web pages, so there is the option of going to ‘text only’ during periods of high demand.65 Professor Handmer gave the example of the British Commonwealth and Home Office websites, which, during extremely high demand following the tsunami, switched to a ‘text only’ service to reduce the memory being used on the site, enabling the site to handle more inquiries or ‘hits’.66 In addition, page design could be altered to speed up access, or information could be fed to other sites like Twitter to relieve demand.67 This happened to an extent on 7 February with the ABC’s use of a Twitter site.68

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5.51 The BoM website has been designed to carry extremely high levels of traffic.69 Though the information maintained on the BoM website is different from that regularly accessed on the fire agencies’ websites, it provides a useful model for the way in which a site can be designed to increase its functionality and accessibility during periods of peak demand. Steps, such as those referred to above, should be taken to preserve the functionality of a single website during periods of extreme demand. 5.52 The Commission is of the view that the bushfire information website should provide timely, accurate and up-to-date warnings and information that is posted by the fire agencies. This needs to be consistent with information being delivered through other means including the VBIL and ABC Radio. The website needs to be functional during periods of high demand and communicate simply text and visual information.

RECOMMENDATION 5.4

The State ensure that the single multi-agency portal for bushfire information be designed to allow Incident Control Centres to directly post information and warnings.

The Victorian Bushfire Information Line

Operations and funding of the vbil 5.53 The VBIL was established in 2003 by the CFA. It first operated during bushfire season 2003–04.70 From 2004, the VBIL operated with the CFA and DSE as joint stakeholders. The Department of Human Services and the Department of Primary Industries (DPI) are now also stakeholders, predominantly in the areas of health and recovery following bushfires.71 The VBIL operates out of a Customer Service Centre (CSC) in Wendouree, Ballarat.72 The VBIL service provided by the CSC gives information to the public via telephone, email, fax and TTY (textphone/telewriter for the speech and hearing impaired).73 5.54 The CSC is funded from a contribution from DSE and DPI for core business and a fee per customer contact during campaigns, funded by the relevant stakeholder. The VBIL service is funded equally by the CFA and DSE. When one agency generates a particular campaign, that agency pays for the VBIL service.74 5.55 The CSC’s base funding for 2008–09 was approximately $1 million from DSE and $550,000 from DPI. VBIL stakeholders were charged campaign fees of approximately $1.3 million from 1 November 2008 to 30 March 2009.75 Campaign fees for 7 February 2009 were $36,350.76 5.56 The VBIL provides information to the public on major bushfires; bushfire safety messages; community meetings; Emergency Relief Centre locations; bushfire recovery; TFB days and fire restrictions; DSE fuel reduction burns and other planned burns; annual DSE fire planning; and community consultations.77 The VBIL is promoted on the CFA and DSE websites and in promotional material distributed by both fire agencies.78 The average call handling time for a VBIL call is six to seven minutes.79 5.57 The VBIL does not report fires, liaise with the Emergency Services Telecommunications Authority or Telstra Triple Zero, or play a role in dispatching emergency services to fires.80 5.58 VBIL staff are recruited by the CSC, with an emphasis on staff with ‘good active listening and question-framing skills’.81 Training is delivered onsite by DSE staff.82 Staff have access to Google maps and VicRoads materials to locate towns and suburbs.83 5.59 There is a Service Level Agreement between the CSC, DSE and the CFA: Victorian Bushfire Information Line Service Level Agreement 2008/2009.84 The Service Level Agreement contains requirements on staffing and reporting. The staffing levels are set in the Agreement by reference to ‘Readiness Levels’. For example, ‘Readiness Level Red’ (referred to as code red) corresponds to FDI forecasts in excess of 50, or when a major fire (or a number of smaller fires) is burning. On these days, the Agreement requires that the VBIL operate extended hours, with the potential for 24/7 hours of operation. It also requires that between 11 and 20 call takers be working on shift.85 163 2009 Victorian Bushfires Royal Commission—Interim Report

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5.60 The VBIL is available all year round, operating during the core hours between 8:00am and 8:00pm on business days. The CSC is able to activate surge capacity within two hours of notification by a State Duty Officer or the iECC Information Unit.86

VBIL ARRANGEMENTS WITH CENTRELINK 5.61 Centrelink has 25 networked call centres around Australia, which deliver information and assistance about government services and payments. Centrelink call centres answer approximately 100,000 calls a day. Centrelink maintains a 24 hour a day, seven day a week standby capacity at its Geelong call centre. It is also able to call on other centres to provide emergency call centre services, subject to limits on access to relevant information about the emergency.87 5.62 Centrelink operates an overflow service to the VBIL whereby specially-trained Centrelink operators can answer VBIL calls at times of peak demand.88 5.63 DSE and Centrelink are parties to a Memorandum of Understanding (MOU).89 The MOU includes the following:

■■ Parties will use best endeavours to provide each other with information (Clause 7.1.3).

■■ Centrelink staff will record information on the calls received (Services Schedule – Clause 3.1.1(g)).

■■ Centrelink is required to provide daily reporting on the numbers of calls received, numbers of calls abandoned, average speed of answer and average handling time (Services Schedule – Clause 3.2.1(d)).

■■ DSE is required to provide Centrelink with the necessary scripts and information to allow its staff to properly answer calls (Services Schedule – Clause 3.3.1(d)).

■■ Centrelink is required to ensure its staff provide callers with information in accordance with the scripts and information supplied by DSE (Services Schedule – Clause 3.3.1(d)). 5.64 Under the MOU, the VBIL provides Centrelink with all necessary scripts and other information required to answer callers’ questions, including secure remote access tokens that enable Centrelink operators to log in directly to the VBIL database.90 5.65 The overflow arrangement is activated by a specific request from the VBIL to Centrelink.91 The MOU’s timeframes for activating ‘overflow’ are conservative. The MOU’s terms allow six or seven hours between a request to activate the overflow and the service commencing.92 But the evidence was that, in reality, there is usually a reasonably rapid activation of the arrangement.93 5.66 Centrelink’s capacity to assist by activating the VBIL overflow is clear. However, there were problems with the outcomes on 7 February. The reasons for these problems are discussed below.

VBIL Call taking parameters and resouRces 5.67 As at 7 February, there were 90 telephone lines into the VBIL call centre.94 There was one queue for calls into the VBIL and no priority was given to different calls — although a VBIL call was answered before general enquiry line calls for DSE and DPI. The general enquiry line was not open on Saturday 7 February.95 5.68 The VBIL call-taking system, as it operated on 7 February, had the following characteristics:

■■ When there was no available line (that is when more than 90 callers rang in at the same time), the caller heard a recorded message informing them that the VBIL was not able to take the call due to high demand, and referred them to Triple Zero or the CFA and DSE websites.96

■■ When there were, at any one time, more than 90 callers attempting to get through to the VBIL, there was no capacity for those callers to be placed ‘on hold’ — as a result, callers who did not ‘get a line’ were not counted in the VBIL’s count of calls abandoned on 7 February.97

■■ When the number of callers to the VBIL exceeded 90 at any one time, the system of overflow calls to Centrelink (see below) could not operate. As a result, those callers could not wait either for a VBIL or Centrelink operator to take their call and, again, the call was not counted in the statistics on abandoned calls.98

■■ When a call overflowed to Centrelink, two of the VBIL’s lines were occupied for the duration of the call — 164 as one line into the VBIL and one line out to Centrelink.99 Information

5.69 The technical and physical limitations of the VBIL system on 7 February contributed to the difficulties callers had getting through to the service. Since the fires, the VBIL has increased the total number of available phone lines to the centre to 210. Sixty of these lines are outgoing lines only, to enable calls to be transferred to Centrelink during overflow periods.100

VBIL WORKSTATIONS AND STAFFING 5.70 On 7 February, there were 20 work stations available at the VBIL for use by call takers. At no stage on the day were all those work stations in use.101 5.71 These work stations apparently comprise simple desks, with phones, headsets and computers. At present, there is no funding for additional work stations, although Ms Venters indicated that consideration was being given to refitting the centre and to new funding arrangements in the next Service Level Agreement.102 5.72 As at 7 February, the VBIL staffing was as follows:

■■ 15 ongoing or fixed-term staff employed by DSE — 13 full-time and two part-time

■■ 35 DSE casuals, able to take all types of calls received at the CSC

■■ 17 DSE casuals trained only to take the VBIL calls received at the CSC.103 5.73 Ms Venters explained that on a typical weekday at the VBIL, operating normal hours, 70 call taker hours would be rostered. On a typical Saturday, operating normal hours, between 32 and 40 call taker hours would be rostered. On a typical summer day, on which high temperatures are forecast, closer to 140 call taker hours would be rostered. On a code red day, Ms Venters said that the number of staff to be rostered is determined by the Service Level Agreement. As is noted above, this requires that between 11 and 20 call takers be rostered.104

PROVISION OF INFORMATION TO THE VBIL AND CREATION OF FAQS 5.74 The VBIL Call Centre staff are supplied with Frequently Asked Questions (FAQs), which they are required to use when answering particular categories of questions from callers.105 5.75 The process intended to operate at the VBIL during fires is that awareness, alert and urgent threat messages are supplied by the CFA and DSE to the VBIL call centre. The Information Officer at the VBIL monitors email, checking for information received from the fire agencies. The Information Officer processes authorised information from the fire agencies and turns it into FAQs used by call takers to answer queries.106 5.76 All VBIL calls are answered using the FAQ database. Two main responses are used when callers have queries relating to fires:

■■ The general FAQs are used when a fire is not known or there is no specific current fire FAQ for a particular fire — in that instance, for example, if a caller says they can see smoke or flames in their area, the call is dealt with by the call taker reading out the information in the Smoke and Fire FAQ.107

■■ Where a fire is already ‘known’ to the VBIL and a specific FAQ has been prepared for that fire, based on information provided by an ICC or the iECC, the call taker provides the caller with information drawn from the specific FAQ.108 5.77 If the fire reported by a caller is not known, the VBIL call takers are trained to search the external CFA and DSE websites for information on the fire. If such information appears on the fire agencies’ websites, this is read to the caller. Standard safety messages (from the general FAQs) are also conveyed to the caller, if appropriate. If there is no information about the fire in a FAQ or on the CFA or DSE websites or a caller is reporting seeing flames, or is concerned about the amount of smoke, they are advised to hang up and ring Triple Zero.109 The protocol requires that once the call taker has concluded a call with a caller who has reported flames or smoke in relation to an unknown fire, the call is escalated via the Duty Officer to the iECC within 15 minutes.

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5.78 If, after information from the FAQ on a known fire has been provided to the caller, the caller reports that the information does not correspond with their experience, or the situation in their area has escalated and they feel immediately threatened, they are advised to ring Triple Zero. Again, once such a caller has terminated the call, the call taker escalates the call to the iECC.110 Alternatively, if the caller does not feel immediately threatened, but does require more information urgently, their details are taken and their query is escalated to the iECC within 15 minutes by phone, and a copy of their request is sent by email. When further information is received from the iECC, it is relayed in a return phone call to the caller, if time permits.111 5.79 The process of escalation was undertaken on a number of occasions on 7 February, but was not always able to be completed in a timely fashion, or at all, given the extreme demands on call takers and all staff on the day.112

VBIL PLANS FOR 7 FEBRUARY 2009 5.80 In preparation for 7 February, the VBIL Duty Officers monitored the information on Fire Web for updates on weather conditions. Daily iECC briefings were also reviewed to keep up to date on forecast conditions that might trigger increased calls to the VBIL. Over the course of the week prior to 7 February, it became clear that the weekend would be one of extremely high fire danger.113 5.81 Plans were put in place to have the VBIL resourced to its highest levels ever for a TFB day.114 Ms Venters met with the VBIL Duty Officers on 5 or 6 February to discuss strategies for the weekend, including contingency plans for resourcing, logistics and IT support, and related issues.115 5.82 There is no specific requirement that the VBIL provide Centrelink with advance notice when it is expecting days of peak demand.116 Prior to 7 February, Centrelink received a situation report from DHS regarding the heatwave and an informal email that indicated that Victoria was expecting a high fire danger day on 7 February.117 The VBIL did not formally notify Centrelink that its overflow services were likely to be required.118 5.83 On the morning of 7 February, Ms Christine Millington, Manager Customer Liaison and Education DSE and Duty Officer at the CSC on 7 February, reviewed and updated the process for activation of overflow arrangements with Centrelink.119

VBIL Staffing on 7 February 2009 5.84 During the course of 7 February 45 staff worked at the VBIL call centre in Ballarat, comprising 33 operators and 12 administrative staff and team leaders.120 5.85 However, perusal of the roster for 7 February demonstrates that at times, including during peak periods in the afternoon and early evening, the number of call takers who were working dropped below 11. Between 2:45pm and 3:15pm, for example, the number of staff taking calls dropped to as low as nine. This is less than the minimum level of 11 call takers required on a code red day under the VBIL’s Service Level Agreement with DSE.121 5.86 It is difficult to understand why that on a code red day, in light of the information available in the preceding week about the extreme weather forecast, the VBIL did not roster closer to the top of the 11 to 20 range for call takers. 5.87 Centrelink had shifts in place with up to 26 staff at various times of the day available to take calls from the VBIL.122

The events of 7 February 2009 at the VBIL and Centrelink 5.88 Unfortunately, the events of 7 February, despite the best efforts and goodwill of those involved at the VBIL and Centrelink, unfolded as a sequence of errors. 5.89 The CSC opened at 6:00am. Ms Millington, Duty Officer for the VBIL, recorded a ‘call spike’ in her log book at 9:00am and increasing activity, including further call spikes, from that time.123

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5.90 At approximately 12:47pm, Ms Millington contacted Centrelink Telephony Network Support requesting that they commence taking the VBIL overflow calls. Initially, Centrelink expressed hesitation about its capacity to assist, as its staff were already taking increased volumes of calls due to the flooding in Queensland.124 5.91 At approximately 1:05pm, Centrelink advised that it would activate the overflow arrangements, and contacted its Geelong call centre and directed it to prepare for activation.125 5.92 At 2:10pm, DSE informed Centrelink it needed to activate overflow arrangements immediately, rather than within the timeframes provided for in the MOU. Ms Tracey Tozer, Business Manager Telephony Network Support, Centrelink, informed the Team Leader at the Geelong call centre to activate three experienced staff immediately.126 Ms Millington manually directed the VBIL overflow to Centrelink at 2:16pm. At 2:18pm the overflow was halted. Ms Millington said this was done because it was discovered Centrelink was not able to access the VBIL database and a request came from Centrelink to halt the activation.127 The evidence from Centrelink suggested that the request may only have been to alter the parameters for the overflow. In any event, the function was turned off.128 5.93 It transpired that, as a result of Centrelink conducting a technology systems upgrade a few days prior to 7 February, Centrelink operators were ‘locked out’ of the DSE database.129 Centrelink’s practice was to test its remote access capabilities once a week and the access problem caused by the system upgrade was not detected until the VBIL requested that Centrelink activate its overflow capacity.130 5.94 With the exception of a few calls received between 2:16pm and 2:18pm, Centrelink operators did not begin answering the VBIL calls until approximately 5:25pm. To overcome the difficulty caused by Centrelink staff being unable to access the VBIL database, information was provided to Centrelink by fax but not before 5:25pm, at which time the overflow to Centrelink recommenced.131 Ms Venters did not know why it took two hours to commence sending information by fax.132 5.95 Shortly thereafter, the fax machine at the Ballarat Centrelink Centre broke down. This necessitated a manager from the Ballarat Centrelink office visiting the VBIL CSC to physically convey the documents back to Centrelink.133 5.96 Ms Carolyn Hogg, Deputy Chief Executive Officer, Centrelink, explained that Centrelink now tests its systems more regularly and accepted that it should have tested its systems after the upgrade.134

TIMELY PROVISION OF INFORMATION TO THE CALL CENTRE AND TO VBIL STAFF 5.97 Information on current fires is provided to the VBIL by ICCs. The material usually comes directly from ICCs or the iECC, by email or, less often, by fax or telephone. When received, the information is used to create a new FAQ, using a template (paragraph 5.74). 5.98 Once an FAQ is complete, it is published on the FAQ database. Call takers are informed by email or verbally that a new FAQ is available. FAQs are intended to be created by the CSC Information Unit as soon as practicable after their receipt. The process usually involves copying the information over without retyping. It is difficult therefore to understand why there were, on occasions, lengthy delays between the provision of information to the VBIL and the creation of FAQs.135 5.99 Generally, the time required to circulate new and updated FAQs is between 30 minutes and an hour, depending on the complexity of the information and the number of other incidents being reported. There may also be a need to clarify or verify information.136 5.100 The system did not work perfectly on 7 February. On a number of occasions information was slow to reach the VBIL or slow to be disseminated within the VBIL, or both. Table 5.3 summarises the evidence on the timeframes during which information was made available on 7 February.

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Table 5.3: Timeframes for making information available through the VBIL

FAQ created for new fire campaign First warning provided to distributed Fire Ignition time the VBIL to VBIL staff Findings137

Kilmore East 11:49am138 3:25pm [four messages, one 4:19pm140 Messages not supplied to the VBIL alert and three urgent threat until 3.25pm under the title ‘Catch‑up attached to one email]139 messages, Kilmore … fire’. This lagged over three and half hours behind the time of ignition of this fire. The FAQ was created nearly one hour after its receipt at the VBIL, adding to the delay. Horsham 12:26pm141 12:46pm [urgent threat]142 1:25pm143 The FAQ was created within approximately 30 minutes of receipt of the message. Coleraine 12:36pm144 1:15pm [urgent threat]145 1:46pm146 The FAQ was created within approximately 30 minutes of receipt of the message. Pomborneit– 1:17pm147 2:03pm [urgent threat]148 2:47pm149 The FAQ was created within Weerite approximately 45 minutes of receipt (known earlier of the message. in day as Camperdown– Danedite Rd fire) Churchill– 1:33pm150 2:07pm [urgent threat]151 3:01pm152 The FAQ was not prepared for Glendonald approximately one hour after receipt Rd Fire of the message. Murrindindi 3:00pm153 3:49pm [awareness]154 4:58pm156 The FAQ was not prepared for 4:46pm [urgent threat]155 approximately one hour after receipt of the message. Redesdale 3:11pm157 3:40pm [awareness message]158 4:45pm160 The FAQ was not prepared for 3:57pm [urgent threat]159 approximately one hour after receipt of the message. Narre Warren– 3:32pm161 6:44pm [alert]162 8:47pm164 The FAQ was not prepared for Crawley Rd 8.28pm [urgent threat]163 approximately two hours after receipt of the message. Bendigo 4:34pm165 5:02pm [awareness]166 5:35pm168 The FAQ was created within 9:15pm [urgent threat]167 approximately 30 minutes. Beechworth 6:09pm169 7:05pm [urgent threat]170 7:44pm171 The message was not supplied until approximately one hour after ignition. The FAQ was not prepared for approximately 45 minutes.

Source: Statements of Ms Venters, Mr Rees, Mr Caughey and Mr Waller and tenders and oral evidence of Ms Venters172

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5.101 Table 5.3 indicates that on some occasions on 7 February, short periods elapsed between the ignition of fires, provision of warning messages by the CFA or DSE to the VBIL, and creation of relevant FAQs. However, on other occasions, there were significant delays. The FAQ for the Kilmore East fire was not created for the VBIL staff until 4:19pm. This is despite the fact that Ms Millington’s log reveals that at 12:39pm on 7 February, she contacted Ms Henshaw of the CFA Information Unit to report that the VBIL had received calls about the Kilmore East fire, which was not yet on the CFA website. Ms Henshaw, who had access to the Incident Management System live feeds concerning fire information was able to supply Ms Millington with some information about the fire and indicated that further information would be available. Nevertheless, messages were not supplied to the VBIL until 3:25pm and the FAQ was not created until 4:19pm.173 5.102 Ms Venters said the different time frames may be explained by virtue of the fact that the Horsham and Coleraine fires were earlier in the day, and during a period when less information was being received at the CSC.174 She said it was also a case of people having to ‘process an immense amount of information’.175

VBIL Calls answered and abandoned on 7 february 2009 5.103 The VBIL experienced unprecedented demand — 12,846 calls were presented to the VBIL from 6:00am to midnight on 7 February. This compares with 2981 calls on 10 January 2009 (during the Delburn fires) and 2544 calls on 11 January 2007 (during the Great Divide fires).176 5.104 The statistics for the VBIL’s performance on 7 February reveal that the CSC fell well short of its performance benchmarks.177 There were high numbers of calls abandoned. Of the 12,846 calls made to the VBIL on 7 February:

■■ 731 calls were answered by the Interactive Voice Response (a recorded message service whereby callers can ‘self help’ by selecting options from a menu without the need to speak to an operator)

■■ 27 calls were made to the after-hours Interactive Voice Response service

■■ 902 calls were transferred to the overflow queue (Centrelink)

■■ 9879 callers entered the operator queue

■■ 1307 calls were terminated before entering the operator queue.178

5.105 Of the 9879 calls that were queued, waiting to speak with an operator, only 1754 were eventually answered and 8125 were terminated while the caller waited in the operator queue.179 5.106 Ms Venters said these figures demonstrated an abandonment rate of 82.2 per cent (8125 calls abandoned from the 9879 calls waiting to speak to an operator).180 The abandonment rate is even higher if the 1307 calls terminated by callers before they entered the queue are included. Of course, those callers may have terminated their calls by choice on hearing the recorded messages that the VBIL was experiencing heavy demand and that callers might instead ring Triple Zero or call back on another occasion. Further, this figure does not include callers who were unable to get a line because the number of people calling the VBIL call centre exceeded the 90 lines available. 5.107 There were also long delay times before calls were answered. The average wait time was 11 minutes 25 seconds. The longest recorded waiting time was 16 minutes and 22 seconds.181 5.108 Due to the technical difficulties on the day, the data on calls overflowed to Centrelink on 7 February is incomplete. Centrelink staff answering the VBIL calls would ordinarily log calls in a DSE database in the same way as the VBIL operators. Due to the failure of the remote access facility, Centrelink staff were unable to do so on 7 February.182 5.109 Other sources of data are also incomplete or inconsistent. Information on call levels for 7 February first supplied by Centrelink to the VBIL in April 2009 was incorrect.183 In June 2009, Centrelink obtained data from Telstra indicating that Centrelink received 117 overflow calls from the VBIL and answered 62 of these, but these figures are also incomplete as there were no statistics available after 9:00pm on 7 February.184 The VBIL has alternative data indicating that 902 calls were overflowed to Centrelink, but it was suggested in evidence that this could not be relied on either.185 169 2009 Victorian Bushfires Royal Commission—Interim Report

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5.110 Data from Centrelink’s national emergency database (which Centrelink staff filled out on 7 February, albeit not uniformly) shows that at least 124 calls were answered.186 5.111 Further, it has also come to light that Centrelink sought information from Telstra that might have enabled it to capture or recreate the relevant phone records. However, Telstra were unable to recreate the data, as it was not sought by Centrelink within 20 days, the normal period before records are destroyed.187 5.112 The data available on calls answered by Centrelink does not appear to match the recollections of staff as to the level of activity. The Team Leader on shift at the Geelong Centrelink call centre recalls that the calls were constant and staff were fully occupied.188 5.113 It is also not possible to determine accurately the abandonment rate of calls to Centrelink because of the doubts about the core statistics. However, taking one version of the Centrelink figures at face value (117 calls received and 62 answered), while noting the significant doubts about the accuracy of this material, the abandonment rate for calls overflowed to Centrelink on 7 February could have been as high as 47 per cent.189 The MOU requires at least 80 per cent of calls to be answered within 60 seconds.190 5.114 Staff at the VBIL call centre maintained logs of calls taken in the Centre.191 The call logs for 7 February reveal that the VBIL staff were placed under considerable pressure.192 The log reveals distressing examples of calls received from people in circumstances of significant danger and stress. Callers included people seeking advice about evacuation for themselves and relatives; young people at home without their parents; people desperately seeking information about the fate of loved ones; callers whose home was under ember attack; and people reporting fires very close to their homes anxiously seeking assistance or advice. Some callers were angry and frustrated about the lack of information.193 The VBIL staff were offered counselling in the aftermath of this difficult day.194 5.115 Witnesses attested to difficulties in reaching the VBIL and deficiencies in the information supplied by the service. Dr John Ferguson of Buxton called the VBIL five times, and when he got through eventually was placed on hold. He said the operator did not know where Buxton was and told him that there was a small grass fire in Murrindindi. He said this did not match his own observations about the threat at that time.195 Mrs Joan Davey attempted to call the VBIL, desperately seeking information about her son’s family and the fires at Kinglake. None of her calls were answered and she was placed on hold for up to two hours.196 Dr Lachlan Fraser of Marysville called the VBIL about the fire threat to Marysville. He was on hold for about 20 minutes, and when his call was answered, the operator had to look up where Marysville was.197 5.116 There appears to have been no way for VBIL staff to isolate the urgent from the non-urgent calls on the night, with the result that call takers were occupied with trivial requests at a time when they were also fielding calls from members of the public in life-threatening situations.198

VBIL Debriefs — past and present 5.117 The Joint CFA/DSE Information Review referred to in paragraph 5.38 also considered the VBIL’s performance. It made the following recommendations to address concerns about the speed of information flow, consistency of formatting, the demand on the system and the desirability of capturing valuable information from callers in fire affected areas:

That the protocols covering the forwarding of authorised information and the formats in which that information is presented be reviewed.

The use of recorded appropriate, updated messages by VBIL be examined as a method of dealing with caller demands.

The possibility for formal processing and use of intelligence gathered by VBIL as part of the information flow system be examined.199

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5.118 Some aspects of the recommendations made in 2006 have been implemented, but it is clear that speed of information flow remains a problem. Debriefs have been conducted with VBIL staff since the January– February 2009 fires. The report of the debriefs reveals that some of the same issues have been raised again. Call takers on 7 February reported the following concerns:

■■ FAQs were too large and difficult for operators to use

■■ operators were not provided with sufficient up-to-date information and the information that they did receive was sometimes unclear

■■ inconsistent naming of fires created confusion for operators

■■ there was a lack of well-trained, experienced call operators

■■ high stress levels due to the failure of the Centrelink overflow capability.200

5.119 The ability of the VBIL to offer a surge in capacity to meet extreme demand was severely hampered on 7 February due to physical constraints (numbers of phone lines and workstations) and staffing levels. 5.120 The State accepted Counsel Assisting’s proposed recommendation that more staff should be rostered on to answer calls during extreme events and that all endeavours should be made to produce FAQs and disseminate them to call takers as quickly as possible.201 5.121 The State indicated that it is considering expanding the VBIL to an ‘all hazards’ Victorian Emergency Information Line. In this context, it intends to examine the operations and procedures of the VBIL, including information technology, telephony and service standards, and protocols on receipt of information.202 Further information on these matters will be adduced in the subsequent hearings of the Commission. 5.122 The time frames for providing information to the VBIL and creating FAQs within the VBIL should be improved. Counsel Assisting proposed recommendations to improve the protocols for handling those links in the information chain. The State agreed improvements are necessary, but suggested that the focus ought to be on staff levels and the currency of information provided to the VBIL.203 5.123 To improve the activation of overflow arrangements with Centrelink, the Commonwealth proposed that DSE be obliged to provide formal advance warning of the potential activation of Centrelink overflow demand as soon as practicable, and that Centrelink and DSE share information about total call demand, overflow parameters to be employed, and the staffing capacity of both agencies.204

RECOMMENDATION 5.5

The State ensure the Victorian Bushfire Information Line is funded to enable it to provide greater surge capacity during extreme events and to improve the efficiency of its internal information function.

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Source: Simon Schulter, courtesy of The Age 172 RELOCATION 6 2009 Victorian Bushfires Royal Commission—Interim Report

6 RELOCATION

This chapter examines whether relocation should be compulsory and whether, given that late relocation is extremely dangerous, departure from an area under direct threat by bushfire should ever be recommended. These two issues are often confused: arguments around compulsory evacuation can slide into arguments around any form of planned or advised relocation. To avoid confusion the Commission has addressed these two issues separately. This chapter also considers who should be responsible for recommending and carrying out relocation, and where people should go.

INtroduction 6.1 Timely departure from an area threatened by bushfire is an integral part of the Prepare, Stay and Defend or Leave Early policy (‘stay or go’). Leaving early is one of the two key choices that the Country Fire Authority (CFA) advises people to make. Leaving early is also one of the most effective means of preserving life. As Community Fireguard facilitator Ms Serafina Munns attested: ‘The safest place to be during a bushfire is somewhere else’.1 6.2 Experience has shown that late departure can be deadly. Until 7 February 2009 most civilian deaths in bushfires in Australia occurred during late relocation.2 This fact underpins an extreme reluctance on the part of the CFA to recommend evacuation of an area threatened by fire. On 7 February, 22 people died in or near vehicles, on roadways or reserves, in locations that suggest they were trying to flee a fire.3 However, the great majority of those who died as a result of the fires died in houses.4 A fresh look at relocation as a life-saving measure is required.

the Terminology of evacuation 6.3 ‘Evacuation’ is a word used in Victoria’s emergency management arrangements: in the Emergency Management Act 1986 and the Emergency Management Manual Victoria (the Manual).5 Evacuation is defined in the Manual as:

… the planned relocation of persons from dangerous or potentially dangerous areas to safer areas and eventual return. It is a safety strategy which uses distance to separate the people from the danger created by the emergency.6

6.4 The law in Victoria does not support the compulsory evacuation of everyone in an area threatened in an emergency. The existing arrangements in Victoria contemplate that a decision to evacuate a dangerous area will be made voluntarily.7 This is consistent with the ‘stay or go’ position, under which residents are encouraged to decide for themselves whether they will stay and defend their home from a fire, or leave early. 6.5 Although evacuation is not mandatory in Victoria, the word has connotations of compulsion, of people being forced to leave their homes against their will. As the Australasian Fire and Emergency Service Authorities Council (AFAC) noted in its submission:

Evacuation is an emotive, urgent word. If the actual word ‘evacuation’ is used when communicating with the community, then it carries connotations of force and authority, i.e that you have to go and go now.8

6.6 In a similar vein, the State urged caution about using the word ‘evacuation’ in warnings because it may involve a perception of a more organised exercise than simply leaving early.9 6.7 These points are well made. AFAC suggested using the word ‘relocation’ rather than ‘evacuation’.10 As the title of this chapter indicates, the Commission has adopted that suggestion. The words ‘relocation’ and ‘relocate’ — or, more simply, ‘leave’ and ‘go’ — have been used in framing recommendations, and where it was the commonly understood terminology on 7 February. Further, it is recommended that the State Emergency Response Plan (SERP) use the word ‘relocation’ in preference to the word ‘evacuation’, to remove possible confusion resulting from the compulsory or mandatory connotations of ‘evacuation’.

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RECOMMENDATION 6.1

The State amend the State Emergency Response Plan so that the word relocation is used in preference to the word evacuation (except in cases where evacuation is clearly more appropriate).

Legislative and policy framework 6.8 The law in Victoria enables the evacuation of people threatened by fire, but does not support the compulsory evacuation of those with a pecuniary interest in any property under threat. Section 31(3) of the Country Fire Authority Act 1958 (the CFA Act) provides:

Any member of the police force may of his own motion or on the direction of the Chief Officer or any officer exercising the powers of the Chief Officer or any officer in charge of a brigade –

(a) close any road in the vicinity of the scene of any fire;

(b) order to withdraw, and (in the event of a failure or refusal to withdraw) remove, any persons who interfere by their presence or otherwise with the operations of any brigade or group of brigades or who are in or on any land building or premises then burning or threatened by fire.

6.9 This section would appear to provide for forced relocation of anyone on land that is threatened by fire. It is, however, subject to what has become known as the ‘pecuniary interest exception’ in section 31(4):

Nothing in this or the last preceding section shall authorize the removal from any land building or premises of any person having any pecuniary interest therein or in any goods or valuables whatsoever thereon.

6.10 Evacuation is dealt with in a similar way in the Emergency Management Act.11 If a State of Disaster is declared, the powers of the Coordinator in Chief include a power to ‘compel the evacuation of any or all persons from the disaster area or any part of it’.12 Under the Emergency Management Act, this power may not be exercised ‘so as to compel the evacuation of a person from any land or building if the person has a pecuniary interest in the land or building or in any goods or valuables on the land or in the building’.13 6.11 In addition, section 36A of the Emergency Management Act enables a senior police officer to declare an area to be an ‘emergency area’ if the size, nature or location of an emergency makes it necessary to ensure public safety. Once an emergency area has been declared, police may direct people on roads, footpaths or in open spaces to leave the area by the safest and shortest route.14 This power does not extend to directing a person to leave their own property.15 6.12 Strictly speaking, the relevant legislation does allow for a limited form of compulsory evacuation of areas threatened by fire, subject to the pecuniary interest exception. However, the pecuniary interest exception is so broad that it would be impractical for police or the CFA to enforce the compulsory evacuation of an area threatened by fire. There can be no question that the pecuniary interest exception encompasses a person who wishes to stay and defend their home against a bushfire. 6.13 Evacuation under section 31(3) of the CFA Act may be initiated by a member of Victoria Police, or by the Chief Officer of the CFA, any officer exercising the Chief Officer’s powers, or an officer in charge of a brigade, and is physically carried out by police. 6.14 The SERP provides that the decision to recommend that people evacuate rests with the control agency, in conjunction with police and other expert advice.16 Once a decision to recommend evacuation is made, police are responsible for carrying out the evacuation process.17 Under the SERP, it is the responsibility of Victoria Police emergency response coordinators to ensure that consideration is given to whether evacuation is necessary.18

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6.15 The SERP notes that there are instances when evacuation may not be the best strategy. In the Manual, Appendix 5 in Part 8 contains advice on evacuation in wildfire emergencies.19 It summarises the fire agencies’ ‘stay or go’ position: that a decision to evacuate or to stay and fight must be made by the individual concerned, must be made well in advance and on the understanding that there should be no last-minute change of plan or attempt to evacuate in the face of a fire. Police are advised to declare an emergency area under section 36A of the Emergency Management Act only at the request or with the approval of the Incident Controller. 6.16 The provisions of the CFA Act and the Manual that cover evacuation during bushfires were synthesised in a letter from Assistant Commissioner Stephen Fontana of the Victoria Police, outlining emergency response arrangements for the 2008–09 bushfire season:

The decision to evacuate any person during an emergency situation must be made by the Incident Controller. This decision is made following consultation with police, and any other expert advice available. In a wildfire emergency, policedo not have the authority to decide on whether residents will be evacuated, only the Incident Controller (from the CFA, DSE [Department of Sustainability and Environment] or MFB [Metropolitan Fire and Emergency Services Board]) can do that.

If and when a decision is made to evacuate, police have the responsibility to carry out that process.

The rights of people to stay and protect their homes must be recognised, as this in itself can be a sound strategy for surviving the passage of wildfire. Indeed, the presence of people prepared to fight for their homes may be all that is required in many cases to save those homes. This right of choice is preserved in the Country Fire Authority Act 1958, and also in the Country Fire Authority’s policy on evacuation during wildfire (see Appendix 5, Part 8 of the EMMV [Emergency Management Manual Victoria]). This policy has also been adopted by the DSE, which is responsible for fires on public land.

A decision to evacuate or to stay and fight must be made by the individuals concerned. This decision should be made well before a wildfire, and should be based on a well prepared home, and also the persons involved being physically and psychologically capable. The decision must also be based on the understanding that there should be no last minute change of plans and evacuation attempted immediately in the face of a wildfire. There are numerous examples of people who have lost their lives in this situation.20

6.17 There are two current policies that govern the CFA’s approach to relocation or evacuation in bushfire emergencies, Evacuation During Wildfire and Advice to the Community Before and During Wildfire.21 6.18 The CFA’s policy Evacuation During Wildfire was first approved in its current form in 1995 and sets out the CFA’s position on evacuation.22

176 Relocation

Box 6.1: Current CFA position on relocation during wildfire

Background A number of studies conducted on the effect of the Ash Wednesday 1983 fires revealed that initially small fires started by spark and ember attack are the most common cause of houses lost in a wildfire situation, and also that people who are well prepared should be able to survive the passage of a wildfire by sheltering in their homes. While a house may burn down in the hours after the fire front has passed, a house will generally survive the initial passage of the fire front if fuel levels around the house have been reduced. Consequently, people who are well prepared and take shelter in their homes have a good chance of surviving a wildfire. They may also be able to extinguish any small fires after the fire front has passed, thereby saving their homes. Also, unless people choose to leave well in advance of the arrival of a wildfire, sheltering in a house will generally be safer than being caught in the open in a motor car and possibly being involved in an accident due to smoke, and conceivably obstructing the movement of fire appliances. Organisational Planning The various emergency management organisations involved in disaster planning must include plans for evacuation, recognising that in certain circumstances evacuation is a valid strategy. To be effective, the community should also be involved in the development of evacuation plans. Also, it must be understood that effective evacuation is dependent upon the early perception of threat. Warnings are an important part of improving this perception. Individual Planning The decision to evacuate or to stay must be made by the individuals concerned. The decision should be made well before a fire, and should be based on an understanding of: ■■ fire behaviour, ■■ how houses are destroyed and what can be done to prevent this, ■■ how lives are lost in fire and what can be done to prevent this, ■■ their responsibility for their own fire safety, and that the CFA may not be able to directly assist them in protecting their homes, ■■ their responsibility to some extent for recognising the threat to their safety, and that they may not be warned officially, ■■ their degree of preparedness, ■■ what it is like to experience a major fire, e.g. noise, a lack of electricity, a lack of water pressure, etc. Who should evacuate While many people survive major fires without an understanding of fire safety, there are some people who should choose to evacuate, and their planning should ensure that they are able to do so safely. These people include: ■■ those who are unsure of whether they or their homes are defendable in a wildfire, ■■ those who would be unable to contribute to the protection of a house (e.g. children, the aged, the infirm, etc), ■■ those who are unsure of whether they would be able to cope physically with the work involved in protecting a house in extreme fire conditions, ■■ those who are unsure of whether they would be able to cope emotionally with the stress and trauma of extreme fire conditions. Decision to stay The decision to stay with the home or evacuate cannot be made effectively unless people have time to implement the decision successfully before the arrival of the fire front. The amount of time available depends on how long before the fire the people perceive the threat to their safety. This perception is a function of: ■■ whether they receive an official or unofficial warning, ■■ whether they understand that they must take some responsibility for monitoring their own safety, ■■ their understanding of fire behaviour. Late evacuation Late evacuation is fraught with danger. People evacuating immediately before the fire front risk exposure to lethal amounts of radiant heat. In addition, loss of orientation, poor visibility, other traffic and lack of information about the position of the fire front contribute to the danger to the late evacuee.23

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6.19 This current policy placed a greater emphasis on the role of households and individuals in understanding the bushfire risk and deciding whether to stay and defend their home or leave early than did the CFA’s earlier policy.24 The ‘paradigm shift’ represented by the adoption of this policy, away from an agency-centred approach towards the current community safety model, is discussed in Chapter 7. 6.20 The CFA’s companion policy Advice to the Community Before and During Wildfire provides direction for CFA personnel who in turn provide advice to the community before and during bushfires.25 This policy states:

The Emergency Management Act 1986 and the Country Fire Authority Act 1958 gives residents the right to stay with their homes during a bushfire. CFA and other emergency services personnel do not have the authority to order the removal of a person from a property if they have a pecuniary interest in the relevant land, building or goods within it.

CFA messages in relation to evacuation during wildfire are:

■■ The decision to leave the area or stay with their property during a wildfire is the responsibility of the individuals concerned and should be made well before the expected arrival of the fire front. The available research suggests that late evacuation by residents is a dangerous option.

■■ If a resident is away from home at the time of the fire they can legally be prevented from entering the fire area and can be prevented from returning to their residence.

■■ Victoria Police manages road access in and out of the fire area. While safety is the overriding concern every effort should be made to allow residents and landholders to reach their properties before the fire impacts and as soon as possible after the fire has passed.

■■ CFA does not encourage any resident to be travelling on the roads when there is a wildfire in the area.26

6.21 CFA policy does not permit CFA personnel to advise residents as to whether they should choose to leave or, having made that choice, when they should do so. A guide for CFA personnel based on the policy Advice to the Community Before and During Wildfire states:

Because of the difficulties in judging these factors [that influence house survival] it is very difficult to say absolutely whether a house would or would not survive a wildfire.

It is therefore very important that personnel do not make statements about whether a house could or should be defended by residents during a wildfire.

CFA personnel may come across houses that would have a limited chance of surviving a high intensity fire in their current state. In these cases CFA personnel are able to provide residents with advice on how to increase the preparedness of the house in case of wildfire.27

6.22 In relation to evacuation, the guide states:

CFA personnel should be careful not to provide residents with specific directions, remembering that the decision to stay with the house or leave, must always be made by the residents themselves.28

ARGUMENTS AGAINST COMPULSORY EVACUATION 6.23 Numerous arguments against compulsory evacuation were canvassed during the first block of hearings. Indeed, no party or witness seriously advanced the position that a policy of mass compulsory evacuation should be adopted in Victoria. Even so it is worthwhile setting out briefly the arguments against compulsory evacuation. 6.24 Mr Bruce Esplin, Emergency Services Commissioner, Mr Alan Rhodes, Manager Community Safety Research and Evacuation for the CFA, and Dr Sarah McCaffrey, Research Forester/Social Scientist with the US Department of Agriculture Forest Service, spoke of the possibility that, if people are evacuated and no fire or other emergency eventuates, they may not respond to future directions to evacuate: the ‘boy who cried wolf scenario’.29 It is accepted that repetitive false alarms may decrease response to warnings and directions to 178 evacuate, although this is less likely if the basis of any false alarm is explained and understood.30 Relocation

6.25 There is a concern that it may promote complacency rather than self-reliance, and residents would have less incentive to prepare their property for the risk of bushfire, in the same way that the ‘stay or go’ policy does.31 The Commission was not directed to any research bearing out this concern, although it was alluded to by Dr McCaffrey during her evidence.32 6.26 Another argument against compulsory evacuation is that people have a civil right to stay and defend their homes, and to risk their lives in doing so is their choice.33 The lay witnesses Dr John Ferguson of Buxton, Mr Peter Olorenshaw of Callignee, Mr John O’Neill of Steels Creek and Mr Peter Brown of St Andrews, each of whom had invested a great deal in their homes and property, were strong advocates of this position.34 Mr Olorenshaw’s evidence was typical:

I am a big advocate of remaining on the property to defend your asset. There are certain responsibilities that you undertake when you farm, those being to your animals and the protection of them as best you can. Also the asset that I have worked for a lifetime to build up. I believe that is a right of all property holders in order to undertake that responsibility, and wouldn’t hesitate in doing that again.35

6.27 The corollary of the civil rights argument is the likelihood of civil disobedience with an order to evacuate.36 For example, the lay witnesses Dr Ferguson and Mr O’Neill said in no uncertain terms that they would not have left their properties even if ordered to do so by police.37 The resources required to remove unwilling evacuees could be used to better effect in other ways, such as assisting others who do wish to leave. 6.28 On a more pragmatic level, it is said that if people are unable to stay and defend their homes the demands on the fire services would increase, and more houses would be lost.38 Mr O’Neill’s experience bore this out:

I am extremely relieved that I was not forced to evacuate from my house in Steels Creek on 7 February 2009. If that happened, our house would almost certainly have been destroyed and my family might now be homeless.39

6.29 A further practical concern is that large-scale evacuations may create traffic congestion, endangering the lives of those travelling on the roads and hindering firefighting efforts.40 6.30 The Commission is satisfied that the pecuniary interest exception should be retained, and that compulsory evacuation should not be the policy of Victoria’s fire agencies. Despite this exception fire agencies maintain a responsibility to provide appropriate information to individuals to assist them with making the decision of when it is time to relocate. This responsibility exists regardless of whether or not those agencies have the authority to compel people to leave their homes. As the CFA’s policy Evacuation During Wildfire states:

… it must be understood that effective evacuation is dependent upon the early perception of threat. Warnings are an important part of improving this perception.41

RELOCATION ON 7 fEBRUARY 6.31 Consistent with its policies the CFA did not recommend evacuation on 7 February. Warnings issued by the CFA that day contained generic advice for people to enact their bushfire survival plan, and about the dangers of leaving late. The CFA’s warnings did not contain specific advice to those who were planning to leave as to whether they should leave, within what time frame, or by what route. 6.32 Awareness messages posted to the CFA’s website on 7 February contained the following advice:

There may be increased amounts of smoke in the area from this fire. Road users are advised to take extra care as road travel may be hazardous due to low visibility from smoke. Even though this fire does not currently pose a threat, people in high risk bushfire areas are reminded to have a bushfire survival plan ready to implement during the summer period.42

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6.33 Some but not all awareness messages asked residents to ‘enact their Bushfire Survival Plans’.43 6.34 Alert messages posted to the CFA website advised:

Be prepared to activate your bushfire survival plan if necessary.

Decide now if you are going to stay or go. Remember that it is very dangerous to leave late with a fire in the area. Road use in the area will be extremely hazardous due to low visibility from smoke. Watch out for fallen trees, power lines, abandoned cars, wildlife and emergency services vehicles.44

6.35 The awareness and alert messages might have been interpreted as advice to those planning to leave that it was time to go. However, it was implicit in the urgent threat messages issued by the CFA on 7 February that safe departure was no longer possible:

As the fire front approaches, it will be unsafe to be either on foot or in a car as the heat radiating from the fire will be intense. Buildings will offer the best protection during the passage of a fire front.45

6.36 Announcements advising people to ‘leave early’ were read repeatedly on 774 ABC Radio during the morning on 7 February:

Today has been declared a day of total fire ban in Victoria and in the Southern Riverina in New South Wales and the Eastern Riverina. The Country Fire Authority reminds you that now is the time to implement your personal bushfire plan. If you’re planning to leave your property, leave early. If you’re planning to stay and defend your property, you should be properly prepared.46

6.37 This ‘leave early’ message was reinforced during interviews given by Mr Stuart Ord of the Department of Sustainability and Environment (DSE) and Mr Esplin. Interviewed shortly before 11:00am, Mr Ord was asked whether it was too late for people in areas threatened by the Bunyip fire to leave. He responded:

I would have hoped … that people in those communities I mentioned and even further away — places like Rokeby, Buln Buln, Fumina, Noojee even — that the people have really thought about this and they’ve already made their decision, and if they’re going to leave, they’re already on the road and getting out of the area.47

6.38 Mr Esplin was also asked to explain what ‘leave early’ means:

Well, if the person’s concerned and hasn’t planned and hasn’t got sort of inbuilt protection for their house and done all the things to clean up their property, leaving now would be a good idea. Don’t wait until there’s a fire — that’s waiting too late.48

6.39 There were isolated instances of specific advice to listeners in particular areas that, if they had decided to leave, they should leave immediately. At about 2:15pm, Mr Peter Lockwood, the Incident Controller for the Delburn fire, was interviewed about an urgent threat message issued for the Churchill fire.49 He advised those communities that might be affected by the fire ‘if they are to leave, they should leave now’.50 Mr Ord was quoted on the 4:00pm news, on the urgent threat messages issued for Wandong and Hidden Valley.51 He said:

People should have already decided whether they’re going to stay or leave. If they are going to leave they need to get out now, well — well ahead of the fire. The fire’s moving pretty quickly and is gaining size very, very quickly.52

6.40 Unfortunately, his advice given on 774 ABC Radio was not reflected in the warnings posted to the CFA website.53 6.41 The Bushfire Cooperative Research Centre (Bushfire CRC)Victorian 2009 Bushfire Research Response Interim Report explored the questions of whether people left, and if so when and why, in its Chapter 2 — Human Behaviour and Community Safety.54 The interim report noted: 180 Relocation

A significant number of residents left their homes and properties due to the bushfires. More than half (approx. 55%) of the households represented in the initial interview sample reported that at least one household member left because of the fires. Some had decided prior to February 7th that they could not defend their homes and that their safest option was to leave well before the fire arrived in their area. Others decided to wait and see what the bushfire was like before deciding whether to stay or go. Not surprisingly, the research has compiled examples of residents who left safely and those who encountered danger.55

6.42 Residents who left early enough to avoid encountering the dangers associated with a bushfire were triggered to leave by factors including extreme weather conditions, learning that fires had started, hearing radio announcements to activate fire plans, smelling or seeing distant smoke, being told to leave, and judging that the fires were too extreme to stay and defend.56 Residents who evacuated late did so for reasons including seeing others leave, losing confidence in their ability to stay and defend, and failure of attempts to defend.57 The Bushfire CRC’s interim report noted that many of those who attempted late relocations were aware of the dangers of doing so, but that people do not always react in a rational manner in high pressure situations: the flight instinct can be very powerful.58 6.43 The Commission heard evidence from a number of lay witnesses who left their homes, as to when and why they left when they did. The range of responses among lay witnesses was consistent with those recorded in the Bushfire CRC’s interim report. The evidence from lay witnesses was particularly informative as to how the ‘leave early’ message was received and understood by them. 6.44 One witness, Ms Jesse Odgers of Kinglake, explained that, as a sole parent, her plan was to leave early on a day of high fire danger.59 Having heard the weather forecast and the warning for 7 February, she took her daughters out of school at lunchtime on the Friday, and left Kinglake for Balnarring. Her house was destroyed in the fire. She testified that she would make the same decision again:

The new house may still burn and I will still implement our leave early plan. It is all just stuff and things. We are what are most important. I would plan to leave early even if I had a fireproof house, because my priority is the emotional health of my children. I do not want my children to go through the frightening experience of being in a bushfire.60

6.45 She was uncertain, however, how she would be able to continue to take time off work to implement her plan to leave early.61 6.46 The Spooner family of Strathewen, the Ananiev family of St Andrews, Ms Anastasia Scott of Marysville, Ms Alice Barber of Pheasant Creek, Mr David O’Halloran’s partner and children from Flowerdale and the Hainsworth family of Kinglake West all planned to leave rather than stay.62 They left when they learned of the fire, in some cases very late and, in the case of the Spooner family, tragically late. Others, such as Ms Hainsworth’s and Mr D O’Halloran’s families, received sufficient warning to be able to leave safely. Ms Karen Ward and her husband had planned to stay and defend their home at Mudgegonga, but left when they saw the fire and saw what they were facing.63 6.47 Mr D O’Halloran explained that it would take a genuine, credible threat of an actual fire to trigger their fire plan for his partner and children to leave.64 On the idea of leaving early on a day of high fire danger, he said, ‘It’s not quite practical to live life like that’ and ‘you can’t live life in that sort of mode of thought’.65 Ms Hainsworth made a similar observation, when explaining why the declaration of a day of Total Fire Ban would not trigger their plan to leave:

We would end up living in other places more than we lived at home in summer. Probably one in every three days lately has been a total fire ban, so why live there if you can’t live there?66

6.48 Perhaps this reluctance to leave home on a day of Total Fire Ban, in the absence of an actual fire, is a manifestation of the ‘cry wolf’ syndrome — a case of repeated false alarms decreasing response. In any event, it appears that the community has not wholeheartedly embraced the ‘leave early’ message. Many, if not most, people who plan to leave will not do so unless and until there is a bushfire in their area. 181 2009 Victorian Bushfires Royal Commission—Interim Report

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6.49 Mr Kieran Walshe, Deputy Commissioner of Victoria Police, was asked about evacuations carried out by police on 7 February. He said:

Although there was no request from control agencies to Victoria Police to evacuate people on 7 February 2009, police members acting in the course of their duties did exercise their discretion for the protection of life and property by recommending that people evacuate the area and assisting those willing to comply where required.67

6.50 Mr Walshe gave a number of examples of evacuations facilitated by Victoria Police members:

■■ The Salvation Army Rehabilitation Centre was located in a pine plantation in the Kilmore area. Sergeant Hesse from Kilmore crossed the Melbourne–Sydney railway line in his four wheel drive to reach the Centre and assisted the six residents to evacuate. He has since learned that the Centre was razed by fire within minutes of their departure.68

■■ Senior Constable Caine of Kinglake and his partner, Leading Senior Constable Wood, attended the Pheasant Creek store sometime after 5:30pm, where about 100 people had gathered with approximately 60 vehicles. They were concerned that the store was a dangerous location due to the presence of petrol. The road to Kinglake had already been cut by fire. Leading Senior Constable Wood drove towards Kinglake West to ensure that the road was passable, while Senior Constable Caine stayed to marshal those present into their vehicles and directed them to Kinglake West. Senior Constable Caine requested a ride with the final vehicle to leave, and saw the fire crossing the road towards the store as they departed. Those at the store were evacuated to the Kinglake West CFA, which was being protected by the CFA.69

■■ Senior Constable Kemezys of Hurstbridge assisted a man to evacuate from a burning property on Jacksons Road, Strathewen at about 4:30pm. Their passage was blocked by fallen and burning trees. At another property in Jacksons Road Senior Constable Kemezys assisted a 12-year-old girl suffering severe burns, lifting her into the police vehicle and driving out to meet an ambulance.70 6.51 Mr Peter Olorenshaw, a serving member of Victoria Police, was on duty with the Latrobe Traffic Management Unit before he was released to return home to defend his property at Callignee. He gave evidence of a warning patrol conducted by him and his partner along Red Hill Road, west of the Mount Tassie ridge.71 He and his partner drove into about 30 properties along Red Hill Road, warning those still present of the approaching fire and asking whether they planned to stay or leave. If they were planning to leave, he advised them to leave straight away. If they were planning to stay, he took their details. Some older couples asked for advice as to whether they should stay or go, and Mr Olorenshaw gave them his subjective opinion that ‘if they were infirm or not capable of actively defending their property then they should leave’. The warning patrol ended when the emergency services were ordered to evacuate from the mountain. 6.52 Mr Walshe also told the Commission what he knew about the evacuation of Gallipoli Oval in Marysville. He said that Leading Senior Constable Hamill and two other police members evacuated approximately 200 people who had gathered at the oval, with about 60 cars, caravans and trailers. He advised the crowd that the fire was only minutes away and that it was necessary for them to evacuate. He directed everyone present to get into their cars and proceed to Alexandra Secondary College. An orderly convoy formed and the cars drove from the oval and out of Marysville, through Buxton and on to Alexandra.72 The Commission also heard evidence from Leading Senior Constable Ken Dwight, who is stationed at Woods Point and was one of the other police members who assisted with the evacuation of Gallipoli Oval.73 He and Senior Constable Peter Collyer were in one of the last vehicles to leave. Mr Dwight explained the decision to evacuate the oval:

There were a lot of cars all together with a lot of people in them. I could see – because I had seen it coming and I could see how hot that fire was coming towards the town. Now, all those vehicles confined to that space with all those people, we would have lost a lot of people if we’d stayed there. We had no fire trucks to protect us, we had no water. Four policeman, basically, and a few SES members, and I’m not sure if there was a CFA there or not, and an ambulance. The best thing that we could think of was that everybody – we knew the road to Buxton was open and it wasn’t under fire, so the best way to get everybody out of 182 there was to head them down to Alexandra via Buxton Road.74 Relocation

6.53 Mr Daryl Hull watched the convoy leave Gallipoli Oval. Mr Hull chose not to join the convoy as he was not prepared to take the risk of driving out along the Buxton Road, because of concerns about driving into the fire, trees falling over the road and cars crashing in the general panic.75 However, he commented that ‘The convoy left in an orderly fashion, the police did a good job there’.76 6.54 Mr Dwight acknowledged the danger of a tree falling across the road, but was confident that he and the others in the convoy would have been able to move it.77 He said that the decision to evacuate the oval was the best option available:

We’re all trained as police officers and in these other organisations [CFA, SES] to make quick risk assessments on the information that we’ve got and you take the best option. If I only saved 10 people out of 100, there’s 10 people we still have, basically, and that’s the way we look at it.78

6.55 These evacuations initiated by members of Victoria Police displayed initiative in the face of the approaching fire, notwithstanding that it was against all the advice about not leaving by car when fires approach. However, they knew the road to Buxton was open and that mitigated the risk otherwise involved. 6.56 The relocations about which the Commission has heard evidence were not examples of the system working to achieve timely and safe relocation of those who wished to leave. The police members concerned found themselves in situations where they were called on to make snap judgements on apparently limited information. While rendering assistance to others they were themselves at great risk.79 6.57 The unsystematic nature of the evacuation of Marysville has led one lay witness to question why some residents were evacuated while others were not.80 The same issue arises in relation to Long Gully in Bendigo, where police advised some but not all residents to evacuate the area.81 6.58 It is instructive to compare these late relocations in the face of looming danger with the timely relocation of Boolarra that took place on 30 January 2009. As described by Mr Lou Sigmund, the Group Officer of the CFA Morwell Group, fires had been burning near Boolarra since 28 January. A community meeting was held in Boolarra on the morning of 30 January 2009. People at the meeting asked when they should leave and the response from other CFA representatives was that they should ‘leave early’. 6.59 Mr Sigmund addressed the meeting, and said that ‘the town was in imminent danger of being overrun by the fire if the wind changed to the southwest and that the town would burn if this were to occur’. He said that people would not get a knock on the door telling them to evacuate. He told people wanting to leave that the preferred option was for them to leave town along the road to Churchill, which is a 20-minute drive from Boolarra. Mr Sigmund told the meeting that the Boolarra CFA would sound the siren when ember attacks began, and that would be the signal to leave town. The siren was sounded at around 1:15pm. A large number of people relocated from Boolarra. An orderly procession of cars, many towing caravans, boats and horse floats, drove out of Boolarra to Churchill. While 29 houses were destroyed in Boolarra that afternoon, no human lives were lost.82 protocols for RECOMMENDING timely RELOCATION 6.60 In the Commission’s view, there must be recognition that the very general advice given by the CFA and others to ‘leave early’ has not achieved the desired result of people relocating. Evidence indicates many people whose fire plan is to leave will not do so unless there is a fire in their area. It is unrealistic to expect that people will leave their homes every time a day of Total Fire Ban is declared, when their experience is that this is rarely if ever necessary. Some more specific triggers to leave are required that will prompt people to leave when it is still safe to do so. The question of how to achieve this is answered in several ways.

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6.61 As discussed in Chapter 5, part of the answer is to revise the fire danger index and the fire danger ratings. Another part of the answer is to provide people with clear advice, when warranted, that their fire plan should be to leave. There must be recognition that some houses are simply not defendable. Equally, there must be recognition that some people are not able to defend their houses, for reasons of age, disability or some other vulnerability. The CFA policy Advice to the Community Before and During Wildfire should be amended so that CFA personnel can recommend that particular households, communities or locations should plan to leave early, based on their assessment of the defendability of the household, community or location in question and the vulnerabilities of the people there. 6.62 The next part of the answer is that warnings issued by the fire agencies should include advice about leaving — a recommendation to relocate — whenever that is appropriate. The Commission recognises that late relocation is extremely dangerous. It is also clear that departure may be possible in certain circumstances when a fire is already burning, and be a safer option than remaining in extreme circumstances. For example, the time available may be adequate for safe departure providing exit roads are known to still be unaffected by the fires. 6.63 To illustrate, on 7 February the fire agencies knew that a south-westerly wind change was forecast for later in the day and that, once the wind changed, the eastern flank of the fire would become the firefront.83 Communities to the east of the path of fires would be under threat after the wind change. These communities included Kinglake and Flowerdale, to the east of the Kilmore East fire; Marysville, to the east of the Murrindindi fire; and Callignee, to the east of the Churchill fire. However, before the wind changed people could have left those communities safely to the north and east — indeed, many people did so. The threat to Kinglake and Flowerdale was recognised in the Kangaroo Ground Incident Control Centre as early as 2:40pm.84 Mr Andy Willans, the DSE fire observer on the Mount Gordon fire tower, had realised the threat to Marysville by 3:30pm.85 The threat to Loy Yang, to the north-east of Callignee, was known in the Integrated Emergency Coordination Centre by 3:00pm.86 The wind change impacted on those fires between 5:30pm and 7:30pm.87 Even on a day as deadly as 7 February, there was time enough to advise people in those communities that, if they were planning to leave, they should do so. 6.64 The Incident Management Team (IMT) — and specifically the Incident Controller for the fire — will have information required to assess whether people in particular locations should leave, if that is their choice. This information includes their existing knowledge of the area: its communities, its topography, locations of particular risk, its road infrastructure and any places of refuge. The IMT will also have information specific to the fire: its severity, its location, its spread, its predicted impact zone, and the weather conditions including any predicted wind change. This is all information that is necessary for the Incident Controller and the IMT to have in order to respond to the fire.88 With that information, the Incident Controller can identify the communities within the fire’s potential impact zone and the time at which the fire may impact on them.89 He or she can then assess whether it is safe for people in those communities to leave, in what time frame, and by what routes. The Incident Controller can also assess whether road blocks should be established to restrict access to areas that may be affected by fire. Having made these assessments, the Incident Controller, assisted by the IMT, can issue warnings that include advice that it is time to leave. 6.65 The protocols of the fire agencies and the relevant CFA policies should be amended to require the Incident Controller to assess whether relocation should be recommended and, if so, to include advice of that recommendation in warnings issued about the fire. Of course, the assessment made by the Incident Controller may be that it is unsafe to leave an area, or that it is unsafe to leave by a particular route. If such an assessment is made, the Incident Controller should include advice to that effect in warnings that are subsequently issued. 6.66 AFAC submitted that it was ‘impractical, unrealistic and unworkable’ to impose such an ‘onerous’ requirement on a single person in a response organisation.90 The Commission disagrees and puts the alternate view that there is no-one better placed to make these assessments than the Incident Controller, properly supported by a competent and well-trained IMT. Incident Controllers are already required to decide what warnings should be issued, and whether and where road blocks should be established. These decisions are based on the same 184 information that is required to assess whether relocation should be recommended, information that is available to the Incident Controller, and which is not readily available to the public. Relocation

6.67 In making these recommendations the Commission recognises that it will not always be possible for fire agencies to give timely advice to those who plan to leave. Education of the community to ‘stay or go’ should continue to emphasise the importance of preparation, in case leaving is not possible, along with the dangers of late departure. Fire agencies should continue to educate those living in areas at risk of bushfire that they may not always receive a warning of an approaching fire. Where possible, advice on relocation should be given.

RECOMMENDATION 6.2

The CFA amend its policy Advice to the Community Before and During Wildfire to enable trained CFA personnel to recommend to particular households, communities or locations that they plan to leave early, based on an assessment of defendability, the vulnerabilities of the people there, and the degree of ease with which people are able to leave the area in relative safety.

RECOMMENDATION 6.3

The CFA and DSE amend operational policies to require the Incident Controller to assess whether relocation should occur and to recommend relocation when warranted.

proposed Responsibility for carrying out RELOCation 6.68 As discussed in setting out the legal and policy framework for relocation, Victoria Police is responsible for carrying out any recommended evacuation under both section 31 of the CFA Act and under the SERP. 6.69 Warnings should be delivered by the various modes for dissemination of bushfire warnings discussed in Chapter 4, including radio broadcasts, the single agency bushfire information website, the Victorian Bushfire Information Line and, when it commences operation, the national telephone emergency warning system. It is anticipated that in most cases people affected will leave using their own vehicles. 6.70 The police should continue to have responsibility for carrying out relocations recommended by an Incident Controller. There are likely to be instances in the future where it may be appropriate to deliver relocation advice to specific locations, as occurred in some instances on 7 February. There is a particular role for police in facilitating the relocation of people in places such as hospitals, aged care facilities, and other institutions, of which the relocation of the residents of the Salvation Army Rehabilitation Centre in Kilmore is a good example.91

Deciding where to RELOCate 6.71 One of the concerns the State raised about mass evacuation was the need for decisions to be made about where people, their possessions and their animals would go, and how they would be accommodated during the period of their evacuation.92 The evidence heard by the Commission from those who left their homes on 7 February is that almost everyone made their own arrangements. Most people stayed with family or friends, some went to hotels, relatively few went to emergency relief centres.93 The same pattern emerged for those people who had to leave after their homes were destroyed by fire.94 This is consistent with the experience in the United States where, according to Dr McCaffrey, the majority of those who evacuate drive out of the area themselves and stay with friends or family or in hotels.95 Dr McCaffrey estimated that only 10–15 per cent of evacuees used designated sites.96 6.72 Further designation of ‘neighbourhood safer places’ as proposed by the State would provide sites of temporary protection from fire.97 In addition, some residents will make private ‘crisis refuge’ plans for temporary relocation to a safer place as discussed in Chapter 8.

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6.73 The evidence indicates that implementation of these recommendations will not result in increased numbers of people seeking shelter at emergency relief centres. However, Municipal Emergency Management Plans prepared by councils are required to designate emergency relief centres in the municipality, and these emergency relief centres should have facilities for sheltering, feeding and personal hygiene for emergency- affected people and their pets.98 As a precautionary measure, councils should review their Municipal Emergency Management Plans before the next fire season, to ensure that they make appropriate provision for relocation during bushfires.

RECOMMENDATION 6.4

Municipal councils review their Municipal Emergency Management Plans to ensure there is appropriate provision for relocation during bushfires, in particular, to indicate the location and arrangements associated with designated emergency relief centres.

Source: Courtesy of The Herald & Weekly Times 186 Stay or Go 7 2009 Victorian Bushfires Royal Commission—Interim Report

7 Stay or Go

One hundred and seventy three Victorians died in the fires of 7 February, two-thirds of them in homes.1 The Emergency Services Commissioner and the State of Victoria have correctly accepted that in light of those deaths, the ‘stay or go’ policy should be re-opened, reviewed and modified.2 This chapter begins with an examination of the historical, evidentiary and philosophical underpinnings of the policy and then explores the evidence relating to the implementation of the policy by the community. The chapter concludes with recommendations for retaining the principal components of the policy but with extensive modification of the accompanying advice and practical direction it offers the community.

The CURRENT ‘STAY OR GO’ POLICY AS APPLIED IN VICTORIA 7.1 As fires blazed on 7 February 2009, Victorian communities and fire agencies made critical decisions affecting lives and safety within the context of an overarching policy framework for community safety in bushfires. The core component of the policy had become known by the slogan ‘stay or go’, but it is more accurately described by its full title, ‘Prepare, Stay and Defend or Leave Early’. 7.2 The Victorian position concerning the advice given to people living in bushfire-prone areas about how to prepare for bushfires, and what to do in the event of a bushfire, is discussed in a position paper of the Australasian Fire and Emergency Service Authorities Council (AFAC), titled Position Paper on Bushfires and Community Safety (November 2005).3 7.3 The AFAC paper articulates what it describes as ‘a national position that provides the doctrine and describes good practice in relation to creating and maintaining bushfire safe communities throughout Australia’.4 AFAC distinguishes between positions that are national consensus statements about best practice, and policies that are created by fire agencies as expressions of those positions.5 While the position has been adopted nationally, aspects of the way it is expressed and applied as policy differ among the states and territories.6 7.4 The position described in the 2005 AFAC paper has been adopted in Victoria as policy.7 As a policy, the position is expressed in the context of Country Fire Authority (CFA) practice and the core CFA documents comprising advice to the community. While the Commission has focused on the practical application of the national position in Victorian agency policy and practice, the Commission’s recommendations for change are informed by an understanding of the theoretical underpinnings and historical development of the stay or go position as developed and expressed by AFAC. Relevant parts of the historical development of the policy are discussed, for that reason. 7.5 AFAC’s 2005 document explains the core tenet of the position in these terms:

With proper preparation, most buildings can be successfully defended from bushfire. People need to prepare their properties so that they can be defended when bushfire threatens. They need to plan to stay and defend them, or plan to leave early.8

7.6 That statement is subject to the caveat that:

It must be recognised that in limited cases, some buildings, due to their construction methods, construction materials, the site they are located on or their proximity to high and unmanageable fuel loads, cannot for all practical purposes be defended against high intensity bushfires. In these circumstances, householders should be encouraged to relocate early if the intensity of an approaching bushfire is likely to make conditions unsafe.9

7.7 This caveat is critical, as the events of 7 February demonstrated, but it is not emphasised in the Victorian advice to communities (paragraphs 7.75 to 7.89 below).

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7.8 The ‘stay and defend’ option draws on three principal conclusions from research:

■■ buildings are ‘more likely to survive’ if someone is there to protect them (noting that fire agencies cannot attend every property)

■■ most buildings lost in bushfires ignite from small fires caused by sparks and embers and, by extinguishing those ignitions, adequately skilled and equipped people can save a building that would otherwise be lost in a fire

■■ the most important aspect of preparation is the creation and maintenance of a ‘defendable space’ within which a property can be defended against embers and radiant heat.10 7.9 Advice to the community about preparation and defendable space is discussed in detail below. Determining whether a property is defendable in given conditions is, demonstrably, a complex task. Staying to defend can and did, on 7 February, involve grave risks. The CFA literature explaining the policy to communities was silent on the risks of physical harm or the ultimate risk of dying in the attempt to defend. 7.10 The ‘leave early’ option is that if planning to leave, people must decide where they will go, how they will get there, and what trigger they will use to initiate their plan. The CFA advice to communities does not include advice about where to go. It does not suggest when to leave, other than through use of the ambiguous term, ‘leave early’, and the identification of a range of possible triggers (paragraphs 7.90 to 7.96 below). 7.11 The AFAC position statement emphasises three critical aspects of decision-making and planning by communities. 7.12 First, to make decisions about whether to ‘stay and defend’ or ‘leave early’, community members must become competent to assess whether their homes are ‘adequately constructed, maintained and prepared to withstand the impact of a fire at its expected intensity’.11 There are two aspects to the required assessment — the competency to assess ‘defendable space’ and, critically, an appreciation of expected fire intensity. 7.13 Second, the position statement explicitly recognises the importance of people in threatened communities having ready access to accurate information to assist in decision-making, both during periods of high fire danger and during fire events. The Victorian practice relating to warnings in the context of the stay or go policy is discussed below (paragraphs 7.57 to 7.58). 7.14 Third, while the primary decision should be made ‘well in advance of a bushfire’, it is explicitly recognised that residents should have ‘contingency plans in case a fire is more intense than expected, or if the building catches fire and cannot be extinguished’.12 On 7 February some community members faced the very circumstances highlighted in the position statement. Plans failed or were changed in the face of extremely dangerous fires.13 The current form of advice to communities and the policies supporting it fail to grapple with the need for contingency plans. What such plans might entail is not explained. Residents must work out for themselves where to go when fires are more intense than expected and when buildings catch fire and cannot be extinguished. 7.15 Because the position allocates responsibility to householders for deciding whether and when they will ‘stay’ or ‘go’, it expresses an approach to evacuation and assisted relocation. As Mr John Gledhill, Chief Officer, Tasmania Fire Service, explained in evidence, ‘the basic message of Stay or Go is that able-bodied people should be allowed to stay with their homes and actively defend them in the event of a fire.’14 7.16 As explained in Chapter 6, fire agencies in Victoria do not forcibly evacuate or, as a matter of policy, recommend or assist relocation. The opposition to forced evacuation is long-standing and pre-dates the development and adoption of the stay or go policy. Legislative recognition of the right of property owners to defend their properties from fire (without being forcibly removed) was enshrined in legislation as early as 1915 and was reiterated in the consolidation of the Country Fire Authority Act in 1958 and in the Emergency Management Act in 1986.15

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7.17 The stay or go policy itself contains several statements about the difficulties of evacuation: last-minute evacuation is dangerous; it is better for people to remain with adequately prepared homes than to be relocated; and large-scale evacuations are problematic. However, the policy also suggests that ‘there will be cases where ordered evacuation will be considered by the authorities, overriding individual choice in the interests of public safety’, while maintaining that adequately prepared and resourced people should not be forcibly removed from their homes.16 7.18 The Victorian policy goes further than rejecting mandatory evacuation. CFA policy does not permit personnel to advise residents to undertake a particular response when threatened by bushfire. Rather, the advice is given that the ‘two safest’ options for residents living in high bushfire risk areas are to stay and actively defend a well-prepared property, or to leave the area ‘before threatened and travelling on roads becomes hazardous’.17 That advice is specifically addressed in Chapter 6 and the recommendations that it be changed are an important aspect of the proposed modifications to the way in which the stay or go policy is currently practised in Victoria.

EMPIRICAL BASIS FOR THE CURRENT STAY OR GO POLICY 7.19 The stay or go policy is said to be strongly grounded in extensive research concerning the effects of bushfires on houses and people.18 Given that the conclusions from the research are translated into messages to the community (‘houses protect people and people protect houses’), it is important to understand what those studies establish and what they do not.19 7.20 The first group of studies examines how buildings ignite and are destroyed, and the significance of the actions of occupants in building survivability. The second group relates to the circumstances in which civilians have been killed in bushfires. 7.21 The key studies have each presented an analysis of primary evidence relating either to buildings or to deaths. Papers reporting on primary research have also reported on policy outcomes (whether to fight or flee, whether staying to defend should be preferred to evacuation) by drawing on research by others. The focus here is on the findings rather than on conclusions drawn by the authors of the studies about policy positions. 20

Loss of Buildings in the Stay or Go Regime 7.22 The most significant learning about the effect of bushfires on houses has been drawn from the Ash Wednesday bushfires which killed 76 people and destroyed 2463 houses.21 Two major quantitative studies examined the effect of the fires on 455 houses in Mount Macedon and on 1148 houses in the Otway Ranges.22 In a single qualitative study, 40 residents of Upper Beaconsfield, 11 of whom had lost their homes, were interviewed.23 The findings of those studies were broadly consistent with two earlier studies and with subsequent retrospective studies.24 7.23 The principal findings of those studies, frequently referred to in the literature explaining the basis for the stay or go policy, were:

■■ There were three possible modes of house ignition — burning debris lodging on combustible material, radiation from fire, and direct flame contact. All three modes played a part in house destruction. In the majority of cases ignition appeared to have been caused by burning debris (embers) that gained entry through gaps or broken windows or that lodged in decking and other combustible structures.

■■ Radiant heat and flame played a significant role in cases in which houses were directly abutting dense, undeveloped vegetation. Ember attack can occur for some time before and many hours after the firefront has passed, but the firefront itself typically impinged on houses for only several minutes.

■■ If houses were attended, house losses were significantly reduced.25

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7.24 The building studies also drew the following conclusions, each of which is important in the context of the 7 February fires:

■■ The spread of fire, when a house ignites, depends on both the suppression activities of its occupants, and on how it is ignited. Occupants were unlikely to survive bushfires if their houses were destroyed very quickly. Fires originating in roofs might be expected to compromise occupant safety.26

■■ While ‘by far the greater proportion of houses offer relatively safe havens during the passage of a fire’ (compared with last-minute evacuation), residents of houses surrounded by exceptionally high concentrations of fuel, such as those near mountains or ash gullies, ‘might sometimes be wise to evacuate temporarily to safe places nearby’.27

■■ The conclusion that there is an improved chance of saving a house by staying with it during a bushfire (than by leaving it) was subject to the qualification that the house is a ‘safe home’ and that there is ‘adequate public warning’ with ‘communication channels to be kept wide open’.28

■■ Severe weather conditions play an important role in the potential for house loss.29 7.25 Evidence received by the Commission to date is incomplete about housing construction and planning controls and the cause of the destruction of houses in the fires of 7 February. However, in its interim report into the 7 February fires, the Bushfire Cooperative Research Centre (Bushfire CRC) drew preliminary conclusions from its survey of over 1000 houses lost in the fires. The conclusions included:

■■ Active defence of structures had a major influence on house survival.30

■■ Direct flame contact from surrounding bushland, and radiation attack, appeared to have been more prevalent in the 7 February fires compared with previously surveyed fires.31

■■ Structures were subject to multiple wind directions during the peak of the fire event, which suggested that multiple firefronts may have approached those houses.32 There was evidence from occupants that the heat was too intense to be able to survive outside, due to several firefronts impacting on the houses or surrounding elements burning.33 This raised the question of the adequacy of the house to provide shelter while multiple firefronts may be active around the house.34

■■ It is reasonable to suggest that more extreme fire behaviour associated with more extreme weather and high to very high fuel loads could lead to a greater exposure to structures. The greater the fire exposure the more readily a structure may be ignited.35

Civilian Deaths in the Stay or Go Regime 7.26 The death toll from the February fires was catastrophic and unprecedented. By comparison with other major fires, the total number of deaths that occurred as a result of the 7 February fires is equal to almost one third of the total number of deaths in Australian bushfires over the last 100 years recorded in the database analysed by Dr Katharine Haynes, a Research Fellow at the Centre for Risk and Community Safety, RMIT University. It exceeds, by 14 per cent, the cumulative total number of deaths in the major fires at Hobart in 1967, Lara in 1969, Ash Wednesday in 1983 and Eyre Peninsula in 2005.36 7.27 The Commission is yet to hear evidence about the actions and intentions of those who died, beyond the evidence that has enabled broad classifications to be reached. However, the proportion of deaths in homes (two-thirds) is strikingly different from previous fires (as discussed below). One hundred and thirteen of the 173 people who died as a result of the 7 February fires died in homes. Seven died in other buildings, 27 died outside but near to homes, 11 died in vehicles, 10 died near vehicles or on roads, 1 died on a reserve and 4 died away from the locations of the fires.37 7.28 AFAC’s position is that, in light of the evidence to date about the deaths as a result of the 7 February fires, the stay or go policy remains under review.38 The State submitted that the policy should be re-opened and proposed recommendations for changes to the policy.39 Mr Alan Rhodes, Manager, Community Safety Research and Evaluation for the CFA, said that the deaths that occurred as a result of the 7 February fires ‘pose questions about the current approach’ — namely whether the options articulated in the advice were, in the conditions prevailing on 7 February, viable, and whether there was infrastructure in place to support the adoption of those options.40 191 2009 Victorian Bushfires Royal Commission—Interim Report

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7.29 In 2008 Dr Haynes and others completed a report for the Bushfire CRC that analysed data on 552 fatalities in bushfire over the past 100 years.41 This report classified the information, including by reference to the deceased’s activity and decision-making at the time of death, against assigned meanings. Activities at time of death included ‘late evacuation’, ‘inside a defendable property, passively sheltering’ and ‘inside a defendable property, actively defending’. Prior to 2008 the only detailed research into the circumstances in which people have died in bushfires in Australia was a 1992 study in which Krusel and Petris of the CFA studied 32 civilian deaths in Victoria in the Ash Wednesday fires, analysing information from the Coroner’s inquest files.42 7.30 The main conclusions from Dr Haynes’ study were that:

■■ the greatest proportion of civilian deaths in bushfires had occurred during attempts at late evacuation (31 per cent in total, 25.7 per cent from 1956 to 2008)

■■ a significant proportion of deaths had occurred while defending properties outside (26.3 per cent in total, 24.5 per cent from 1956 to 2008)

■■ a minority of deaths had occurred inside homes (8.3 per cent in total, 13.6 per cent from 1956 to 2008) and of those, most occurred while the victims were considered to have been ‘passively sheltering’ or engaged in what the study described as ‘meagre and unsuccessful attempts to defend’.43 7.31 The trends for the entire period are broadly consistent with the trends for each of the major fires examined as case studies (Hobart, Lara, Ash Wednesday, and Eyre Peninsula).44 7.32 Dr Haynes’ research findings (and similar observations about relative death rates contained in earlier reports) are said to substantiate the stay or go policy.45 7.33 The historical analysis discloses clear trends. Because those trends have not been replicated in the 2009 fires, further evidence and analysis is required before definitive conclusions can be drawn about previously accepted core propositions concerning the relative risks of staying to defend, and leaving (whether early or later). 7.34 As Dr Haynes points out, analysis of intentions and actions from historical data is constrained by limits in the available data, including in some cases, inconsistencies and lack of precision.46 As a result, categorisation of behaviour and intentions requires a number of assumptions that may obscure the complexity of events facing householders when decisions are required in the face of a fire and when plans fail. Key among them in Dr Haynes’ analysis are that deaths occurring inside a house are interpreted as deaths ‘inside a defendable property’, irrespective of housing construction or surroundings, and the assumptions entailed in designating the deceased as ‘passively sheltering’ or engaged in ‘very meagre and unsuccessful attempts to defend’.47 Assumptions of that kind will be re-examined in future hearings. 7.35 For the purposes of this interim report, it is of greater value to ask an open question about what the historical analysis reveals about risks to human life and safety (and what measures would protect life), than to focus on whether the existing policy is ‘validated’. Important implications from the work of Dr Haynes and Krusel and Petris are:

■■ The importance of warnings to decision-making. Krusel and Petris concluded that 12 of 32 civilians who were killed in Victoria on Ash Wednesday died because they did not recognise the real threat to their safety in time to implement an effective survival strategy. Krusel and Petris concluded that, ‘it follows that if people do not receive a warning in time to implement effective survival strategies, a good understanding of bushfire safety is immaterial’.48 Dr Haynes found that many people underestimated the ferocity of the fires they faced, and on Ash Wednesday many people, although aware of the fires, were taken by surprise by the sudden wind change in the early evening when it was too late to evacuate.49

■■ The difficulties and risks of implementing a fire plan. Dr Haynes’ study showed that most fatalities involved victims who were aware of the fire and were carrying out a plan. Dr Haynes concluded that ‘the relatively high rates of death in this group are probably attributable to the fact that the activity of “carrying out a plan” usually involves exposure to the fire and physical threat’, and noted that the study was not able to include comparative figures of successful defence of a property compared with all 50 192 those attempts at a defence. Stay or Go

■■ The difficulties of assessing the ferocity of fires, and preparedness. Dr Haynes concluded that ‘this study yields some difficult examples for the “prepare, stay and defend” argument — for example, how do we know how much preparation to fight the fires is enough? Even those who plan to stay are often not well-prepared; they do not expect to lose electricity or water, they have no back up plan and do not wear adequate protective clothing’.51

■■ The primary importance of recognising and targeting vulnerable groups. Dr Haynes includes among them the elderly and frail, men who die attempting to defend property outside and women and children who die fleeing or sheltering in an undefended home.52 Dr Haynes found that in the 1967 Hobart fires ‘people were aware of elderly or frail in their community but, because of lack of planning and urgency, they had to look after themselves and their immediate family. This had disastrous consequences for their vulnerable neighbours’.53 ‘While some elderly and infirm people had made plans with neighbours to help or pick them up, this did not occur due to panic and hasty evacuations, rather than because of infirmity’.54

■■ The fact is that late evacuation is dangerous, and occurs. This is taken up in Chapter 6. 7.36 Both the fact of the deaths as a result of the 7 February fires, and the historical analysis, strongly suggest that practice and policy ought to focus on alleviating the very real risks and challenges facing community members preparing for and confronting bushfires.

THE Philosophical UNDERPINNING TO STAY OR GO 7.37 The stay or go policy expresses a philosophical position about the respective roles of fire agencies and the community in protecting against and preparing for the risks posed by bushfires. 55 Mr Rhodes gave evidence that during the 1990s a broad paradigm shift occurred in Australian emergency management away from an agency-centred approach and towards shared responsibility between emergency services and the community in dealing with bushfire risk, often referred to as the ‘community safety approach’. He said that amendments to the CFA evacuation policy during and after 1995 reflected that shift. He characterised the present stay or go policy as epitomising this shift, ‘by identifying the critical role of the public in preparing for and responding to bushfire threat’.56 The shift in emergency services towards an active role for the community was integral to the stay or go policy gaining momentum.57 7.38 A 1999 study by the CFA explained the evolution of the policy in Victoria in the following way:

Encouraging greater community responsibility coincides with a shift in the focus of emergency activity from incident suppression and operational pursuits towards risk management and incident prevention. This has required the formalisation of policies relating to emergency management and evacuation. Together, all these factors have resulted in considerable changes in CFA’s approach to community safety.

In the last decade, CFA has (a) adopted a new philosophy encouraging greater community self reliance; (b) translated the research findings and understanding generated from this work into the Stay or Go message; and (c) formalised its policy position on evacuation. As a result, its policy, philosophy and messages are better aligned.’58

7.39 In light of the events of 7 February, the authors of the CFA study presented a prescient observation of the implications of translating research and philosophy into a message to the community:

While the options of stay or go generally reflect the two most viable survival strategies, the message has essentially simplified a decision which, in reality, is far more complex.

The notion of stay or go represents a complex decision which agencies are asking the community to make. It has been useful in forcing people to confront and recognise choices, but like all slogans its real meaning is far more significant. The options are underpinned by a series of confusing possibilities and decision making processes …

It is unrealistic to expect people to respond to disasters in a uniform manner, or in a ‘rational’ manner according to what the emergency services might try to prescribe … there are likely to be people at each wildfire in the foreseeable future whose responses do not reflect the ideals of stay or leave early … it is highly likely that there will be people who ‘wait and see’, or ‘do as much as possible’ and then leave, in future wildfire events.’59 193 2009 Victorian Bushfires Royal Commission—Interim Report

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REVIEW OF THE stay or go POLICY PRIOR TO 7 FEBRUARY 7.40 By 2008, research conducted by or on behalf of the CFA had shown that:

■■ people living in fire-prone areas had often not developed comprehensive bushfire survival plans

■■ a significant proportion of those at risk adopt the strategy of waiting to see what happens during a bushfire and leaving if the situation becomes dangerous

■■ there was community disquiet about the level of warnings and information provided to communities during short-duration fires, with some residents reporting that the absence of timely warnings precluded them implementing a plan to leave early

■■ even if people have knowledge of how to act, it is likely that a significant proportion of them will lack the capacity needed to implement the policy options

■■ the ‘leave early’ message was not well understood.60 7.41 In November 2008, AFAC commenced a review of the stay or go policy (as expressed in the 2005 document). AFAC has, since 7 February, produced a draft discussion paper on the policy entitled Prepare, Leave Early or Stay and Defend a Property.61 The current version of the paper (19 May 2009) observes, among other things, that:

■■ while householders should make every attempt to prepare their properties, agencies should encourage householders in properties that are poorly prepared or difficult to defend, to leave early when the bushfire risk is high or extreme in their locality

■■ the option of community fire refuges requires new consideration

■■ while mass evacuation is not endorsed, there are occasions where selective, early relocation of people is appropriate, including in periods of very high or extreme fire danger.62 7.42 In their earlier 2004 draft review of the policy, Professor Handmer and others concluded that key policy implementation issues that required addressing included:

■■ distinguishing between survival strategies for ‘normal’ bushfire events and ‘mega’ events, ‘as the prepare, stay and defend option may be challenged by extreme bushfire events’

■■ defining when it is not safe to stay

■■ defining how early is early enough

■■ the role of warnings in implementing the policy

■■ lack of understanding of the stay or go message at the community level

■■ physical, social and economic barriers to adopting the options offered by the policy

■■ differences between rural communities and interface communities

■■ macro social trends and their impact on the stay or go policy — in particular, people’s growing expectation that they would be protected from risk by authorities.63

COMMUNITY IMPLEMEnTATION OF THE stay or go policy 7.43 Key conclusions from the evidence heard by the Commission concerning the implementation of the major requirements of the policy (‘prepare’, ‘stay and defend’, and ‘leave early’), both on and prior to 7 February, are as follows.

THE PREPARE PHASE IN STAY OR GO 7.44 In relation to community preparedness generally:

■■ Victoria’s theoretical framework for community engagement to encourage preparedness for bushfire (described in Living with Fire — A Community Engagement Framework, 2008–2012) is sound. The effectiveness of a preparedness model to motivate preparation for bushfire depends upon 194 how programs are translated into practice.64 Stay or Go

■■ The context in which community members must choose between the options presented by the policy is complex. Mr Rhodes describes it as ‘a multi-dimensional concept’ involving a number of underlying assumptions or conditions.65 Implementing a fire plan and making a choice between staying or going require multiple levels of decision-making, both well before and during a fire. While the overall message is that people should have a plan and not change it at the last minute (as discussed below) circumstances can change and re-assessment (even to re-affirm a plan to stay or go) is necessary in stressful circumstances. This was an important theme in the evidence.

■■ There is no standard set of measures that constitute adequate preparation. Effective preparedness depends on a range of factors including house type, property location, surrounding vegetation and personal readiness. It is necessary to think of preparedness relative to an event. Preparation that is effective in one set of circumstances may not be effective in another. People may be able to defend a property with relatively modest levels of preparedness if a fire is of low or moderate severity, but be unable to do so in an extremely dangerous bushfire.66 This was true on 7 February, when many residents planned and prepared for ‘normal’ bushfire conditions and were not adequately prepared for the extremely dangerous fires that eventuated.67 This is a critical point and was a major theme in the evidence.

■■ Some community members will prepare well and be able to deal with bushfires in accordance with CFA advice. A number of lay witnesses from whom the Commission heard were greatly assisted by the CFA material and advice about preparation and were able to successfully implement fire plans.68

■■ Preparing a property for bushfire requires significant work, effort, resources and time.69

■■ Despite preparation, for many lay witnesses the intensity of the fires was beyond anything they had expected or could have prepared for. Fires had to be fought for lengthy periods.70 Mr Daryl Hull said:

the thought of a fire of that magnitude ever coming to Marysville seemed an impossibility, in anyone’s imagination.71

Mr Bevan Gobbett of Clonbinane said:

there was nothing — nothing at all could prepare you for what actually happened on that day and how intense that fire come in.72

■■ For a variety of reasons some community members will not be adequately prepared or adequately informed at the time of a fire.73 What it means to have an appropriate bushfire plan is not well understood. Many community members will not have an appropriate bushfire survival plan at the time of a bushfire.74 On 7 February, levels of bushfire preparedness varied widely among householders.75 Much last-minute, reactive planning took place.76 Levels of planning and preparedness varied according to the location of households.77

■■ Only one-third of individuals surveyed in the Bushfire CRC research into the 7 February fires had received information about how to prepare for a bushfire prior to the 2008–09 season.78

The Role of Contingencies in planning for stay or go 7.45 A significant element in any advice to the community on stay or go policy is that the best plans may fail. A plan or attempt to leave early may become impossible. A plan or attempt to defend may have to be abandoned, including because of the intensity of a fire. 7.46 Many of the lay witnesses told of having to change plans and being in situations of extreme danger. Houses caught alight rapidly, far more quickly than expected, and were unable to be extinguished.79 Raining embers could not be extinguished. Spot fires became overwhelming.80 Pumps and water supplies failed.81 The intensity of the fire was frightening and overwhelming, prompting people to flee.82

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7.47 Dr Lachlan Fraser of Marysville told the Commission:

Everything caught fire. At first the embers were such that you tried to put out individual embers and stamp out some and put some out with a hose, but it didn’t take long before green rhododendrons and azaleas burst into flame … I was using bucket and hose to put out spot fires. I was running to the back of the house to put out fires there with the hose at the back … There were great showers of embers coming through the carport. … One person was not enough to stop all those spot fires. The final blow was that the neighbour’s house became like a torch. There seemed to be a wind that came now up our street. It seemed to come across into my house and the neighbour’s house set fire to my eaves. Then I knew it was time to go.83

7.48 The Commission is yet to learn of the plans of most of the 173 people who died in the fires.84 7.49 Many responses to the threat of fires on 7 February did not accord with the ideals in the policy. More than half of the households in the sample interviewed by the Bushfire CRC reported that a household member carried out a late evacuation because of the severe conditions of the fires, and a very small number of interviewees sheltered passively throughout the fire.85 7.50 The accounts given to the Commission about people’s experiences on 7 February are consistent with the research about experiences of previous fires. 7.51 The stay or go position statement expects that when community members implement the policy by making a decision to stay or go, that they will factor in ‘contingency plans’ (Plan B or C) in case a fire is more intense than expected or if a building catches fire and cannot be extinguished.86 7.52 The CFA literature, however, deals with contingencies only in part. When the core document, Living in the Bush: Bushfire Survival Plan Workbook, is read carefully, it communicates a hierarchy of risk — for example, staying in an unprepared home is preferable to being out in the open. It fails, however, to explicitly and directly engage with failed plans, and how to plan for contingencies.87

FLEXIBILITY IN THE STAY OR GO POLICY 7.53 A benefit of the policy, theoretically, is that it allows for necessary flexibility, having regard to the fact that preparation that is effective for one set of circumstances may not be effective in another, and a plan that is suitable for one location may not be suitable for another.88 However, in practice, the advice to the community falls short, and can be improved in several important respects. 7.54 First, it emphasises pre-fire season planning and ‘sticking to your plan’.89 The CFA literature does not explicitly advise that it may be appropriate to plan to stay, but in some locations this may not be safe in certain situations, in particular under extreme fire weather conditions. While encouraging thorough preparedness and methodical implementation of plans is an important objective, it should not be emphasised without also communicating that plans (particularly plans to stay and defend) might well need to be changed, depending on fire weather conditions. The advice should engage directly with the time- sensitivity of pre-determined fireplans. 7.55 Second, while the CFA literature emphasises that it is important to prepare a defendable space and to assess the factors that are relevant to defendability, it does not specifically advise that in some situations, some houses will not be defendable (see below). The advice is that there are ‘two safest options’: leaving early or staying to defend. The advice should be tailored to local geographical and topographical circumstances. The prevailing CFA literature, particularly the most recent Living in the Bush, is virtually silent on the dangers and effort involved in staying to defend, particularly in extremely dangerous bushfires. The CFA advice to the community fails to distinguish between low-intensity and high-intensity bushfires, where the risk factors are quite different. 7.56 This discussion highlights the importance of a change in policy to permit CFA members to recommend leaving early (as discussed in Chapter 6), and to give timely, frank and realistic warnings about expected fire behaviour and intensity, and the associated risk of harm to human life.

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Warnings and the Stay or Go Policy 7.57 In the following statement, Mr Bruce Esplin, Emergency Services Commissioner, explained the view, prevailing on 7 February within the stay or go policy framework, as to the role of warnings to people in a potentially affected community:

The role of the information given on the day is for the people who have planned. So hopefully people would have taken the sensible – if they are planning to leave they should have left by this stage. The information provision during the day should be information to help those people who have taken a considered, logical decision that they are capable of staying and defending a property that is capable of being defended. The information that comes, then, is to enable them to activate their planning. So over the course of those levels of warning I would hope that people would be using it to make sure their pumps are ready to go, do the last little bits, put on their protective clothing; it is information according to the policy that is used to help people make that last little bit of preparation before the fire arrives.90

7.58 Mr Esplin also explained the importance of the provision of information to help the community understand and prepare for bushfires, and of the need to avoid encouraging late evacuation.91 7.59 The role of warnings, within the policy framework as described by Mr Esplin, is not one the Commission can endorse, having regard to the totality of the evidence on warnings (Chapter 4). 7.60 The stay or go advice sits (as it should) in a policy framework that assumes and expects that agencies should attempt to provide information to communities about fire location, rate of spread and predicted wind change, so that they can implement the policy.92 The provision to the community of fire prediction information is one of the important responsibilities of a fire agency.93 7.61 Research into the major fires in Australia has identified the significance of warnings to assist community members make decisions and to put plans in place to protect their safety, both before and during a fire event.94 7.62 A significant number of lay witnesses, when speaking about their experiences of the 7 February fires, impressed upon the Commission the relevance and importance of receiving information about expected fire location, direction and intensity, irrespective of whether their plans were to stay or go.95 While the most effective warning is one that is received by people who will know what it means and how they plan to act on it, a specific warning identifying a real threat, the time the threat will materialise, and advising specific action to be taken, has a good chance of increasing effective action, even among the unprepared.96 7.63 Encouraging preparedness is unquestionably important, as is avoiding late and dangerous relocations. But a policy framework that warns only the prepared is unrealistic. The policy and practice, in relation to warnings, must cater for both the prepared and the unprepared. People look for warnings when threatened or potentially threatened by fire. The application of the stay or go policy should reflect that reality.

PREPARING VULNERABLE COMMUNITY MEMBERS FOR STAY OR GO 7.64 The stay or go policy states explicitly that consideration should be given to relocating vulnerable residents during bushfires.97 The Commission heard compelling evidence about the need for preparation and advice to the community to specifically contemplate and provide for vulnerable members, including children, people with disabilities and the elderly, and the tragic consequences of failing to so do.98 7.65 In the CFA literature, including the core publication, Living in the Bush, in which the stay or go policy is explained, there are references in the text to children and older people. It is noted:

■■ bushfires can be a stressful experience for everyone, including children

■■ that children and older individuals are at a higher health risk

■■ that the elderly and young (including infants) are particularly at risk from heat-related illness. 7.66 Such messages greatly understate the risk to children and older people. The understatements are accompanied by photographs of families with obviously young children apparently engaged in planning. A caption to one family photograph reads, ‘Staying with your home, if it is well prepared and you are physically and mentally able to actively defend, is the safest option’.99 197 2009 Victorian Bushfires Royal Commission—Interim Report

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7.67 There was only limited evidence before the Commission as to the 173 people who died in the fires. It came in the form of a table prepared by the Victorian Police.100 The table does not contain names. In each case, it sets out the age, residential address and a short note as to where the body was found. Three matters merit a note here. First, 113 of the 173 were listed as having been found within the structure of a house. Second, an age of 80 or above was noted for 17 of the 173. In percentage terms, that is approximately double what would be expected on current age/population figures. Third, 23 of those who died were under 17. Of that 23, 15 were found within the structure of 6 houses. There was also the evidence of Ms Jill Kane about the death of her disabled brother at Bendigo; Mrs Joan Davey about the deaths of her son, daughter-in-law and two grand-daughters; Mr Denis Spooner as to the death of his wife and son; and Mrs Carol Matthews about the death of her son.101 7.68 The stay or go messages to families with young children, older people, and disabled people should be changed to an emphasis on relocation.

Preparing Urban Communities for Stay or Go 7.69 The stay or go policy is intended to apply to both rural communities and urban communities on the urban/ rural interface such as Bendigo. However, the communication of the policy has a rural focus. Aspects of its language do not readily relate to an urban context.102 7.70 Work is needed to raise awareness amongst the more urban communities on the urban/rural fringe of the risks of bushfires and the need for preparation. The advice to communities should consider and address the specific issues that arise for urban communities, in particular that leaving early in such communities is not likely to require leaving the night before or early in the morning of a high risk day (and accordingly such advice is impractical); and that the traditional understanding of leaving the bush to go into town does not easily translate to urban communities.103

COMMUNITY EDUCATION AROUND STAY OR GO 7.71 The stay or go policy is predicated on the understanding that to grapple with the complexity of the decision- making and preparation required to successfully implement the policy, community members need the assistance of community education programs. The CFA’s view is that it cannot be assumed that people will make appropriate choices without such education.104 7.72 The CFA has taken a multi-faceted approach to educating the community, recognising that the more significant outcomes of household and community preparedness only occur over the long-term and require sophisticated interaction between the community and fire agencies. The CFA’s Community Fireguard program sets a good example of best practice. There is scope for its development, particularly in how it is applied to the peri-urban fringe.105 To be effective, well-funded long-term education programs are needed.106 7.73 Public education reaches and can be effective for some groups of people, but others are not reached, may be unaffected, or cannot take action for themselves. Even the most successful community and public education campaigns reach only a proportion of the intended audience. As noted previously, only one-third of individuals surveyed as part of the Bushfire CRC research had received information about how to prepare for a bushfire prior to the 2008–09 season.107 7.74 Education programs are not a panacea. They are but one necessary measure to be used in conjunction with other necessary measures, such as effective warnings and situational awareness in agencies and communities, community refuges, and measures to assist the creation of defendable space.108

understanding the term ‘STAY AND DEFEND’ 7.75 The stay or go policy emphasises staying to defend as one of the ‘two safest options’ for community members responding to bushfires.109 The core advice to the community is that ‘staying to defend a well prepared home during bushfire is a safe option if you are physically and emotionally able to defend your home’.110 7.76 The single most important fire protection measure in the ‘stay and defend’ component of the policy is the existence of a ‘defendable space’ around the home. Within the context of the policy, ‘defendable space’ is intended to be an area of managed vegetation and reduced fuel load around the home which reduces fire 198 intensity, radiant heat and the likelihood that flames will come into contact with the home. Stay or Go

7.77 Defendable space is a relative concept. It can only be assessed in the context of the nature and extent of the severity of fire and weather conditions on the one hand, and, on the other, adequacy of design and maintenance of a house and the level of active defence that can be mounted during a bushfire. Whether or not a house is defendable is a function of the interplay of all those factors.111 Some of those factors are static or relatively so (for example, topography, house construction). Others are variable, either during the year or fire season (for example, fuel loads) and some are realised within shorter windows of time (weather and fire intensity). 7.78 The events of 7 February made it clear that even well-prepared properties may not be defendable in certain conditions or circumstances. Some properties in some locations may be defendable in some fire-weather conditions, but not in others.112 This was not clearly recognised in CFA advice in the lead-up to 7 February. 7.79 Creating and maintaining a defendable space requires detailed consideration and planning, substantial time and physical effort, and financial resources.113 7.80 The ‘stay and defend’ option assumes that a considered assessment has been made of the defendability of a house.114 7.81 Despite the advice to community that staying to defend is one of the ‘two safest options’, CFA policy forbids its members advising people about defendability. That policy is based on two considerations. The first is that under the stay or go policy the decision to leave the area or stay with their property is the responsibility of individuals. The CFA personnel guidelines caution that, ‘CFA personnel should be careful not to provide residents with specific directions, remembering that the decision to stay with the house or leave, must always be made by residents themselves’.115 The second consideration is the complexity of the assessment required. The guidelines provide:

A range of factors will influence the likelihood a house can be successfully defended. These include house design, construction and maintenance, vegetation management, fire intensity. These factors are very complex and may vary significantly throughout the fire season or even on any given day … Because of the difficulties in judging these factors it is very difficult to say absolutely whether a house would or would not survive a wildfire. It is therefore very important that personnel do not make statements about whether a house could or should be defended by residents during a wildfire. CFA personnel may come across houses that would have a limited chance of surviving a high intensity fire in their current state. In these cases CFA personnel are able to provide residents with advice on how to increase the preparedness of the house in case of wildfire.116

7.82 Recommended changes to the policy (to allow CFA members to advise residents that the best option is to leave) are discussed in Chapter 6. In the context of CFA advice on stay or go, the complexity and variable nature of ‘defendable space’ should be reflected in advice to the community about the core policy options. As noted above, the advice on preparation currently does not sufficiently emphasise that staying to defend will not be safe in some situations, in particular in extreme fire weather situations, and that plans may need to change. As Dr Kevin Tolhurst observed, the concept of defendability needs to be communicated in the public as a concept, not a guarantee.117 7.83 Despite this complexity, it is clear that assessments about defendable space can be made. Even relatively general assessments of local risk, based on an overall view of topography and weather conditions, would improve the position of residents. Mr Esplin said in evidence that ‘there are communities within Victoria where the safest option is probably to leave on most of those days’ (days of extreme fire risk).118 Mr Gledhill explained that the Tasmanian Fire Service has recently undertaken precautionary ‘triaging’ of properties in areas threatened by bushfire. Where time and sufficient warning of an approaching fire permit (which will not always be the case) fire service personnel classified properties as defendable, undefendable or defendable with fire brigade assistance. Residents of properties classified as undefendable were advised to relocate.119

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7.84 Dr Tolhurst considered that it would not be difficult to have fire agency personnel making assessments of homes over the course of a year, and that with some assistance and a modest amount of training, people could use a computer-based tool to assess the defendability of their properties, taking into account variations in the published fire danger index, and other factors.120 7.85 The State said in submissions that it will, in the future, support members of the community in their decision- making by providing guidance, including an online risk assessment tool to help residents better assess the defendability of their homes and the risks they face under different weather and fire conditions.121 The State also agreed with the proposed recommendation of Counsel Assisting that the CFA consider how to provide individual advice to residents in bushfire prone areas about the defendability of their homes and said that the CFA would be developing a program for that purpose.122 Mr Rees had accepted in evidence that people need guidance of that kind.123 7.86 The risks attached to staying to defend include the risk of dying in the attempt.124 That risk is insufficiently addressed and is understated in the advice on the stay or go policy in the CFA publication Living in the Bush.125 7.87 Implementation of the ‘stay and defend’ aspect of the policy requires that residents be emotionally, physically and psychologically able to defend their property from fire, and that they are able to self-assess that capacity when deciding whether to stay or go. Such an assessment is difficult if not impossible. Communicating the emotional, physical and psychological effects of defending a property is very difficult. Few people have the opportunity to learn from experience.126 7.88 Living in the Bush suggests actively involving children in the defence of homes. During examination Mr Rhodes accepted that it is preferable that children not be present at all during a bushfire.127 7.89 The creation of a defendable space around the majority of properties in bushfire prone areas is not mandated by law and is subject to various government controls that may limit residents’ ability to remove vegetation and reduce fire risk. The Commission is yet to hear any detailed evidence on planning and building controls, or about building construction.

Community understandings of the term ‘LEAVE EARLY’ 7.90 AFAC (in its 2005 position statement) and the CFA (in advice to the community) have refrained from precisely defining ‘leave early’. The advice also does not tell people where to go.128 The CFA advice is that leaving early means ‘leaving home before a fire threatens and road travel becomes difficult’. Living in the Bush identifies the following as possible triggers:

■■ the declaration of a Total Fire Ban (TFB) day or other high fire danger days

■■ ‘when you hear about a fire burning in your district’.129 7.91 The Victorian Auditor-General recommended in 2003 that the CFA reconsider its official advice that all residents planning to leave should do so by 10:00am on high fire danger days. The Auditor-General considered that advice about when to leave should be based on local risk assessment.130 7.92 AFAC’s view is that the selection of a trigger to indicate that people should leave early is ‘very complex’ and that more research is needed, but in the meantime TFB warnings, fire weather/danger warnings, or warnings of fire in an adjoining district may all be used as a trigger.131 Mr Rhodes accepted that official warnings could be used as a trigger.132 7.93 ‘Leave early’ is not a concept that is well understood in the community.133 On 7 February a range of triggering events prompted people to implement their fire plans, including general warnings prior to the day or the fact that it was a TFB day, while for others, it was the first sighting of smoke.134 Yet others waited, in vain in most cases, for an official warning advising them to leave. 7.94 Leaving on days of TFB (which is the current official measure of high risk fire days) is widely regarded as inconvenient and disruptive. Saturday 7 February was the eighth in the preceding 11 days that had been declared a TFB day. Several lay witnesses whose plan was to ‘leave early’ said that the declaration of a TFB provided some guidance, but that something more was needed, including advice about extreme fire risk.135 200 Stay or Go

Source: Courtesy of The Herald & Weekly Times

7.95 CFA research shows that many people ‘wait and see’ whether fire will threaten their area before deciding to leave.136 7.96 The advice on triggers for leaving early is currently unsatisfactory and should be modified. A cascading series of triggers, as follows, would incorporate the need for flexibility:

■■ leaving on extreme fire risk days (which is the safest option)

■■ leaving when you are advised to be ‘on alert’ in relation to a fire that has commenced. This requires that you pay attention to fire information sources (such as 774 ABC Radio or fire agency websites) on days of TFB and extreme fire risk

■■ if you have not acted on either of the above, if you become aware of fire in your area or possibly threatening your area, you should ascertain if it is safe to leave, and if so, you should go to your nearest designated community fire refuge or ‘neighbourhood safer place’.

THEMES IN THE EVIDENCE on Stay or Go 7.97 The evidence of events and experiences of 7 February consistently underscored the importance of the following:

■■ advice about implementing the stay or go policy, particularly advice about staying to defend, needs to be given and understood with an appreciation of the dangers and difficulties of confronting extreme fires

■■ implementation of the stay or go policy, particularly the ‘stay and defend’ option, needs to take into account local conditions and fire intensity

■■ there is a need to allow for contingencies — to have plans A, B and C

■■ there needs to be more particular assistance to community members in relation to ‘leaving early’ and assessing house defendability.

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7.98 The evidence also revealed that Victorian fire agencies implement and conceptualise the role of the stay or go policy consistent with their overarching framework for managing bushfire risk and community safety. Their approach is characterised by a drive for philosophical purity and theoretical consistency — an assumption that all aspects of the engagement between community and agencies must be consistent with the ideals expressed in the policy about how people do and should behave. 7.99 The pursuit of consistency has been important in the opposition to evacuation.137 It was one of the grounds on which the 2005 refuges policy, Fire Refuges in Victoria: Policy and Practice, was adopted.138 It governs, at least in part, the CFA policy forbidding members giving advice to residents about the defendability of their houses.139 It was reflected in the attitude that ‘warnings are for the prepared’ (paragraphs 7.57 to 7.63 above). 7.100 A cautionary note is sounded about that approach as it has several difficulties. First, while the problems feared to be caused by inconsistency (people will be confused) are often asserted, no persuasive evidence of them has been provided. 7.101 Second, the approach engenders assumptions (contrary to the evidence) that people will consistently behave as the models predict, and can tend to understate the difficulties of implementing the policy. 7.102 Third, the approach promotes rigidity and uniformity where flexibility and appreciation of diversity are called for. 7.103 Fourth, the approach can result in the delivery of an overly simplistic message. For example, studies showing the dangers of late evacuation and the effect on house survival of occupants actively defending their home are translated into the slogan: ‘people save houses, houses save people’. In reality, the lessons from past bushfires are more complex and varied. 7.104 The critique of this approach matters because, if unexamined, it can result in the promotion of policy consistency as an overriding value. It can mean that communities are not warned (or warned less effectively than they could or should be) and that they are less likely to be assisted when things do not go according to plan. The Commission has recommended that there be a single overriding value — the protection of human life. 7.105 The protection of that value requires flexibility and a willingness to engage with complexity and diversity. As Mr Rhodes wrote:

We are dreaming if we think ‘stay or go’ is the solution for everyone, or that it will work for everyone in all circumstances. The context in which people make decisions [is] very complex and we cannot assume that people will make appropriate choices or that they will have the capacity to carry out their decisions. We are dreaming if we think we have got it right and can dismiss different approaches, or vary our approach and for example, in some circumstances actually advise people to stay and in others be more proactive in advising evacuation.140

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RECOMMENDATION 7.1

The CFA revise the publications and programs by which it communicates with the community about preparing for bushfires and what to do in the event of a bushfire to:

■■ reinforce existing advice that community members should prepare, and decide, well before a fire occurs, whether to leave early or stay and defend their homes; and

■■ clearly convey the following principles: −− the safest option is always to leave early rather than to stay and defend, −− not all homes are defendable in all circumstances and householders are advised to undertake an individual assessment of defendability, −− unless a property is defendable the advice is to leave early, −− the impact of topography, fire weather and fire intensity on defendability should be factored into household assessments, −− the risks of staying to defend include the risk of physical injury and death, −− contingencies are needed as the best-made plans may fail, −− even if a plan is to stay, preparations to enable leaving should also be made, including the preparation of a ‘relocation’ kit specifying the location of designated community fire refuges, −− there could be psychological impacts of staying to defend a property, −− it is inadvisable for children to be present during the defence of properties, −− practical steps are needed to protect the vulnerable. Families with young children, older people, and disabled people are advised to plan for early relocation, −− advice on triggers for when to leave to incorporate the need for flexibility, the dangers of leaving late and the understanding that a warning may not be received, and −− advice in relation to the policy specifically targeted to urban communities on the urban/rural interface.

RECOMMENDATION 7.2

The CFA consider the means of providing individual advice to residents in bushfire prone areas, as to the defendability of their homes.

RECOMMENDATION 7.3

The CFA ensure its members are fully trained as to the changes to the advice to the community set out in Recommendation 7.1.

RECOMMENDATION 7.4

The CFA train facilitators and educators and ensure manuals, brochures and other materials are enhanced to incorporate changes to the advice to the community in relation to the ‘stay or go’ policy, and the changes recommended elsewhere in this report.

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RECOMMENDATION 7.5

The State and its agencies implement an advertising and awareness campaign on the changes to policy and practices as set out in this report, such as the Standard Emergency Warning System, telephony- based warning system, use of sirens by local communities, refuges and relocation.

Source: Craig Abraham, courtesy of The Age

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Much attention and effort has been focused on developing policies and procedures to assist people who are in their homes in the event of a bushfire. However, less attention has been given to the needs of those who are not at home when bushfires threaten, including travellers, visitors and tourists, and those located at work, in hospitals or other health facilities, or in schools, kindergartens or child care centres.

Greater consideration must be given to identifying areas of risk more broadly. People need a range of options to increase their safety and chance of survival during the passage of a bushfire, especially when they are not at their homes, or when their home does not provide adequate protection. This chapter explores bushfire risk areas, considers options for fire refuges and other ‘safer places’, and assesses the special needs of schools and children’s services.

IDENTIFYING bushfire risk 8.1 Areas of Victoria at risk of bushfire are identified in several different ways. The evidence to date has revealed different processes for identifying areas at risk for the purposes of:

■■ emergency management planning

■■ land use planning

■■ building regulation. 8.2 In its submissions and further material, the State raised a further process for identifying areas of bushfire hazard — township protection planning.1 8.3 In accordance with section 20 of the Emergency Management Act 1986, local councils must prepare and maintain a Municipal Emergency Management Plan (MEMP) that identifies and describes risks in the community, including the risk of fire. 8.4 Part Six of the Emergency Management Manual Victoria (the Manual) contains guidelines for municipal emergency management planning which use a risk management approach to identify and assess the risks that might give rise to an emergency in a municipality.2 The MEMPs for the Mansfield Shire Council and the Baw Baw Shire Council were tendered to the Commission through Mr Robert Spence, the Chief Executive Officer of the Municipal Association of Victoria (MAV).3 Both MEMPs refer to the hazard analysis undertaken in their preparation, and set out the results of that analysis.4 Bushfire is identified as a risk for both municipalities. 8.5 For land use planning purposes, a wildfire management overlay may form part of a municipal planning scheme, to identify areas at particular risk from wildfire. The purposes of wildfire management overlays include:

To identify areas where the intensity of wildfire is significant and likely to pose a threat to life and property.

To ensure that development which is likely to increase the number of people in the overlay area:

■■ satisfies the specified fire protection objectives.

■■ does not significantly increase the threat to life and surrounding property from wildfire.

To detail the minimum fire protection outcomes that will assist to protect life and property from the threat of wildfire.5

8.6 Designation of a wildfire management overlay by a local council imposes planning controls to ensure that:

■■ water is available to enable life and property to be defended from wildfire

■■ there is safe access for emergency and other vehicles

■■ the design and siting of buildings and works improves protection for life and minimises the level of fire impact

■■ fuel (ground fuel and shrubs) is managed to reduce potential fire intensity in the vicinity of buildings.6 206 Risk and Refuge

8.7 The Country Fire Authority (CFA) has published a guide for residents Building in a Wildfire Management Overlay — Applicant’s Kit.7 8.8 For building regulation purposes, the designation of an area as a bushfire prone area triggers the application of bushfire-specific performance criteria in the Building Code of Australia.8 The Building Code of Australia in turn references Australian Standard 3959– Construction of Buildings in Bushfire Prone Areas.9 Until March 2009 a council could designate areas in its municipal district as bushfire prone areas.10 On 11 March 2009, the Building Amendment (Bushfire Construction) Interim Regulations 2009 effectively designated the whole of Victoria as a bushfire prone area, having the effect that all new buildings must undergo a site assessment to determine the level of bushfire hazard and whether specific construction requirements apply. These Regulations expire on 10 March 2010.11 8.9 The Commission has not assessed the extent to which these existing processes are integrated. It intends to deal with building and planning matters in its forthcoming hearings. It may address the issue of integrating risk assessment methods in this context. 8.10 The Commission notes that fragmented planning, including risk identification, was one of the factors that lead to the development of the Integrated Fire Management Planning Framework (IFMPF).12 The IFMPF arose from recommendations made in the Report of the Inquiry into the 2002–2003 Victorian Bushfires, for a new, consolidated approach to fire management planning.13 The recommendations aimed to achieve:

… greater consistency, more effective co-ordination, better co-operation, effective and concurrent implementation of response and recovery activities and reduced duplication of effort.14

8.11 The IFMPF was endorsed by the State in September 2006 and a State Fire Management Planning Committee established in October 2007.15 A draft State Strategy for the IFMPF has been prepared and circulated to stakeholders for comment.16 However, the IFMPF is unlikely to be implemented before 2012.17 While progress has been slow, it is clear from the evidence of Mr Norman Free, the Manager of the State Fire Management Planning Support Team, that considerable work has gone into integrating State and municipal fire management planning.18 8.12 The Commission endorses the concept of integrated, whole-of-government, fire management planning and hopes that this effort leads to planning processes that are easier to use and make communities safer. The Commission shares the frustration expressed by Mr Bruce Esplin, Emergency Services Commissioner, and Mr Free, at the slow progress in implementing this concept.19 8.13 Principle One of the draft State Strategy for the IFMPF, ‘Planning Together’, includes consistent assessment of risk.20 The State Fire Management Planning Committee is considering the adoption of a risk assessment tool, known as the Victorian Fire Risk Register (VFRR), to enable consistent assessment of risk across all agencies.21 The VFRR is a Victorian version of a mapping application, developed by the New South Wales Rural Fire Service, and used in fire management planning. A handout produced by the CFA describes the VFRR as:

… a systematic process that identifies assets at risk from wildfire, assesses the level of risk to assets and provides a range of treatments to mitigate the risk. Treatments may include activities such as fuel reduction, community education programs and safety audits.

The output process is twofold. A series of large output maps are produced displaying assets at risk and risk mitigation treatments, supported by a short document which provides the context, the community participation strategy, a summary of the assessment process and a textual record of all assets and treatments.22

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8.14 A paper prepared by Mr Russell Rees, Chief Officer of the CFA, for the State Fire Management Planning Committee (26 March 2009), reported positively on trials of the VFRR. It noted the lack of a consistent, state-wide approach to identifying, prioritising and documenting wildfire risk across Victoria, and recommended the approval and funding of the VFRR implementation plan.23 The Commission was not told informed whether the State Fire Management Planning Committee approved implementation of the VFRR. It infers from the evidence of Mr Free that implementation was delayed whilst awaiting the outcome of further trials of the VFRR.24 Subject to the outcome of those trials, the Commission endorses the CFA’s proposal to approve the implementation of the VFRR. 8.15 There may be processes for identifying areas at risk of bushfire in addition to those discussed above. The State referred in its submissions to a process of township protection planning as part of the CFA’s operational preparedness, to determine the level of fire fighting and other resources required by communities during a fire emergency.25 One key component of the township protection planning process will be:

… a mapping component that identifies and details the demography and topography of a township and surrounding area. This includes the identification of assets, heritage areas, critical infrastructure, community gathering locations and particular areas of hazard.26

8.16 In its submissions the State also raised the proposed designation of neighbourhood safer places (paragraphs 8.114 to 8.133). 8.17 The Commission has been provided with only an outline of both proposals and did not have the benefit of examining the proposals in its hearings.27 Given the similarity in aims between the VFRR and the proposed township protection plans, the Commission encourages the integration of these processes. The Commission also encourages those developing the State’s proposal to extend township protection planning to ensure that it takes into account the considerable work that has already been done to bring about integrated, whole-of-government fire management planning. 8.18 On the evidence considered to date, the VFRR looks to be a most useful tool with which to designate areas at risk of bushfire in Victoria. Any areas identified by the VFRR should be referred to in the MEMPs of relevant local councils.

RECOMMENDATION 8.1

The CFA report to the Commission on the outcome of the trials of the Victorian Fire Risk Register and progress with its implementation.

RECOMMENDATION 8.2

The Municipal Association of Victoria report to the Commission on the progress of amendments to Municipal Emergency Management Plans by those municipal councils trialling the Victorian Fire Risk Register.

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Fire refuges AND SAFER PLACES

PROTECTION OF LIFE: opTIONS FOR THOSE SEEKING SAFETY 8.19 Those who find themselves threatened by bushfire need options. During bushfires, some people will find themselves in circumstances where they need to take shelter other than in their homes. This may be because their plan to defend their home cannot be implemented in the circumstances, or their plan fails and the house burns. They may also plan to leave but are unable to reach a place away from the firefront in time. Visitors to an area threatened by fire may find themselves caught in the open and some people may not have planned well enough for the risk of fire. Finally, some people with well prepared plans may change their minds when faced with an extremely dangerous fire. 8.20 Once it is accepted that the protection of human life is paramount, it is clear that provision must be made for residents and visitors who need to resort to a ‘Plan B’ or ‘Plan C’ during the course of a fire. 8.21 In 2005, the Office of the Emergency Services Commissioner (OESC) produced the Victorian Government’s current policy on fire refuges, Fire Refuges in Victoria: Policy and Practice (the 2005 Fire Refuges Policy).28 The policy, and the considerations that underpinned its development, are discussed in this chapter. One of its core tenets is that the ‘provision of a fire refuge is a municipal decision, to be based on the rare and exceptional circumstances where other bushfire safety strategies are less effective’.29 8.22 Since the application of the 2005 Fire Refuges Policy, designated fire refuges have all but ceased to exist in Victoria. There are now only nine refuges, located in two municipalities.30 The Commission believes this is primarily because the policy characterises refuges as appropriate only in ‘rare and exceptional circumstances’. 8.23 Evidence before the Commission suggests that the 2005 Fire Refuges Policy gives insufficient weight to protecting life and to the range of circumstances in which people may need to seek shelter during the passage of a firefront. The Commission considers that a fundamental review of the policy is required to ensure that people have access to the broadest possible range of options in the event of a bushfire. The Commission is aware that the OESC has commenced a review of the Policy (see paragraph 8.111).

Terminology 8.24 A refuge is a place that provides people with short-term shelter from the passage of a fire.31 In light of the evidence that people may need to seek refuge, the availability of refuges should be more systematic than being available in ‘rare and exceptional circumstances’. 8.25 In keeping with its conviction that the protection of human life is paramount, and that individuals and government share responsibility for risk identification and mitigation, the Commission proposes both government identified and managed refuges, and private arrangements by individuals. Consistent with the notion that Plan A is a household’s or institution’s primary fire plan, and that Plan B or Plan C are additional, less preferred, options for emergency circumstances, the following types of refuges are proposed:

■■ Designated community fire refuges, identified, constructed or refurbished by the State (following the review of the 2005 Fire Refuges Policy) and maintained by councils

■■ Neighbourhood safer places, identified by the State in consultation with councils, and maintained by councils. It is noted that the State’s proposal suggests that the CFA would assess and manage neighbourhood safer places

■■ Privately identified safer places, being arrangements made by individuals should their plan to stay and defend fail, or should they find themselves otherwise exposed. These arrangements could include options like their own in‑ground swimming pool, or a neighbour’s ploughed paddock. 8.26 None of the options outlined above can completely guarantee the safety of those who use them. In particular, care needs to be taken to ensure that it is understood that Plan B and Plan C are ‘safer places’ that may increase a person’s chance of survival, but still entail some risk, both in moving to them during a fire, and while sheltering in them. They cannot be considered, nor should they be described as, ‘safe’. 209 2009 Victorian Bushfires Royal Commission—Interim Report

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8.27 While not the Commission’s preferred terms, some witnesses made reference to ‘informal refuges’ and ‘ad hoc’ refuges. This is an area, like the language used for describing a fire, which needs further work. The issue of accurate, accessible and succinct language for fire, refuges and other matters will be considered by the Commission in future hearings.

History of fire refuges in victoria 8.28 There is a significant history of fire refuges in Victoria as summarised below. 32 8.29 The Report of The Bushfire Review Committee on Bushfire Disaster Preparedness and Response in Victoria, Australia, following the Ash Wednesday Fires 16 February 1983 (Ash Wednesday Report) considered refuges.33 The Ash Wednesday Report noted that no comprehensive policy or system existed for bushfire shelters prior to the 1982–83 bushfire season. However, the material available to the inquiry indicated that there had been instances in which ‘large numbers of people found communal shelter in large, well-constructed buildings and survived, even though the fire threat outside the buildings was acute’.34 The report states:

Under local disasters plans, consideration should be given to designating buildings which could serve as emergency communal shelters. Such buildings would need to be assessed by a competent authority for their fire-resistant capability and for availability of fire-fighting equipment and water supply.35

8.30 The Ash Wednesday Report recommended that there be an examination of:

Assistance by the State Government to local government in the provision or adaptation of buildings which could serve as communal shelters.

Suitability of school buildings for use as shelters, particularly to mitigate the possibility of students being exposed to risk by being sent home ahead of an advancing fire front.36

8.31 Following the recommendations in the Ash Wednesday Report, fire refuges were established in Victoria in a number of fire prone areas. Signs were erected to indicate their location. Some refuges were buildings, others were simply open areas such as sports ovals and beaches.37 8.32 In 1988, the State Disasters Council published a guide Constructing a Public Building to Act as a Community Refuge (the 1988 guide).38 This document contained guidance about choosing suitable sites, and the design and construction of community buildings suitable for dual use as refuges:

If you are constructing a public building for your community, you should also consider making it a community refuge. … The protection offered by a building can be enhanced by incorporating the siting, design and construction procedures discussed in this paper. … A population with a knowledge of, and confidence in a refuge is less likely to depart in a confused, dangerous headlong rush to hoped‑for safety when a natural emergency threatens, or has happened.

The physical presence of a community refuge can act as a focus of hazard awareness and counter- disaster planning at the individual and family levels.39

8.33 These comments ring true. They are in marked contrast with the findings of the 2001 Working Party, set out below, which suggest that the provision of refuges, in and of itself, tends to render the population less self- reliant and more likely to leave their homes ‘as late as possible’ seeking refuge. The 1988 guide contains a number of useful recommendations, including use of non-flammable materials, sealing external openings, and using concrete slabs and steel roofing.40 These recommendations appear to provide a sensible set of criteria that might be applied when building a community venue that might also serve as a refuge. The Emergency Services Commissioner is urged to reconsider this guide in his review of the 2005 Fire Refuges Policy.41

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8.34 In 1997, a Coronial Inquiry into deaths during fires in the Dandenongs found that there was community confusion about the location of refuges, and about the difference between refuges and relief centres.42 During those fires, several hundred people sought shelter at the Ferny Creek Horticultural Centre, which was a designated fire refuge.43 There was confusion on the day, as emergency services were not aware of the presence of these people. A number of other people sought shelter at other locations that were not designated refuges. The Coroner noted that:

Many residents were unsure of the location of the emergency shelters and relief centres. There is a lot of confusion in relation to what a fire refuge is and what an emergency shelter is. Many residents self evacuated to locations that were not designated evacuation centres which placed them at risk as no police or other support services knew that they were there and therefore could not assist or register same.

One of the most important issues for the effective management of large numbers of people during a major ‘wildfire’ emergency is the provision of safe community fire refuges and emergency shelters …

In addition it is important to ensure that any designated ‘fire refuge’ or ‘emergency shelter’ is in fact safe for the community in the event of bushfire.44

8.35 Following the 1997 Coronial Inquest, a working party of representatives from the CFA, the then Department of Natural Resources and the Environment, the Victorian State Emergency Service, the Department of Justice, Victoria Police, MAV, and a number of councils (collectively referred to as the 2001 Working Party) undertook a review of the use of fire refuges. In April 2001, the working party published its findings in a report titled Examining the role of fire refuges in helping people minimise the risk of bushfire in Victoria.45 The 2001 Working Party reached a view that refuges had become ‘untenable’, and recommended their abolition. It concluded:

The current formal designation of public refuges in some parts of the state is untenable and dangerous in the context of very high to extreme bushfires because:

■■ Refuges have neither been selected nor maintained in accordance with any performance criteria or standards;

■■ Many refuges are located so far from their population catchment that people would need to drive to them – an extremely dangerous practice;

■■ Most refuges could not cope with their current population catchment;

■■ Adjacent vegetation or the refuge being locked when needed could compromise their safety.

Municipal councils are exposed to the risk of liability by designating public refuges. If councils were indemnified in respect of such liability, they could not guarantee safe shelter during very high to extreme bushfires in designated fire refuges.

Even with discontinuance of the use of fire refuges, the inappropriate legal exposure of councils needs to be addressed as a matter of urgency.

Visitors and other non-residents need special consideration in bushfire safety. It is assumed that they do not know the location of designated refuges nor access routes.

Local, well chosen informal places of shelter (particularly as part of a personal survival strategy) offer people of Victoria a better chance of surviving a high intensity bushfire than designated / formal fire refuges.

The best chance to survive a bushfire is through community education to understand the need for, and the development of, a personal survival plan. Through their planning, people will decide to ‘stay and defend’ or ‘leave early’. If they decide to stay, their plan will help them to prepare their property to minimise the risk and assist them to locate an open space or building where they can shelter by or with their neighbours as the fire front passes through.46

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8.36 The 2001 Working Party report recommended that, due to the risks associated with designated refuges, the Victoria Emergency Management Council should remove all reference to designated formal fire refuges in the Manual and formulate guidelines for ‘Local Informal Places of Shelter’.47 8.37 The report of the 2001 Working Party also recorded the ‘strong view’ expressed by ‘more than thirty agencies and councils in attendance’ that the provision of designated fire refuges makes communities:

■■ Less self reliant

■■ More likely to evacuate an area late, in the knowledge that there is a designated fire refuge within driving distance

■■ More prone to seek help from and even blame the relevant emergency authorities if something goes wrong.48

8.38 The suggestion that the mere provision of refuges increases the propensity of people to leave an area late was not supported by any formal research cited by the 2001 Working Party, nor was the suggestion that provision of refuges encourages the community to blame the emergency authorities. 8.39 The 2001 Working Party expressed a clear preference that the State cease designating refuges. However, it was accepted that the development of ‘informal places of shelter’ might occur. The 2001 Working Party report reveals the emergence of four strong themes, which have continued to feature highly in the debate about refuges:

■■ the involvement of councils in any aspect of provision or operation of refuges ‘exposes them to the risk of liability’

■■ provision of refuges may undermine the ‘stay or go’ policy

■■ it is difficult or impossible to guarantee the safety of refuges

■■ informal places of shelter are preferred.49 8.40 Each of these propositions find expression in the 2005 Fire Refuges Policy, which is discussed in more detail below.50 8.41 The suggestion in the 2001 Working Party report that ‘local, well chosen informal places of shelter … offer … a better chance of surviving’ seems contradictory. Rather, people need to be advised that, even when refuges are formally designated, there may be occasions when it is not possible to safely reach them. In such cases, the person may need to fall back to a ‘Plan B’ or ‘Plan C’ to increase their chance of survival. 8.42 This does not diminish the need to provide designated community fire refuges in the first place — nor does it assist in determining whether any particular refuge is more, or less, safe than any other. The relative safety of each will depend on the circumstances of a particular fire, and the capacity of the individual to safely reach the refuge. 8.43 In 2001 the CFA developed draft guidelines for fire refuges and emergency relief centres.51 The performance criteria in the guidelines are very similar to the criteria ultimately set out in the 2005 Fire Refuges Policy. The CFA guidelines were used to assess existing or proposed refuges. Significant problems emerged, as the majority of refuges assessed by the CFA did not comply with the performance criteria.52 From 2001 onwards, most refuges in Victoria were decommissioned.53 8.44 In 2003, an Auditor-General’s report, Fire Prevention and Preparedness, considered refuges.54 Survey results presented in the report indicated that a significant proportion of residents (24 per cent in the Dandenongs and 30 per cent in Gippsland) planned to go to a local refuge if they left their homes during a fire.55 8.45 The Auditor-General’s report noted that, following the work of the 2001 Working Party, some councils had removed all signage and information from refuges ‘because of concerns about legal liability’, and that, where signage did exist, processes for ongoing risk assessment, building and maintenance standards and operation in the event of a fire were insufficient.56

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8.46 The Auditor-General’s report recommended that:

…the OESC, in consultation with the CFA, the DSE [Department of Sustainability and Environment] and local government, urgently progress work on a consistent Statewide position on fire refuges which incorporates a risk assessment process, standards for fire refuges and aligns with the policy position on evacuation. 57

8.47 The OESC conducted a lengthy review process that culminated in the State’s 2005 Fire Refuges Policy.58 The policy states that:

■■ fire refuges will only be provided in rare and exceptional circumstances

■■ the decision whether to provide a refuge rests with the municipal council

■■ if a refuge is to be provided, the refuge must comply with published standards and guidelines.59 8.48 The performance criteria in the 2005 Fire Refuges Policy include ‘fixed’ and ‘operational’ components, including criteria for:

■■ siting and fuel management

■■ design and construction

■■ water and firefighting equipment

■■ capacity, availability and access

■■ facilities

■■ criteria for operation and for attendance by a fire crew.60 refuges in Victoria in February 2009 8.49 Since the promulgation of the 2005 Fire Refuges Policy, no new fire refuges have been designated. Many venues are unlikely to meet the criteria in the policy. 8.50 On 7 February, the only existing designated fire refuges were:

■■ Mansfield Shire Council:

– Woods Point mine adit

■ Baw Baw Shire Council:

– Walhalla Township

– Dam wall, Moondarra Reservoir

– Rawson Shopping Centre

– Dam wall, Thomson Reservoir

– Allambee Camp

– Catherine Creek Recreation Camp

– Noojee Hall

– Tanjil Bren dugout.61 8.51 The Woods Point mine adit (or mining tunnel) refuge is dealt with in the Woods Point and Surrounding District Community Safety Plan, which is a sub-plan of the Mansfield Shire Municipal Emergency Management Plan 2008–2010.62 This is discussed in more detail below.

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8.52 The Baw Baw Municipal Fire Prevention Plan 2007–2012 briefly refers to the eight refuges located in the shire.63 It says:

Refuge Areas

It is impossible to provide any location that is guaranteed safe from a wildfire, however, it is the MFPC’s [Municipal Fire Prevention Committee’s] objective, along with other organisations involved in emergency management, to define locations that may offer the best refuge for persons who may be affected by wildfire. This allows the brigades and the MFPO [Municipal Fire Prevention Officer] to request or provide for special treatment of an identified site to support its use in a fire emergency.64

8.53 It appears that very few designated refuges are located on council land. For example, Thomson Dam wall is operated by Melbourne Water, Moondarra Dam wall is operated by Gippsland Water and the Tanjil Bren dugout is on Department of Sustainability and Environment (DSE) property. 65 Rawson Shopping Centre is assumed to be a commercial operation, although it appears the centre car park is Council land. Noojee Hall is owned by the Council.66 Mr Spence accepted in evidence that it was unlikely any money had actually been spent by councils on the existing designated refuges.67 The Woods Point adit project was funded by a local grants program administered by Emergency Management Australia (part of the Australian Government Attorney-General’s Department).68 8.54 In his oral evidence, Mr Spence revealed concerns about a number of the refuges in Baw Baw Shire Council. Correspondence was produced that suggested some were not compliant with the 2005 Fire Refuges Policy. Those refuges have not, however, been decommissioned.69

use of refuges 8.55 The Commission has heard evidence about two refuges that existed as at 7 February — the Woods Point mine adit (a formal designated refuge, recognised under the relevant MEMP) and the Walhalla Long Tunnel Extension mine (which is not officially designated).70 These refuges are described in detail below. However, the Commission notes that, as they are both longstanding physical structures specific to a particular location (that is mines), these refuges may not be typical of the kinds of refuges that would be available or appropriate in other communities or locations.71 8.56 Other evidence relates to ad hoc refuges — namely venues sought out by members of the community on 7 February, often in desperate circumstances.72 Some attempts to find ad hoc refuges were successful and saved lives. Other attempts were more fraught. 8.57 The Bushfire Cooperative Research Centre’s Victorian 2009 Bushfire Research Response Interim Report 2009 contained preliminary research results on refuges.73 The report noted that refuges and shelters ‘emerged as an important issue’.74 It revealed that some in the community were unclear about the location of refuges. Residents of Kinglake and Kinglake West were recorded as believing that evacuation to firestations was advisable as these would be well defended. The report stated:

In summary there appears to be evidence that many community members regard public buildings, ovals and emergency services facilities as safe places of refuge during a bushfire. There is some evidence of support for purpose-built community shelters in which residents can take shelter during a bushfire. Several of those interviewed reported that they were considering building personal shelters or ‘bunkers’ to protect them from bushfire.75

THE WOODS POINT refuge: A CASE STUDY 8.58 The Commission heard detailed evidence about the Woods Point adit, from Mr Kenneth Dwight, Leading Senior Constable at the Woods Point Police Station.76 It provides a useful model of how a community might establish a refuge, draw up guidelines for its use and educate the community about the circumstances in which the refuge might be safely used.77

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8.59 The town of Woods Point has a permanent population of about 30, but during the fire season there are commonly tourists in the area.78 The adit is a 50-metre-long shaft, with benches, chairs and basic supplies including water, fuel, food and medical equipment. It was used in the 1939 fires.79 The adit has mesh and bolts, concrete culverts and an airlock between the concrete and the main tunnel. Thick felt blankets cover the entrance to the main tunnel. Water is pumped from a large dam in the adit, with a gravity-fed pump, and hosed onto the blankets.80 8.60 The Woods Point and Surrounding District Community Safety Plan, which is a sub-plan to the Mansfield Shire MEMP, designates assembly areas and appoints a fire warden and a fire refuge warden. The fire refuge warden is responsible for opening the refuge when advised by police, or the control agency dealing with the fire, and is on standby on ‘Code Red’ days (designated as days with a fire danger index above 35). Steps are taken if a fire starts, or advances, within nine kilometres of Woods Point. Community members are advised to monitor the radio, activate their fire plans, satisfy themselves how long it will take them to reach the refuge and pass on communications via a telephone tree.81 8.61 Pamphlets giving directions for using the adit are distributed in local stores and throughout the Shire.82 The pamphlets are extremely useful and provide information that may not otherwise be accessible, particularly to visitors. Mr Dwight has also, on occasion, distributed a brochure designed for tourists to campsites in the area.83

THE WALHALLA mine AS A REFUGE: A CASE STUDY 8.62 Walhalla has a permanent population of approximately 12 to 20 people, although this number may swell by two or three hundred people during holidays and long weekends.84 The Long Tunnel Extended mine in Walhalla is a tourist attraction, not far from the centre of town. It has long been used as a fire refuge (including during the 1939 fires), although it has not been formally designated as a refuge.85 8.63 The Hercules Mining Company is the lessee of the mine, which is controlled by DSE. The mine is equipped with water, power and an emergency generator. The main chamber, deep underground, can accommodate 200 people. There is a canvass cover which may be placed over the entrance if necessary.86 8.64 Mr Simon Seear, a CFA volunteer, whose family has a long connection with the town of Walhalla, gave evidence.87 Mr Seear has secured permission to use the mine, as required, during fires, and he and other CFA members inform local residents and visitors about use of the refuge. Since the February 2009 fires, a CFA volunteer has prepared a flyer containing information about use of the refuge, which contains useful instructions and a map. It is intended to be made available to local residents and visitors.88 8.65 Fire threatened the town of Walhalla on the afternoon of 7 February, coming within a couple of hundred metres of the main street. On the morning of 7 February, Mr Seear visited camp sites in the town and advised campers to leave the area, or to proceed to the refuge if they decided to stay and fire threatened the town. As the fire approached, CFA volunteers alerted residents to the approaching fire, met with them at the hotel in the main street and directed those who wished to take shelter to proceed into the mine. About 30 people (all but six people then located in the town) proceeded into the mine.89 8.66 Mr Seear noted that:

The vast majority chose to head for the [mine]. Even people who I know in previous years had determined their bushfire plan was to ‘stay and defend’ took the opportunity to go underground. ... The feedback I have since received from some residents has been to the following effect: ‘thank God someone took control and told us what to do’. This to me was good news that our preparations were of significant use. We now want to put up a sign about use of the [mine] as refuge before the next fire season.90

8.67 The Walhalla mine is a good example of a sensible local solution for an isolated town. It is clear that those in the town gained comfort from the planning that had taken place prior to the day. The mine served the town well.

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other refuges 8.68 The Commission heard evidence of people using open spaces and public areas as ad hoc refuges on 7 February. This ranged from what might be described as the informal but organised approach adopted at Gallipoli Oval in Marysville, to truly ad hoc attempts to find shelter in places like the Kinglake West School. 8.69 Some lay witnesses were dismayed that they were unaware of any refuges in their area, or were not sure which venue was to be used.91 For example, Dr Lachlan Fraser had thought the Marysville golf course was a designated fire refuge. In the event, he did not have time to get to the golf course and ended up staying at the local football ground (Gallipoli Oval, Marysville) for the night.92 Some witnesses chose their own places of refuge.93 A number of people congregated at Gallipoli Oval, in Marysville, on the evening of 7 February.94 Mr Daryl Hull said he was aware the oval was a meeting point to be used if there was danger in the town.95 A convoy left that oval as fire approached.96 8.70 There were examples in which members of the community sought refuge in private properties, and of circumstances where the owners were not able to offer them protection.97 8.71 Mr Paul Hendrie, Captain of the CFA Brigade in Kinglake, attested to the fact that there had been two fire refuges in Kinglake (Kinglake East Primary School and the Community Centre) but both had been decommissioned. Despite its decommissioning, a number of people gathered at the Kinglake East Primary School on 7 February. Some broke into the multipurpose room and sought refuge. Both buildings survived the fires.98 Another witness took shelter at Kinglake West School. The school burned to the ground around him, and he decamped to a nearby oval.99 8.72 Mr David O’Halloran was aware that the cricket ground at Yarra Valley Recreation Reserve was known by locals to be a refuge in Flowerdale, albeit unofficial.100 He said it would be good to have a designated fire refuge.101 On 7 February, the Flowerdale pub became an informal venue where a number of people sought refuge.102

MAV position on refuges 8.73 Mr Spence gave evidence on the position of MAV and 77 councils. He advanced a number of reasons why councils had decommissioned and generally not sought to designate public fire refuges, following the release of the 2005 Fire Refuges Policy:

■■ the inconsistency of designated public fire refuges with the ‘stay or go’ policy

■■ the increased risk to personal safety unless designated public fire refuges are located close to communities or the people that move to them in the event of a fire

■■ the implicit representation that, by designating a place as a public fire refuge, individuals will be safe from a fire, when safety may not be guaranteed

■■ the failure or inability of previously existing public fire refuges designated by councils to meet the performance criteria mandated by the 2005 Fire Refuges Policy

■■ the fact that a number of existing designated public fire refuges were at locations not recommended in the 2005 Fire Refuges Policy, such as schools or on private property

■■ the cost of making buildings or other places compliant with the performance criteria in the 2005 Fire Refuges Policy, or of replacing buildings or other places with new compliant facilities

■■ the exposure of councils to legal liability, and the refusal of the State to provide any immunity from such action.103

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8.74 Mr Spence also suggested that if the State specifically required the provision of designated fire refuges, MAV ‘would hope that steps are taken and guidance would be given’ in relation to:

■■ the types of communities and areas in which refuges should be established

■■ who, and in particular which, expert agencies would determine their specific location

■■ the number to be established in any community, municipality, region or in Victoria

■■ the capacity of any particular designated public fire refuge

■■ their standards for the design, construction, siting, operation and performance

■■ responsibility for their establishment and management, during and after a fire

■■ the provision of necessary funding

■■ the immunities that are to apply.104 8.75 Mr Spence emphasised Councils’ limited financial resources. He suggested that any requirement that councils provide designated public fire refuges would be likely to raise issues unless adequate funding was provided.105 Mr Spence suggested existing funds may need to be diverted from other activities such as family and community services or infrastructure services and raised the possibility of a rate increase in some municipalities.106 He said the financial burden might fall most heavily on municipalities with the least resources ‘being municipalities which are densely vegetated with numerous small and often disparate communities, and whose rate-paying populations are relatively limited’.107 8.76 Despite concerns regarding costs, Mr Spence was unaware of the details of the Commonwealth’s package of $79 million under the Natural Disaster Mitigation Program.108 The guidelines for grants under this scheme make specific reference to ‘grass roots disaster resilience’ projects, and to local government using funds to ‘disaster proof’ public infrastructure.109 8.77 The MAV also expressed its concerns about liability and the possibility of litigation. Since at least 1998, councils have made representations to the State seeking immunity from tort liability in respect of provision, maintenance and promotion of refuges.110 Councils have an immunity in relation to aspects of their road management functions. However, they do not have an immunity in relation to the other core services they provide, such as child care, immunisation, maternal health and aged care.111 Despite this concern, Mr Spence was not aware of a council being sued in relation to a MEMP, a Municipal Fire Prevention Plan, provision of assembly areas or provision of refuges.112 8.78 The Commission has not considered the issue of immunity (a legislative provision that prevents action being taken against a person, thereby removing the legal rights of a person who has suffered loss to take action) or indemnity (an agreement to be responsible for the financial liability for all or part of the damage that another party may suffer). It notes that it is possible that, if the designation of community fire refuges is undertaken by the State, questions of legal liability of councils may change. However, councils are likely to retain some role in advising on the selection of appropriate sites, and maintaining and operating designated community fire refuges. Issues of immunity, indemnity or funding are matters for the State to consider in developing its revised policy on refuges. 8.79 The position adopted by councils about refuges may be inconsistent with their existing obligations on emergency management. In accordance with section 20 of the Emergency Management Act, councils are obliged to prepare and maintain MEMPs. In relevant regions, councils are also required to prepare Municipal Fire Prevention Plans under section 55A of the Country Fire Authority Act 1958.113 8.80 The Commission rejects the suggestion made by Mr Spence that councils are mere followers who are effectively limited to implementation of State policy.114 Councils carry the core responsibility of preparing and executing MEMPs.115

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8.81 The Commission notes the intention that MEMPs and Municipal Fire Prevention Plans be revisited as part of the implementation of the new IFMPF, but that work has not progressed to a stage where changes to those plans have been made. In particular, the IFMPF process has not yet touched on the question of refuges.116 Issues that arise in relation to township protection plans, neighbourhood safer places, and any future work on municipal emergency management planning, should all take place in the framework of the emerging IFMPF. An integrated approach should be adopted.

CFA position on refuges 8.82 Mr Rhodes, Manager, Community Safety, Research and Evaluation for the CFA, gave evidence about the CFA’s position on refuges.117 He suggested that the OESC Guidelines (the 2005 Fire Refuges Policy) ‘do not preclude the designation of locations as Fire Refuges’.118 Although this is technically correct, the evidence of Mr Rhodes suggests that the policy is heavily weighted against the designation of fire refuges. Mr Rhodes said:

If fire refuges were to be formalised as a bushfire safety option they would need to be purpose built to meet appropriate safety standards and be capable of accommodating large numbers of people and animals for unknown periods of time. The questions of who is responsible for managing the fire refuges and ensuring safety standards are complied with would also need to be addressed. Refuges would need to be audited on a regular basis to ensure that they continue to comply with safety standards.119

8.83 While the Commission accepts that new designated community fire refuges may need to be purpose built, it awaits the OESC review of the 2005 Fire Refuges Policy to ascertain the degree of retrofitting that may be required for existing buildings. 8.84 Mr Rhodes suggested that ‘informal, local places of shelter’ provide a ‘viable alternative to official fire refuges’.120 He said:

Nevertheless, informal places of shelter could either replace the need for formal fire refuges or complement them and perhaps make formal places of refuge more viable by reducing potential demand.121

8.85 In his oral evidence, Mr Rhodes distinguished between formal municipal refuges and informal places of shelter. He suggested that the characterisation of such places might alter the way people interpret and apply the ‘stay or go’ policy. He said the following:

… when those places have been used in the past, that’s given people the idea that these could be formalised into places of shelter. Once you formalise them, they are no longer really serving the function that they served in these major fires because in the major fires they are effectively informal places of shelter. Once you designate them as a refuge, then you are changing the context in which people in that area might then make their decision about what to do. So, consequently, rather than be a place where people might go to if they are caught in the open, which is what they do during the fires, you are actually suggesting this is a place where the community could go, which is different from in fact what happens during the fires. Once you get to the point of saying this is a designated safe place that people could go to, you may be opening up the possibility of the whole community, for example, going to a particular location. Now, I’m not saying that’s impossible and it is not impossible to manage, but it is a very different thing from what actually happened during these fires.122

8.86 Mr Rhodes appears to suggest that the formal designation of a particular venue as a refuge or a safe place might inspire large numbers of people to go to that place. It is accepted that more people may be likely to attend a formally designated community fire refuge than another venue that has not been called a refuge or signposted as such. However, with the adoption of neighbourhood safer places (paragraphs 8.114 to 8.133), there would be more options available locally, some in closer proximity to a home that proves difficult to defend. In addition, individual households may choose privately identified safer places as their most viable option.

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8.87 Mr Rhodes emphasised that ‘you would still need to make sure that people are making choices that are as informed as possible about what’s safe or safer than another place. So it would still require some advice or education of what constitutes a safer place’.123

Expert opinion on refuges 8.88 Mr David Packham is adjunct Senior Research Fellow at the School of Geography and Environmental Science at Monash University. He provided his expert opinion on the use of fire refuges based on his experience in fire science and sociology of disasters.124 Mr Packham is in favour of a new approach to refuges.125 He advocated using existing structures and open spaces, selected and designated following assessment with the CSIRO House Survival Meter, developed by Andrew Wilson after the Ash Wednesday bushfires, which he referred to as the ‘Wilson meter’.126 8.89 In his evidence, Mr Packham advocated giving more thought to using existing venues, given the rarity of bushfires:

It occurs about every 30 years or so, and not over the entire state, so it seems a bit of almost overkill to me to build absolutely bomb proof fire shelters everywhere and to maintain them for about the 30 years that you need to maintain them …127

8.90 Mr Packham expressed the view that the CSIRO House Survival Meter provides an adequate guide, such that if a building or structure reached 98 per cent ‘survivability’ on the meter, it would constitute an adequate fire refuge.128 He explained that an assessment using ‘the meter’ takes approximately 30 minutes.129 8.91 Mr Packham said that one could be very safe without meeting all of the requirements of the 2005 Fire Refuge Policy: ‘the actual scientific base behind these recommendations, I think if you look into the literature, is going to be extremely weak indeed’.130 8.92 He suggested that a number of venues might constitute adequate refuges:

■■ some pubs are capable of providing adequate shelter, at least where there are people available to defend the building131

■■ a town shopping centre132

■■ ovals and sporting grounds, if they are green and or do not have too much fuel around the outside133

■■ fire stations (although Mr Packham also acknowledged that some fire stations had burned down during bushfires)134

■■ public toilets, provided they are brick.135 8.93 The Commission also heard from Mr John Nicholson, Director of Community Safety Services Pty Ltd.136 He consults in fire and emergency risk management and planning. Mr Nicholson also has significant experience as a career officer with the CFA between 1967 and 1999.137 8.94 Of the 2005 Fire Refuges Policy, Mr Nicholson said he found it ‘disappointing in that it provides no firm leadership on an issue critical to the safety of some Victorians and others’.138 He said:

[T]he policy itself is quite a tome and I prefer to see things done simply and I think that the wildfire management overlay... That provides guidance there for people… That’s already there.139

8.95 In his opinion, there is a need to provide refuges in some parts of Victoria, including areas where travellers and tourists regularly visit, such as the Great Ocean Road, or other isolated areas and communities.140 Mr Nicholson said the responsibility for designating refuges should rest with the State, with advice from the CFA and in consultation with the community, municipality, Victoria Police and Victorian State Emergency Services.141

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8.96 In his view, suitable criteria for the selection of refuges could be drawn, by analogy, from those in the Victoria Planning Provisions (subsection 44.06–1 Building and Works, Wildfire Management Overlay) relating to water supply, access, building and works and vegetation.142 He accepted that application of these criteria to existing venues may require modifications to some buildings.143 8.97 He suggested a number of existing venues that might constitute adequate refuges, such as hotels, beaches, ovals and sporting grounds.144

REVISITing THE 2005 STATE refuges policy 8.98 Mr Rees and Mr Esplin accepted that the current policy on the provision of refuges needs to be revisited.145 8.99 Mr John Gledhill, Chief Officer of the Tasmanian Fire Service and a Director of the Australasian Fire and Emergency Service Authorities Council, gave evidence that in his opinion (not formally that of the Council), fire refuges could be an option for some communities, noting that, for others, it may be impracticable.146 He said that refuges are a ‘far better and practical alternative to forced or directed evacuation and, with more work, can sit comfortably within the structure of Stay or Go’.147 South Australia is also reconsidering its position on refuges.148 8.100 The 2005 Fire Refuges Policy has not resulted in any new refuges being established in Victoria, and has raised questions about the few existing refuges that continue to be recognised. In the Commission’s view, the current lack of refuges fails to provide for those who find themselves in danger when their plans fail, those who are overwhelmed by circumstances, those who change their minds and those who have no plan. The lack of refuges in Victoria also fails to assist people in areas threatened by fire who are away from their homes, such as employees, visitors, tourists, travellers and campers. Any option that reduces the risk to people in these circumstances warrants consideration by the State. 8.101 A new approach, which is capable of providing more options for the community, should be embraced. The new approach should shift the emphasis away from an exclusive focus on purpose-built structures acting as refuges, and permit the use of existing venues (including car parks, amenities blocks and dam walls) and open spaces (such as ovals, sporting grounds and race tracks). 8.102 A regime for designating community fire refuges should balance achievable criteria for their identification and operation, with the need to provide a range of options with appropriate minimum safety standards. The responsibility for such a regime derives equally from the State’s responsibility for the life and safety of all its citizens, from the CFA’s obligations to protect communities from the hazards of bushfires and from councils’ obligations for local emergency management.149 8.103 Individuals and households also have responsibilities to maintain a fire plan with a range of options. The designation of refuges will not exclude the use of privately identified safer places for individuals to seek refuge, as and when required, as these are quite different concepts.150 8.104 The question of refuges has generated intense debate over a number of years in Victoria.151 The debate has been accompanied by policy statements that do not appear to have a firm foundation in fact (paragraph 8.38). 8.105 The MAV and the CFA have commonly advanced the view that the mere provision of fire refuges encourages people to leave their homes late, thereby placing them at risk.152 It is also often said, including in the 2005 Fire Refuges Policy, that the provision of fire refuges undermines or would be inconsistent with, the ‘stay or go’ policy.153 The Commission is not convinced about the validity of these assertions, or that they have been adequately tested. No empirical evidence was provided by witnesses to support these claims.

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8.106 For a number of years, the CFA and MAV have argued that designated community fire refuges should only be provided in rare circumstances, because of inherent risks in their selection and operation.154 At the same time, however, both organisations have advocated the use of ‘local informal places of shelter’ selected by members of the community (alone or in groups).155 It is not clear why CFA and MAV suggest that the State should not designate ‘safer’ places, but that individuals should be encouraged to do so. It would seem more logical that selection of places to shelter during the passage of a fire front be undertaken by an agency of the State, with expertise in fire behaviour and emergency management. The Commission believes that the task should be undertaken in a partnership involving the State, the CFA, local government and residents, taking account of the experience and perspectives of each party, rather than being left to individuals. 8.107 It is accepted that, regardless of the system for selecting and operating formally designated community fire refuges, some people may, on occasion, have to abandon a plan to travel to a designated refuge, and opt for another venue. That may be a venue that has been designated as a refuge, or it may not, depending on the nature of the emergency and the options available to those affected. This is a question of necessity, and should not drive the central policy, which should be focused on the designation of refuges according to achievable criteria for their identification and operation, balanced with the need to provide a range of options. 8.108 Mr Nicholson expressed a view that the CFA should, when possible, provide resources to assist in the defence of a designated community fire refuge whenever such refuges may be directly impacted by fire.156 Mr Packham said that once the initial attack by the CFA is exhausted, it should set up protection in safe areas to defend refuges.157 8.109 The CFA should give active consideration to providing resources to assist the defence of formally designated community fire refuges during the passage of a fire. This may not always be possible, and decisions will be made in light of all the circumstances pertaining to the allocation of resources to suppress a particular fire. Nevertheless in the Commission’s view, the existence of known local places where people are likely to congregate heightens the possibility of some protection being available from the fire services. The State accepted this in its written submissions.158 8.110 Further, where possible, providing a means to actively protect designated community fire refuges, in the form of a water source, hoses and firefighting equipment, provides those sheltering there with the best chance of survival, even when CFA resources are not present.

RECOMMENDATION 8.3

The CFA give priority where possible to provide resources to assist in the defence of designated community fire refuges and neighbourhood safer places at times when they are likely to be in use.

review of the 2005 Fire Refuges POlicy 8.111 In its submissions, the State indicated that the OESC and the CFA would review the 2005 Fire Refuges Policy and, in so doing, would consult widely, including with MAV.159 The Commission has neither heard evidence as to the scope of the OESC review, nor its expected date of completion. In oral submissions, it was suggested that the development of new standards to replace the 2005 Fire Refuges Policy ‘is something that realistically will take a couple of months’.160 8.112 The State urged that any recommendations about designated or formal refuges should await the outcome of the OESC review in order to avoid ‘unrealistic community expectation that fire refuges will be available for the next fire season’.161 8.113 The Commission notes that the State proposes to identify neighbourhood safer places and urges swift implementation of this concept, as well as the recommendations of the OESC review particularly in fire‑prone areas.

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A new CoNCEPT — neighbourhood safer places 8.114 In its submissions to the Commission the State recognised that there must be ‘additional options’ for people who are unable to shelter in a prepared home or are caught in the open during a fire and submitted that ‘consideration should be given to incorporating fire refuges into bushfire policies as places of last resort’.162 But it asserted that ‘it will not be possible for this to occur in time for the next bushfire season’.163 In oral submissions, Mr Allan Myers QC reiterated as follows:

We say this very very clearly and plainly. It will not be possible for refuges to be established before the next fire season … [t]here will have to be careful consideration of the standards that apply to a refuge.164

8.115 The State urged that any recommendations concerning formal designated fire refuges be delayed, to avoid unrealistic expectations that fire refuges will be available for the next bushfire season, to ensure that adequate time is given to establishing appropriate standards for refuges and addressing other key issues (such as the number of people who might use a refuge and the availability of parking), and to undertake community education about any new arrangements.165 8.116 The State suggested that the Commission should consider other options such as ‘safer places in a neighbourhood, informal places of shelter and township protection plans’.166 In this context, it indicated that the State will ‘for the next bushfire season’ start identifying appropriate sites as neighbourhood safer places and will ‘educate the public about the appropriate use of those places’.167 8.117 Following the conclusion of the hearings, the State supplied a document titled Further Material of the State of Victoria, documentation concerning township protection plans and a further document, Country Fire Authority: Business Case for Community Safety Preparedness Programs for 2009–2010 (July 2009).168 The Business Case reveals that considerable work has been undertaken by PriceWaterhouseCoopers, at the request of the CFA, to develop a business case and identify funding needs for community safety programs for the next fire season, including township protection plans and neighbourhood safer places.169 8.118 The State indicates it could being rolling out a program of township protection plans in 50 towns by next bushfire season, and could commence identifying neighbourhood safer places.170 The Commission commends this action, suggest that the sites be identified based on bushfire risk. 8.119 The neighbourhood safer places program will assist communities or groups to identify safer places in their neighbourhood. The State proposes that a neighbourhood safer place:

… will provide a space which is a place of last resort for individuals to access and remain in during the passage of fire through their neighbourhood, without the need to take a high risk journey. They are intended to provide a place of relative safety – they may, for example, be a house in the street built of brick rather than wood.171

8.120 Documents provided by the State indicate that:

■■ The neighbourhood safer places program is likely to be a partnership arrangement among the CFA, local government and local communities.172 The State will develop, and the CFA will administer, the program with local participation and engagement.173

■■ The program will build on existing programs like Community Fireguard and be integrated into township protection plans, but will not be dependent upon these plans.174

■■ Areas of highest risk will attract attention as a priority, including ‘interface areas’, bush and parks areas and the highest bushfire risk localities. Neighbourhood safer places will be identified in high risk communities where either the pilot township protection plans are put in place, or there is an existing fire prevention and community engagement process, such as the Community Fireguard.175 This is a sound approach.

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8.121 There is promise in the State’s proposal for neighbourhood safer places. While not fully developed in its submission, the concept appears to have a number of features in common with both formal and informal refuges. However, it also appears from the State’s submissions that the neighbourhood safer place might be a broader notion than a refuge. For example, reference is made to taking shelter in a neighbour’s home. The Commission suggests that full development of the concept should separate those refuges or ‘safer places’ designated and organised by government, and the private arrangements of individuals, as laid out in paragraph 8.25. 8.122 The criteria for neighbourhood safer places, and the way in which they might operate, were not explored in the evidence of the State’s witnesses. However, it is noted that the concept of neighbourhood safer places is consistent with the approaches to refuges advocated by Mr Packham and Mr Nicholson, and is not inconsistent with the evidence of Mr Rhodes. 8.123 The Commission agrees with the State’s position that a ‘one size fits all’ approach to fire refuges is not appropriate for all communities.176 Each community faces different risks and has its own needs. The evidence suggests that a more creative approach to refuges is desirable, so that a broader range of venues available in, and suitable for, local communities can be used to provide shelter to some residents. 8.124 The submissions of the State suggested:

Informal, local places of shelter provide a viable alternative to formally designated refuges and also overcome some of the issues associated with official fire refuges including the need for travel to these sites and management and implementation issues.177

8.125 The intention appears to be that neighbourhood safer places will be identified by the State, and that the CFA will assess and manage them. In contrast, local informal places of shelter are described in a manner that suggests they are to be self selected by individuals. Accordingly, it appears that the State proposes a three-tier system comprised of: (1) designated refuges (identified and managed pursuant to revised criteria) (2) neighbourhood safer places (identified and managed pursuant to the criteria set out in its further submissions) (3) informal, local places of shelter (referred to at some length in the submissions of the State and in the evidence of Mr Rhodes). 8.126 This is broadly consistent with the Commission’s proposed approach to characterising and identifying refuge options, as outlined in paragraph 8.25. 8.127 Though councils are not mentioned, the Commission urges that they be involved, particularly as is necessary to ensure conformity with MEMPs and Municipal Fire Prevention Plans. It is expected that councils would also be involved in assisting to identify suitable locations, and in communicating the location of neighbourhood safer places to the community. Consideration should also be given to whether councils will have a role in the ongoing maintenance of neighbourhood safer places.

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8.128 The Further Material of the State of Victoria document sets out what the State describes as the important features of a neighbourhood safer place. Such places:

■■ are relatively close to, or within, the neighbourhood

■■ are well known to the neighbourhood and highly accessible

■■ are in an appropriate site with managed vegetation

■■ offer protection from radiant heat

■■ lessen the threat from ember attack, high smoke concentration and other elements arising from the passage of a bushfire through a neighbourhood

■■ if they are a building would meet the relevant construction standards

■■ have access to water and fire fighting equipment

■■ have a level of organisation to give a degree of confidence to those seeking shelter from the onset of bushfire

■■ are in locations that will be recorded in the Municipal Fire Prevention Plans and MEMPs and will be communicated to the local community.178 8.129 The criteria for identifying neighbourhood safer places appear sound. They are similar to the alternative approach to the current criteria for designating fire refuges, suggested by Mr Packham and Mr Nicholson. The manner in which the criteria have been presented tends to suggest that safer places will often be a building or structure, but not necessarily so. This is a sound approach and, again, is consistent with the expert opinion given in evidence. 8.130 The Commission would also propose the inclusion of a criterion that the CFA will, where and when possible, provide resources to assist in the defence of neighbourhood safer places. This position was endorsed by the State in its written submissions and is considered by the Commission to be an important component of any strategy that promotes safer places in neighbourhoods. 179 8.131 The Commission has not heard detailed evidence on the tools that might be suitable to assess risk and determine appropriate standards for neighbourhood safer places. However, in developing the criteria for neighbourhood safer places the State should consider tools such as those referred to by the expert witnesses. 8.132 A matter that requires further consideration is nomenclature. In the proposed approach, the distinctions between each of the categories (designated fire refuges, neighbourhood safer places and informal fire refuges) tend to fall away. Evidence in Chapter 4, illustrates the confusion that can occur with unnecessarily complex classifications, and the benefits of clearly communicating the purpose and use of terms used to describe an emergency procedure. As noted in paragraph 8.27, the Commission intends to consider terminology for a number of fire-related matters in future hearings. 8.133 The Commission would also reiterate its view that, even with the introduction of neighbourhood safer places, a third tier of ‘privately determined safer places’ will continue to be used and should therefore be considered as part of the range of options. Such places are identified by individuals and carry no imprimatur from the State. They are not governed by the operation of any set criteria, but ideally are selected by individuals on the basis of the information available to them about what may present a safer option in the circumstances prevailing during a bushfire. Individuals will turn to such places at short notice, out of necessity, when all other options, including the capacity to get to another type of refuge, fail. However, they should be predetermined in personal or household fire plans, as non‑preferred options so that people have alternatives if they are caught in extremely dangerous fires.

224 Risk and Refuge

RECOMMENDATION 8.4

The State replace the 2005 Fire Refuges in Victoria: Policy and Practice following its current review by the Office of the Emergency Services Commissioner.

RECOMMENDATION 8.5

The State promulgate criteria for the identification and operation of neighbourhood safer places, and involve councils and local communities in their development and implementation as appropriate.

RECOMMENDATION 8.6

The State to have commenced progressively identifying, establishing and advertising designated community refuges and neighbourhood safer places, giving priority to areas where bushfire risk is identified as high.

RECOMMENDATION 8.7

Municipal councils record the location of designated community fire refuges and neighbourhood safer places in Municipal Fire Prevention Plans and Municipal Emergency Management Plans, and inform residents and visitors about their use and location.

RECOMMENDATION 8.8

The State to have developed uniform signs for designated community fire refuges and neighbourhood safer places in Victoria.

RECOMMENDATION 8.9

The CFA maintain an up to date, state-wide list showing the precise location of all designated community fire refuges and neighbourhood safer places, and provide the list to DSE, Victoria Police, the State Emergency Service, the Municipal Association of Victoria, the Office of the Emergency Services Commissioner, and the Victorian Bushfire Information Line.

RECOMMENDATION 8.10

The State report to the Commission on the results of the implementation and effectiveness of its township protection plan program and neighbourhood safer places program.

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Schools and THE SAFETY OF CHILDREN 8.134 The Minister for Education is responsible for school education in Victoria. The Department of Education and Early Childhood Development (DEECD) operates and oversees all government schools. Nearly one in three students in Victoria is educated in a non-government school. These schools are overseen by the Association of Independent Schools of Victoria or the Catholic Education Commission of Victoria. All schools are registered by the Victorian Registration and Qualifications Authority and undergo regular reviews to be eligible for re-registration. Improvements to bushfire preparedness could be built into the registration requirements for government and non-government schools alike.180 8.135 The Minister for Children and Early Childhood Development has responsibility for children’s services, which are services providing care or education for four or more children under the age of 13, in the absence of their parents or guardians. This includes kindergartens, child care centres, preschools and early learning centres. Licensees of children’s services include councils, incorporated associations, community services organisations, school councils, some independent schools and commercial entities. The Secretary of DEECD is responsible for licences and their requirements.181 8.136 Three government schools (Strathewen Primary School, Marysville Primary School, Middle Kinglake Primary School) and three kindergartens (Kinglake Kindergarten, Flowerdale Kindergarten and Marysville Kindergarten) were destroyed by fire on 7 February.182 This begs the question: ‘what would have happened had these fires occurred on a Friday?’ 8.137 DEECD is commended for moving quickly and decisively in reviewing its existing policies, assessing refuges at schools in bushfire prone areas, and announcing and implementing a changed policy approach.

The policy framework as at 7 February 8.138 Bushfire policies for schools in Victoria, as at 7 February, were less than ideal.183 The need for a policy for schools was identified in the Ash Wednesday Report.184 Mr Rees recalled that, during the Ash Wednesday fires, children were dropped off by school buses in dangerous circumstances. He said ‘it is certainly an area that needs some work’.185 8.139 DEECD now has responsibilities under the Emergency Management Manual Victoria for the development of a statewide emergency management policy, including guidelines for government schools.186 Mr Tony Cook, Deputy Secretary for the Office of Children and Portfolio Consolidation, indicated that materials developed by DEECD for government schools are also available to non-government school authorities for their consideration.187 As at 7 February, a range of policies and procedures were in place for emergency management and bushfires that affect schools:

■■ the Victorian Government Schools Reference Guide requires all school principals to develop Emergency Management Plans for each school, and for such plans to be tested and reviewed annually. This is effectively a requirement to self audit188

■■ the Managing Schools Emergencies Manual189

■■ the Bushfire Safety Checklist (and associated explanatory notes) requires principals to ensure that, prior to the fire season, the school’s Emergency Management Plan is reviewed, the school’s ‘stay or go’ plan is tested, the school bus plan is reviewed, fire hazards around the school are reduced, fire protection equipment is present, and there is a continuous supply of water190

■■ the Bushfire Preparedness for Schools intranet site.191 8.140 In preparation for the 2008–09 bushfire season, on 28 October 2008, DEECD circulated to all schools an alert requesting schools to review their Bushfire Safety Checklist. In light of the forecast extreme fire danger for 7 February, the Bushfire Safety Checklist was again circulated to government schools on 6 February.192 DEECD’s decision to highlight the need to take measures during the fire season, and in particular prior to 7 February, was sound.

226 Risk and Refuge

8.141 The position in relation to children’s services was less rigorous. A document titled Emergency Procedures — Guidelines for Kindergartens and Childcare Centres was developed in 1998 to assist children’s services to develop emergency procedures in the case of fire. However, adherence to the guidelines is not a requirement of the current licensing regime for the services.193 8.142 As at 7 February, there was no state-wide policy requiring government schools to either evacuate, close schools or use a fire refuge in event of fire. During 2008, for example, there were a number of Total Fire Ban (TFB) days, but no schools closed for that reason. In particular, it is noted that no schools closed on the TFB days on 5 and 6 February 2009.194

CHANGES MADE SINCE THE FIRES 8.143 Since 7 February, DEECD has implemented significant policy changes:

■■ a new procedure for school closures on TFB days and days of extreme fire risk

■■ a safety audit of refuges in schools in the Eastern and Northern Metropolitan Regions

■■ provision of the Bushfire Safety Checklist to children’s services.195 8.144 DEECD’s Regional Directors now determine whether to close schools at risk of fire threat, on the advice of the CFA and emergency services. Schools have been closed in a number of regions on TFB days since 7 February.196 For example, on 27 February, 189 government schools and 221 licensed children’s services were closed and, on 3 March, 313 government schools and 264 licensed children’s services were closed.197 8.145 Mr Cook indicated the DEECD had not received negative feedback about the large number of school closures in February and March.198 There may be debate about the merits of closing schools on TFB days. It has an impact on working parents, and may create a situation in which children are left at home alone. It is possible that DEECD will receive different feedback from parents during the next bushfire season, particularly if there is a large number of school closures in that season. DEECD may need to revisit its policy in light of any such feedback, but at this stage, it appears the community has welcomed the revised approach. 8.146 DEECD also commissioned a report by the Victorian Managed Insurance Authority to investigate the fire safety levels of refuges in a number of its schools.199 The results were troubling. Seven were assessed as unacceptable; a further seven were assessed as ‘marginal’. The remaining 18 were assessed as acceptable, subject only to the completion of high and urgent priority recommended works. Only one of the 18 acceptable refuges did not require high or urgent priority works.200 Rectification works were identified and graded according to urgency.201 Mr Cook said DEECD is costing the works required. School principals have been provided with a copy of the report relating to the refuge at their school.202 8.147 On 24 February, DEECD provided children’s services with the guide to Fire Readiness in Rural and Regional Children’s Services and the Bushfire Safety Checklist for Victorian Children’s Services and recommended they review their plans in light of these documents.203 Mr Cook accepted that children’s services (kindergartens, early learning centres and childcare services) may face additional challenges because the venues from which they are operated are less homogenous than schools, and they are operated by a varied group of entities. He also accepted that it is more likely that children’s services will need to identify nearby refuges, rather than being able to perform adequate rectification works onsite.204 He said DEECD might consider making compliance with the Bushfire Safety Checklist a licence requirement.205 The Commission suggests that DEECD give this active consideration, as one way of providing greater protection to very young children. 8.148 DEECD has been actively considering future policy options. One such option was the prospect of auditing the Emergency Management Plans of schools in higher risk areas.206 In its written submissions, the State said it was now preparing a policy to the effect that School Emergency Management Plans would be certified twice yearly through the School’s Compliance Checklist.207 The Commission welcomes this change, and suggests that it would be prudent to formally audit the plans of schools in bushfire prone areas prior to the next fire season.

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8 Risk and Refuge

8.149 Mr Cook said DEECD’s overarching aim is to ensure that schools never reach a situation in which children and staff are forced to shelter in a school during the passage of a firefront. School closures, or early evacuation, are the primary focus of the policy. However, if a situation does arise where there is insufficient time to move children to a safer area, improved onsite refuges (following rectification works) should offer additional protection.208 8.150 In the context of the State’s ‘stay or go’ policy, DEECD has essentially adopted an approach of leaving early, through its policy of school closures on TFB days and days of extreme fire risk. As with households that plan to leave early, schools may find themselves in a situation in which a fire occurs on a day when students are in attendance. As such, schools need a ‘Plan B’ in the same way that households need a ‘Plan B’. DEECD, and non-government school authorities, are urged to ensure that schools in bushfire prone areas have either a certified refuge or a neighbourhood safer place for the students to shelter from the fire. 8.151 In the same way that householders need rudimentary fire-safety skills, teachers, and those responsible for the care and safety of young children and students, need emergency response skills in the event of a bushfire or other natural hazard. The Victorian Registration and Qualifications Authority is urged to ensure that government and non-government schools are audited as part of re‑registration requirements to ensure they have adequate bushfire safety procedures in place. 8.152 The Commission notes the matters discussed above, and that DEECD is in the process of reviewing a number of its policies and processes, to continue to develop bushfire preparedness and safety strategies for schools and children’s services. The ongoing work of DEECD is encouraged.

RECOMMENDATION 8.11

The Department of Education and Early Childhood Development complete a review of all refuges in all schools in areas at risk of bushfire.

RECOMMENDATION 8.12

The Department of Education and Early Childhood Development give priority to rectification works to refuges identified in the Victorian Managed Insurance Authority report.

RECOMMENDATION 8.13

The Department of Education and Early Childhood Development review the adequacy of bushfire fire protection measures in children’s services facilities including kindergartens, child care centres, preschools and early learning centres.

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9 INCIDENT MANAGEMENT: A CASE STUDY

This chapter examines the incident management structure which operated in Victoria on 7 February 2009. It looks at the importance of fire information, and in particular the role of Information Units and fire prediction in that structure. It then considers the practical operation of that structure in one instance on 7 February — the fire that started at Kilmore East. The chapter presents an incomplete account of the emergency response to that fire. However, some conclusions can be drawn on the effectiveness of some of the procedures and systems, and recommendations are made for the 2009–10 fire season.

AustralaSIAN inter-service incident management system 9.1 The Australasian Inter-Service Incident Management System (AIIMS) was developed in Australia in the mid 1980s.1 It was modelled on the United States National Inter-Agency Incident Management System, which in turn was modelled on military operational functions.2 It is used by all Australian fire agencies, and many state emergency services.3 Using the same system allows the exchange of fire managers with the United States and Canada for further experience and support. Victoria Police use a different incident management system and discussions have been ongoing over recent years to integrate the two. However, an integrated system was not in place on 7 February.4 9.2 AIIMS was adopted as the system of incident management for the Country Fire Authority (CFA) and the Department of Sustainability and Environment (DSE) in early 1990.5 AIIMS was introduced in an effort to provide more effective command, control and coordination within and across agencies.6 The introduction of AIIMS recognised that complex, fast moving fire events require more coordinated control arrangements beyond local volunteers at the brigade and group level.7 9.3 Volunteers and career CFA staff may be drawn on to fulfil AIIMS positions, depending on their training. 9.4 The principles of AIIMS, as outlined by Mr Russell Rees, Chief Officer of the CFA, are:8

■■ management of incidents by objective

■■ one controller of the incident — the Incident Controller

■■ delegation of functions depending on complexity of the incident

■■ span of control — one person responsible for five people at any one time

■■ the development of a plan outlining strategies and tactics to combat the incident. 9.5 The functions of the Incident Management Team (IMT) as outlined by Mr Rees are:

Command and control under AIIM-ICS9 rests with the Incident Management Team (IMT). In broad terms, the responsibilities and functions of the IMT are as follows

Incident Control: an Incident Controller (IC) will be designated to have overall management of the incident. The IC, in consultation with the other members of the IMT, will determine a control objective that will become the foundation for the development of strategies and the subsequent Incident Action Plan.

Operations: the Operations Section is responsible for the control of operations and the direction of agency resources in accordance with the Incident Action Plan.

Planning: the Planning Section is responsible for collecting and analysing incident information, predicting incident behaviour, recording the location and tasking of resources, and preparation of alternative strategies to control the incident.

Logistics: the Logistics Section provides facilities, services and materials required to combat the incident.10

9.6 The AIIMS functional structure used on 7 February to manage the Kilmore East fire is depicted in (Figure 9.1).

230 Incident Management: A Case Study

Figure 9.1: Elements of the AIIMS structure referred to in this chapter

Incident Control

Deputy Incident Controller

Planning Operations Logistics

Situation Divisions

Information

Source: Adapted from Exhibit 131 – Mapping Information Flow During Critical Incidents (TEN.033.001.0001)11

9.7 Mr Rees explained that the Information Unit, which assumes control of all information to the public, has been integrated into the planning section of the IMT. It became a formal part of the AIIMS structure in 2003.12 9.8 Mr Rees also explained that, under AIIMS, incident management is classified into levels 1, 2 or 3.13 In a fire incident:

■■ A level 1 fire is a small fire in area, attended by one or two trucks, which is of short duration and is dealt with at the incident. The Incident Controller will be the senior person at the fire exercising control.

■■ A level 2 fire is a developing fire incident or one that requires more than the initial responding resources. A level 2 incident may be managed at the incident itself or at an Incident Control Centre (ICC) and involves the Incident Controller delegating some functions to others, thereby forming the IMT.

■■ A level 3 fire incident is a large complex fire incident, which may run for days, where a large number of functions are delegated. Such a fire is run from an ICC. The responsible IMT, under the Incident Controller, will directly manage the fire through its operations, planning, and logistics functions.14 9.9 At times in evidence the ICC (the facility) and the IMT (the management team) have been used interchangeably. This is reflected in this chapter. 9.10 In preparation for 7 February, 20 level 3 ICCs were designated and established in pre-determined locations across the State.15 Kilmore fire station was one of the pre-designated ICCs meant to be able to operate with a level 3 IMT ‘virtually immediately’ on the outbreak of fire.16 As evidence referred to later demonstrates, Kilmore was not staffed to operate as a level 3 IMT at the outbreak of the Kilmore East fire. 9.11 Apart from the Kangaroo Ground ICC, which is a permanent facility, the Commission has not examined the state of readiness of other ‘pre-designated ICCs’.

THE IMPORTANCE OF FIRE INFORMATION 9.12 Traditionally firefighters have focused on putting out fires. Evidence before the Commission has highlighted that while extinguishing the fire should be the primary role of firefighters, once this is no longer possible, putting out information to the public is an equally important role. 9.13 The importance of gathering fire information, communicating among agencies and warning the public have been the subject of numerous recommendations in reports, investigations, and Coronial Inquests on Victorian fires over the last 70 years. A selection of some of the previous reports’ comments and recommendations about fire information follows. 231 2009 Victorian Bushfires Royal Commission—Interim Report

9 INCIDENT MANAGEMENT: A CASE STUDY

9.14 In his report about the 1939 bushfires, Justice Stretton referred to the desirability of early detection of fire and made a number of recommendations including the use of lookout towers and the consolidation of information received concerning fires ‘in a central body devoted to firefighting’.17 9.15 The Report of the Bushfire Review Committee on Bushfire Disaster Preparedness and Response in Victoria, Australia following the Ash Wednesday Fires, noted the important role of communications in fire, the imperative of fire organisations having ‘assured links between them’, and the necessity for timely warnings to communities. The report commented that timely warnings particularly applied ‘to notification of wind changes and forecasts of fire front movement’.18 The issue of warnings is further discussed in Chapter 4. 9.16 The Coroner investigating deaths during the 1997 Dandenong Ranges fires commented that fire information and ‘communication needs to flow to the community in a timely way to assist in the process of early warning and management of risk’. This passage was used in the CFA’s submissions to the 2002–03 bushfire inquiry.19 9.17 The May 2003 Victorian Auditor-General’s report Fire Prevention and Preparedness observed that the most detailed planning may be ineffective if residents do not have access to information that provides the earliest possible warning of fire in their area and indicates the path and intensity of fire.20 9.18 The Report of the Inquiry into the 2002–03 Victorian Bushfires also recommends more emphasis on communication of fire information and warnings. These recommendations highlight the need for timely and effective warnings to potentially fire affected communities:

Recommendations

That in relation to the provision of information to communities affected by fires and other emergencies, DSE and CFA ensure that:

Incident Management Teams understand that one of their primary responsibilities, in co-operation with the Municipal Emergency Response Co-ordinator, is to keep the community informed as to where the fire is and its likely path, what is being done to combat the fire and any preparations the community should undertake;

Community Information Units are effectively integrated into the Incident Management Teams; and

They continue to develop a joint internet-based communications tool to provide information and advice to both affected and broader communities during fires.

Conclusion

Community expectations have changed significantly both in terms of the service communities expect from Government, and in terms of the information they demand from Government during emergencies.

Experience in Victoria during the Longford Gas Crisis and in New York following the 11 September 2001 terrorist attacks, highlights the importance — and value — of providing authoritative, realistic and accurate information to threatened or affected communities. This information can assist a well-prepared community to adopt the safe behaviours necessary to survive an emergency such as bushfire. 21

9.19 Mr Chris Carson, CFA Officer, presented a paper to the then Australasian Fire Authorities Council (AFAC) conference in 2004 in which he observed that many people are ill prepared for bushfires and that firefighting agencies can offer two interventions that could assist:

… most obviously, the suppression activity of the wildfire combating agencies; and most importantly, the flow of information, warnings, and advice to those at risk. The former represents the traditional role of fire agencies, and the latter an opportunity as yet poorly understood. 22

9.20 In 2005 AFAC emphasised that ‘Access to accurate and timely information during periods of high fire danger and fire events is crucial to enable people to make appropriate decisions concerning their safety’. AFAC pointed out that the fire agencies needed to ‘provide the media and the community with information that is accurate, relevant, adequate, consistent, useful and timely’.23

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9.21 The report of the July 2006 Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media During Fire Incidents observed that:

The value of providing timely and accurate information to the public during times of crisis has been repeatedly demonstrated during natural disasters and other emergencies both in Australia and overseas. As an effective means of empowering communities and minimising loss of life and property, it is a tactic historically more often honoured in the breach than in the observance.24

9.22 To ensure public expectations about warnings were met, the report also stated it would be necessary to review staffing and the physical resources of Information Units.25 9.23 In 2007 Mr Ross Smith, a forester with extensive rural fire management experience, provided the CFA and DSE with a further report, Key Issues Identified from Operational Reviews of Major Fires in Victoria 2006/07.26 This report reviewed the debrief outcomes of firefighters from the 2006–07 bushfire season and again emphasised the importance of providing fire information to communities potentially affected by fire. Its recommendations were accepted by Mr Rees and Mr Ewan Waller, Chief Fire Officer, DSE on behalf of the CFA and DSE respectively.27 The report stated:

There are three things that any fire authority must do whenever a fire is recorded on its area of responsibility:

■■ The authority must gather reasonable intelligence about the fire location to identify where and in what it is burning (e.g. aerial reconnaissance, remote sensing, on ground investigation, lookout tower observation, verified/verifiable public reports).

■■ The authority must either initiate suppression action against the fire or undertake investigation and/or observation to determine what suppression action is feasible and what an appropriate strategy is.

■■ If there is a threat or a potential threat to the community, the fire authority must provide timely public advice, alerts and warnings to the community. 28

9.24 By the 2008–09 bushfire season, it was clear that there was a longstanding appreciation and acknowledgement in the fire agencies of the need to gather intelligence about fires and use that information to the benefit of communities threatened by fire, to ensure timely and accurate public advice. This understanding was acknowledged by Mr Rees in his evidence, when he referred to the CFA philosophy that ‘provision of information to the community before and during a major incident was one of its core responsibilities’. 29 Providing fire information to the community, Mr Rees stated, ‘plays an important part in achieving safe, self-reliant and resilient communities. Such information enables community members to make informed decisions about their own fire safety’.30 The Commission agrees.

Information Unit — AIIMS 9.25 In an attempt to better manage information flow, Information Units became a formal part of the AIIMS system in 2003. Information Units are responsible for the control of all information disseminated to the public.31 The Information Unit is incorporated into the planning section of the AIIMS structure. Figure 9.2 provides an example of the position of an Information Unit — which sits inside the Planning Section — in a level 3 Incident.

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Figure 9.2: Information Unit within the AIIMS Structure

Incident Control

Planning Section Operations Section Logistics Section

Information Unit Information Unit Leader

Information Officer

Media Officer Media Liaison Officer

Media Escort

Community Officer Community Liaison Officer

Community Meeting Presenter

Source: Exhibit 131 – Mapping Information Flow During Critical Incidents (TEN.033.001.0001) at 002432

9.26 In 2008 the CFA and DSE published guidelines for the conduct of the Information Unit which provide that:

Once an IMT has been established, the duties of the Information Unit and the roles within it require the Information Officer or Information Unit Leader managing the Unit to have direct and easy access to the Incident Controller, Planning Officer, Situation Officer and possibly the various specialist units as established. As a result, the Information Officer or Information Unit Leader managing the Unitmust be located at the Incident Control Centre.33

9.27 The guidelines note that it is ideal to have the Information Unit at the same location as the ICC but envisage that this may not be possible. They refer to the possibility of the Information Officer being located at the Regional Emergency Coordination Centre (RECC) pending establishment of an ICC.34 9.28 The evidence before the Commission is that the Information Officer for the Kilmore ICC was located at the Seymour RECC for some hours after the outbreak of fire on 7 February.35 However, based on the evidence of Mr Rees about the preparedness of pre-designated ICCs, there is no clear reason why an Information Officer and Unit should be located anywhere but at the ICC for a level 3 IMT. Mr Rees referred to the necessity of the Information Unit operating out of the ICC. He stated:

I strongly support the fact that the information unit should run out of the ICC’s. There is plenty of evidence that the further you take it away, the less you get information. 36

9.29 The Information Unit, through the Information Officer, is responsible for:

■■ disseminating information directly to locally identified conduits

■■ disseminating information to the integrated Emergency Coordination Centre (iECC) for state level dissemination

■■ reporting to the RECC on dissemination networks used and providing to the RECC copies of the information released by the ICC. 37 234 Incident Management: A Case Study

9.30 The Information Unit is required to give priority to providing information to communities that are near a fire incident who are, or may come under, direct threat.38 That requirement carries with it a duty to ensure ‘that accurate up to date incident information is provided to the public, local community, other relevant agencies’.39 9.31 The Planning Section of the IMT, which contains the Information Unit, is referred to as a source of information in the 2008 guidelines:

The Planning Section develops formal documentation relating to the future development of an incident to enable operational strategies to be implemented to deal with the incident events.

This information provides a sound understanding of the potential to impact communities, the likely degree of effort required to resolve the incident and consequently a good basis for Information Unit understanding of information needs. The Planning Section is required to undertake the following functions:

Incident Prediction. The document will contain the following information:

■■ Current and anticipated weather

■■ Current and anticipated Fire Danger Index

■■ Fuel loads in the area currently burning and likely to burn

■■ Description of current and predicted fire behaviour

■■ A summation of the total distance spread

■■ A description of any significant issues or priorities likely to face the IMT

■■ There is likely to be an analysis of a map indicating the likely spread of the fire

Incident Action Plan. This document will contain the following information:

■■ A statement of the current objective of the suppression strategy including resources

■■ A list of the critical issues (warning, alerts, resource needs). 40

9.32 Information cannot be released by the Information Unit without the authorisation of the Incident Controller irrespective of whether the information is prepared at the ICC or at an alternative location.41 Information created by the Information Unit at the iECC must be authorised by the State Duty Officer.42 9.33 The guidelines clearly set out the responsibility of the IMT through its Information Unit to gather and provide fire information. The guidelines properly prioritise the provision of information to communities near a fire or communities that may come under direct attack by fire. This report returns to the role of the Information Unit and its place in the Incident Control structure later in the chapter after the management of the Kilmore East fire is examined.

FIRE PREDICTION 9.34 The Planning Section also has responsibility for providing incident prediction, which is ‘most likely to be an analysis on a map indicating the likely spread of the fire’.43 Fire analysis and prediction is important to the management of the fire suppression effort and to the provision of timely, accurate advice to communities potentially threatened by fire.44 Fire behaviour analysts provide fire spread predictions for going bushfires and identify human, economic and environmental assets that may be impacted by fire. They also make recommendations about firefighting safety issues relating to fire behaviour and fire weather.45 9.35 Mr Rocky Barca, a qualified level 3 Incident Controller and Deputy Incident Controller at the Kangaroo Ground ICC on 7 February, provided evidence to the Commission on the importance of fire prediction within the ICC.46

I use such things such as weather, wind, temperature, relative humidity and the potential for a wind change, the fuels which a fire is potentially burning in and, using the McArthur meter as a guide, come up with a potential forward rate of spread, flame height and spotting potential of that incident. That gives us an indication of where that fire may be in the next few hours, in the next shift, in the next day or so, so then we can start developing strategies for the control of that incident and also to alert any communities which may be at risk from that developing situation. 47

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9.36 Mr John Cowan assisted in the Planning Section at the Kangaroo Ground ICC on 7 February. He has been a volunteer member of the CFA for 31 years and has held senior positions in the organisation.48 Because of his training and experience he has undertaken fire prediction work. He gave evidence of the importance of fire prediction in relation to the management of resources.

You need to make sure that you don’t put the resources on the ground and that you have deployed in a situation where they might be caught up in a wind change. You need to understand the tactics of a fire, the situation, where it is going, the terrain it is going on to see whether the fire is actually able to be fought successfully using current tactics. It might be trying to put someone down in a gully or on top of a hill where it is too dangerous. So that is a very important role.49

CASE STUDY: KILMORE EAST FIRE 9.37 The Kilmore East fire is the only fire that has been considered in any substantial detail so far in evidence before the Commission. That evidence is not complete as only a partial account of the emergency response to the fires has been heard. However, an analysis of the evidence received to date concerning this fire provides a sound basis for conclusions on the effectiveness of some procedures and systems.

THE ICC AT KILMORE 9.38 The Kilmore East fire was reported at 11:49am.50 At 12:05pm the Kilmore CFA volunteer Captain, Gregory Murphy, received a call from regional Operations Officer Peter Creak, Seymour, to indicate that Kilmore fire station should become the ICC for the fire and that Mr Murphy would be the Incident Controller.51 Mr Murphy possessed level 2 Incident Controller qualifications.52 The Kilmore ICC is the nominated level 3 ICC for the Mitchell catchment area, which covers the Seymour and Northern highway groups.53 9.39 Kilmore was one of the 20 pre-designated level 3 ICCs prepared in anticipation of the conditions forecast for 7 February.54 It was supposed to be at a ‘heightened state of readiness’ for the day.55 The pre-designated level 3 ICCs were meant to be ready for a ‘warm start’ — ‘people there, all the facilities, the equipment is up and running and tested’. Mr Rees said he was assured that this was the case with the pre-designated ICCs.56 9.40 The CFA State Duty Officer on 7 February was Mr Gregory Paterson, a career officer in the CFA. He understood the Kilmore ICC was a level 3 ICC and ‘hot’ in the sense that it had in place an Incident Controller, and that Operations, Planning and Logistics Units were ready to operate at the start of a fire. 57 According to Mr Paterson, during the morning of 7 February, he requested that Ms Michelle Koehler, CFA State Emergency Coordination Centre (SECC) officer, contact the regional duty officers and area coordinators so that he could be sure of the level of preparedness of the ICCs. He believed as a consequence of this contact that the Kilmore ‘was a hot level 3 ICC.’58 9.41 However, the evidence of Mr Murphy disclosed that the Kilmore ICC was not ‘hot’ (despite efforts having been made on 6 February to prepare it) and certainly not staffed to a level 3 capacity in the manner described by Mr Rees or Mr Paterson. Mr Murphy was tasked as Incident Controller without a level 3 qualification. He had ‘no prior knowledge [he] would be utilised as a level 3 Incident Controller’.59 This is not a criticism of Mr Murphy as he was placed in an invidious position. 9.42 Upon his appointment as Incident Controller, Mr Murphy was required to establish an IMT at the Kilmore fire station from scratch. Mr Tim Tingiri, who had previously been dispatched to the fire as Commander of the Kilmore pumper, was recalled and appointed Situation Officer. 60 Mr Tingiri apparently had undertaken some form of incident management training. He appeared to Mr Murphy to be the most suitable person at the time to undertake the role, although Mr Murphy did not believe Mr Tingiri to have a level 3 qualification. Mr Tingiri had no prior knowledge he would be appointed Situation Officer, a position that carries with it the responsibility of bringing together situation reports of the fire and fire prediction.61

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9.43 Other appointments were made to make up the team and to enable the ICC to become operational. The Operations, Logistics and Planning Officers, as far as Mr Murphy was aware, were not level 3 IMT qualified.62 9.44 There was no Information Officer at the Kilmore ICC at the time the ICC became operational at approximately 1:05pm. The Information Officer arrived at the ICC at approximately 3:30pm.63 9.45 Mr Murphy was informed that information concerning the Kilmore East fire, including the release of threat messages concerning that fire, would be processed through the RECC at Seymour as opposed to the Kilmore ICC. Mr Murphy did not see any of the threat messages concerning the Kilmore East fire prior to 3:30pm. He was aware of threat messages being issued but because these were issued from the Seymour RECC, he was unaware of the frequency or content of such messages.64 9.46 At the iECC, at least initially, there was no knowledge that the Kilmore ICC was not staffed at all, let alone not staffed as a level 3 ICC. Mr Rees did not find out that the Kilmore ICC was not pre-staffed until after the event in the following days, although he did ask on the afternoon who the Incident Controller was for the fire.65 Mr Paterson said he was surprised when informed at 2:30pm that a level 3 Incident Controller was being transferred from Mansfield to Kilmore.66 9.47 Mr Rees became aware ‘probably within the first hour of the fire’ there was a level 2 Incident Controller, but said that at the initial stages of the fire this was appropriate and that he knew ‘the fundamentals were there’ but that he didn’t know ‘that we weren’t at the level of readiness that I would have – well I knew was the case at other incidential control centres’.67 9.48 Mr Murphy stated the line scan of the Kilmore East fire which was requested at 12:33pm did not arrive at the Kilmore ICC whilst he was Incident Controller, nor was he aware, or made aware, of any services that could have been offered by the iECC concerning the prediction of fire.68 9.49 The lack of preparedness of the Kilmore ICC meant that systems and protocols were not in place to provide accurate and timely information on the fire.69 It was unreasonable to place the burden of creating and then managing an IMT for a complex, fast-moving fire on unprepared and underqualified CFA personnel. The lack of preparedness, in so far as it affected the provision of information on fire to the public, meant that threat messages and warnings concerning this fire were not issued in a timely manner and failed to contain relevant details and information. Just why the Kilmore ICC was in such a poor state of preparedness has not to date been explained in evidence, and cannot therefore be the subject of a specific recommendation. 9.50 The Commission will pursue in future hearings the following issues:

■■ why the Kilmore ICC was not prepared to operate as a level 3 ICC

■■ the procedures the CFA considers should be established to ensure pre-designated level 3 ICCs are adequately prepared.

RECOMMENDATION 9.1

The State ensure that State Duty Officers of the CFA and DSE be given direct responsibility for ensuring pre-designated level 3 Incident Control Centres within their respective control are properly staffed and equipped to enable immediate operation in the case of a fire on high fire risk days.

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The ICC AT KANGAROO GROUND 9.51 The Kangaroo Ground ICC is approximately 50 kilometres south of Kilmore. It is a permanent ICC facility and as such is equipped with desks and prearranged allocations of space for the ICC team. It also has computer and IT facilities, although the fit out at Kangaroo Ground is not as up to date as other permanent ICCs across Victoria.70 9.52 The Kangaroo Ground ICC was set up for a ‘hot’ start as a level 3 ICC on 7 February. Planning, Operations, Deputy Operations and Logistics Officers were in place.71 Other personnel were on site as back up, including support for the Information Unit.72 9.53 While the Kangaroo Ground ICC was a designated level 3 ICC, it was not given responsibility for the Kilmore East fire on 7 February.73 It did become a Divisional Command of the Kilmore ICC and was ‘activated’ as the ICC in control of the Kilmore East fire at 5:42am on Sunday 8 February.74 A Divisional Command normally reports through and takes instructions from the IMT Operations Officer and the Incident Controller of the fire.75 9.54 As a consequence, the Kangaroo Ground ICC was not authorised to issue threat messages or other information concerning the Kilmore East fire on 7 February.76 9.55 Mr Jason Lawrence was the Incident Controller of the IMT at Kangaroo Ground on 7 February. He is a CFA career firefighter, holds the position of Operations Officer, and when asked if he held, and has been trained in, level 3 Incident Controller qualifications Mr Lawrence stated he had ‘undertaken training to that effect’.77 Mr Lawrence had no experience as a level 3 Incident Controller in any previous bushfires.78 9.56 Mr Barca was also rostered to the Kangaroo Ground ICC, where he took the role of Deputy Incident Controller of the IMT. Mr Barca is employed by Parks Victoria and is accredited as a level 3 Planning Officer and level 3 Incident Controller.79 Mr Barca had operational experience as a level 3 Incident Controller at Victorian Bushfires in 2002, 2003 and over the summer of 2005–06. In 2006 he was Incident Controller at the Kangaroo Ground ICC when Kinglake was under fire threat. He has served as Acting Chief Fire Officer for DSE.80 9.57 The practice is that the appointment of Incident Controller is dependent on the location of fire ignition. If the fire starts in land for which DSE has responsibility, a DSE Incident Controller takes charge; if it starts in land where the CFA has responsibility, a CFA Incident Controller takes charge.81 9.58 This method of selection is flawed. On 7 February it led to the appointment of a level 3 Incident Controller at the Kangaroo Ground ICC who was inexperienced in the role and not formally qualified, over a person highly experienced and qualified for the level 3 Incident Controller position.

RECOMMENDATION 9.2

The CFA and DSE agree procedures to ensure the most experienced, qualified and competent person is appointed as Incident Controller for each fire, irrespective of the point of ignition of the fire.

on ground reporting 9.59 Examining the information that was available concerning the Kilmore East fire on 7 February provides perspective on the adequacy of the warnings released on the day. 9.60 When reported at 11:49am, the Kilmore East fire was entered on the CFA electronic Incident Management System (IMS).82 Mr Paterson gave the fire, when it first came up on IMS, ‘exceptionally high priority’.83 At 12:10pm Mr Paterson recognised this fire would potentially impact on the Hume Highway and on the Sydney–Melbourne rail link.84 At this time an iECC Situation Officer was dedicated to the Kilmore East fire.85 9.61 At 12:08pm Ms Colleen Keating, Fire Tower Operator at the Kangaroo Ground fire tower, took a bearing on the Kilmore East fire. She spoke with fire tower operators at Mount St. Leonards and Pretty Sally and was informed that the Kilmore East fire was heading towards a Blue Gum plantation and was building fast. 238 That information was conveyed to Mr Lawrence at the Kangaroo Ground ICC.86 Incident Management: A Case Study

9.62 At 12:21pm the Police Forward Command Log recorded a concern about the potential of the Kilmore East fire and at 12:30pm the log noted the fire was a ‘major concern’ of the fire agencies. The log referred to the possible impact on the Melbourne–Sydney rail line and the Hume Highway.87 At approximately 1:00pm the Hume Highway was closed to traffic upon request from Mr Murphy.88 Deputy Commissioner Kieran Walshe, Victoria Police, said that the request was received by police at approximately 12:37pm.89 9.63 Mr Kenneth Williamson, a 30 year volunteer member of the CFA and Whittlesea Fire Brigade Captain, provided evidence concerning the progress of the Kilmore East fire.90 At 1:02pm on 7 February he spoke to Mr David McGahy, volunteer Captain of the Arthurs Creek/Strathewan CFA Brigade. He said that it was more than likely that the fire would jump the Hume Highway and that once it was in the Mount Disappointment area it would have a free run and be hard to pull up. Mr Williamson appreciated that once the fire was in the pine plantation on the western side of the Hume Highway it would be impossible to stop at the Hume Highway.91 9.64 At the time of the conversation with Mr Williamson, Mr McGahy at Arthurs Creek was able to observe that the volume of smoke from the Kilmore East fire had grown enormously.

All I could do was recognise that the wind was blowing straight at us and it didn’t take Einstein to work out that if the wind stayed at the intensity that it was blowing and in the direction that it was blowing there was a good chance it was going to hit us.92

9.65 Mr Murphy appreciated that once the fire was in the pine plantation its intensity would increase, the fuel load would be such that ‘all of the requirements for a very large, very difficult fire had been met’.93 At approximately 11:50am, after dispatching the initial response units to the fire, Mr Murphy observed the large column of smoke generated by the fire. The column of smoke he said ‘told a story that — yeah we were going to struggle with that [fire] and we did’.94 9.66 At 1:19pm an entry in IMS recorded the fire near the Hume Highway and noted that spotting over the highway was likely.95 Superintendent Rodney Collins at the iECC reported to the State Emergency Response Coordination Centre that the fire was spreading south at a rapid rate and Wandong may be directly impacted.96 9.67 At around this time, the fire was also in a forested area between Wandong and Clonbinane.97 Mr Williamson described the fire conditions as extreme and measured a slight wind change from north-west to a westerly at 100 kilometres per hour.98 The fire in the forest area was running, he estimated, at 20–30 kilometres per hour, and he said that later in the day the speed of the fire was greater than this, ‘roaring — I’ve never seen anything like it’.99 These observations of the fire made by Mr Williamson were reported back to his group officer Mr Rod Holland. However, it is unclear whether they were passed on to the Kilmore ICC.100 At around 2:00pm Mr Williamson observed the fire behaviour to be erratic and spotting all over the place.101 9.68 At 2:12pm Ms Keating at the Kangaroo Ground tower was provided with information, which she passed onto the Kangaroo Ground ICC, from Mr Peter Coleman, the Pretty Sally tower spotter, to the effect that the fire had crossed the Hume Highway north-east of Wandong. Mr Coleman also stated the fire was heading towards Mount Disappointment and Kinglake West.102 At this time burnt leaves were dropping in the Kangaroo Ground area.103 9.69 At 2:25pm the Strath tower (operated by Melbourne Water) in the Mount Disappointment State Park was evacuated because of the potential threat of fire.104 The evacuation was reported to the Kangaroo Ground ICC at 2:36pm.105 9.70 Spotting of the Kilmore East fire was reported at 2:33pm into the top end of Wandong on 774 ABC Radio and at about 3:00pm around Humevale by the Kangaroo Ground tower. At 3:22pm further heavy spotting was observed in the Humevale area.106 9.71 Deputy Group Officer Lindsey McHugh reported at 3:06pm that the fire had progressed across Mount Disappointment much faster than anticipated and was coming over the top of the mountain into Bruces Creek.107 9.72 Triple Zero calls, presumably concerning spotting of the fire, were received from the Strathewen area from 3:43pm.108 239 2009 Victorian Bushfires Royal Commission—Interim Report

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9.73 At approximately 3:30pm information concerning the Kilmore East fire was provided to fire behaviour analysts at the iECC. This information came from a report of an aircraft over the fire. The information demonstrated the fire was further advanced than expected and the rate of spread was faster than predicted.109 9.74 The first callout for the Arthurs Creek Brigade was at 3:43pm. The brigade was dispatched to a spot fire in Eagles Nest Road, Strathewen.110 Other spot fires were breaking out. Within 20 minutes ‘the mountains were starting to spot and the speed of the oncoming fire was something to behold’.111 By 3:55pm Mr Williamson was concerned the fire was such that the whole mountain might be lost.112 At 3:57pm he requested that ‘VicFire’ organise an urgent threat message be made to the residents on Kinglake mountain.113 He believed he also made the same request to the Whittlesea Divisional Command through Mr Holland. In referring to the Kinglake mountain he meant the whole mountain from Mount Disappointment to Kinglake.114 9.75 At 4:05pm the fire was reported at St Andrews.115 Mr David Cooper, a volunteer firefighter and Deputy Group Officer, Lower Yarra Area, who was based at Kangaroo Ground on 7 February, dispatched a tanker to St Andrews at approximately 4:00pm after receiving a report from Mr McGahy that the fire at Arthurs Creek ‘was totally out of control’.116 When Mr Cooper arrived at St Andrews he observed a significant running fire spreading rapidly.117

KANGAROO GROUND ICC information 9.76 At the Kangaroo Ground ICC there was an early understanding about the potency of the fire and the risk of danger to those in its path.118 Mr John Cowan, volunteer CFA member and level 3 Planning Officer, assisted at the Kangaroo Ground ICC.119 He arrived at the ICC at approximately 1:30pm. He understood at that time the fire was about to cross the Hume Highway at Wandong. He took account of the potential of the south- westerly change to impact on the fire ‘because that is drilled into all the CFA firefighters in fire behaviour courses’.120 Soon after arrival he predicted:

… that if [the fire] continued in the direction it was going, there were definite impacts into Flowerdale, Kinglake West, Kinglake, St Andrews and to a lesser extent into eventually Toolangi through the back of Christmas Hills. 121

9.77 Mr Cowan did not see any line scan of the Kilmore East fire, nor was he provided with any other information concerning aircraft observation of the Kilmore East fire.122 9.78 At 2:40pm Mr Barca was informed by the Kilmore ICC that the fire had passed Wandong and was heading in a south-easterly direction and about to enter Mount Disappointment.123 Mr Barca was concerned. Using his experience and training he determined at that time that the fire would have a forward rate of spread of 20 kilometres per hour, flame height varying from 5 to 30 metres crowning in forest areas, and that spotting would occur up to 20 kilometres away.124 Mr Barca stated:

I came to the conclusion that the fire was likely to reach Whittlesea before the predicted wind change in the early evening. With the predicted south-westerly wind change, the fire was likely going to head towards various communities in the Kinglake area, by which I mean the townships of Kinglake, Kinglake West, Strathewen, St Andrews, Steels Creek, Flowerdale, Humevale and surrounding towns and areas.125

9.79 Mr Barca attempted to pass this information to Mr Creak at Seymour and Mr Murphy at Kilmore but could not get through on the phone.126 9.80 At 2:59pm an entry was made on the CFA IMS in relation to the Kinglake fire:

Prognosis as follows: from ASS [Air Attack Supervisor] the fire front will not be held and aircraft are only capable of protection. This fire will run south and east. Potential areas impacted include Upper Plenty, Eden Park and Whittlesea.127

9.81 At 3:30pm an entry by the Incident Controller at the Kangaroo Ground ICC, Mr Lawrence, reflected that power/transmission lines in Kinglake (SP Ausnet) ‘were potentially in the path of the fire’.128 This concern for the transmission lines at Kinglake was passed onto the Operations Manager in the Region 13 RECC 240 who indicated to Mr Lawrence he would pass the information onto SP Ausnet.129 Incident Management: A Case Study

9.82 At 4:00pm reports from the CFA radio and the Operational Unit at the Kangaroo Ground ICC informed of ember attack at Kinglake West, Eagles Nest (Arthurs Creek) and Panton Hill.130 9.83 At 4:08pm Mr Lawrence informed Mr Graham Armstrong, Operations Officer at Region 13, that there were ‘a large number of assets in the fire path’ that could not be defended. These included water treatment facilities at Yan Yean and Sugarloaf and transmission lines in the Kinglake area. Mr Lawrence formed the opinion that as strategic infrastructure could not be defended, the focus of attention would be solely on the ‘protection of life and property of potentially affected townships, including Arthurs Creek, Strathewen, St Andrews, Kinglake West and Kinglake and other smaller communities in between’. At this time the Kangaroo Ground ICC predicted without the wind change the fire would run to Diamond Creek.131 9.84 An entry into the IMS at 5:11pm from the Kilmore ICC advised the wind change would arrive sooner than expected, and was now anticipated to impact on the western flank of the Kilmore East fire at 6:30pm.132 iECC information 9.85 At 12:55pm on 7 February the CFA produced an electronic map of the estimated fire location for the Kilmore East fire.133 A line scan of the fire was commenced at 12:46pm and a second line scan was run at approximately 12:55pm.134 Line scans are infra red aerial readings generally collected by a light aircraft flying across the path of the fire.135 Their collection is limited by suitable flying conditions and this restricted flights on 7 February.136

Source: Country Fire Authority

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Figure 9.3: Kilmore East fire line scan 12:46–12:49pm

Source: Exhibit 157 (EXP.003.006.0002)137 242 Incident Management: A Case Study

Figure 9.4: Kilmore East fire line scan 12:55–12:58pm

Source: Exhibit 157 (EXP.003.006.0003) 138 243 Note: Figure 9.3 was taken at a height of 20,000 feet and Figure 9.4 is taken at a height of 10,000 feet. 2009 Victorian Bushfires Royal Commission—Interim Report

9 INCIDENT MANAGEMENT: A CASE STUDY

9.86 In the nine minutes between the two line scans, the fire is shown to have developed. The area of active firefront is greater and the plume of the fire is drawn in an easterly direction by upper winds.139 The line scan image shows spot fires ahead of the fire and demonstrates the plume of the fire is drawing the fire together.140 The fire at this stage was incapable of being suppressed.141 Dr Kevin Tolhurst, Senior Lecturer, Fire Ecology and Management, University of Melbourne, was of the opinion that the fire was out of control 20 or 30 minutes after ignition.142 These line scans provided the basis for a later prediction of the path of the Kilmore East fire, which showed the fire going through the Kinglake region.143 9.87 An article published in The Australian on 14 February 2009 reported concerns and statements attributed to Mr Waller, Mr Rees and Mr Bruce Esplin (Emergency Services Commissioner) as follows:

… they had a sense of dread early on about the Kilmore East fire. ‘I knew that was a dangerous place for a fire’ [Esplin]

… as soon as we saw the Kilmore East fire, in a very short time we knew we had a real problem. It was running towards populated areas. You could run a ruler along where it was going to run – you knew straightaway [Waller].144

9.88 Mr Rees said the article did not represent his language. He said he had a concern for the Kilmore East fire like a number of other fires burning on the day. Mr Rees said he appreciated that if the fire got across the Hume Highway and into Mount Disappointment, the fire would not be controlled on the day and that it would impact on communities and populated areas.145 9.89 Mr Waller stated in evidence that he did have a sense of dread, early on, concerning the Kilmore East fire because of where the fire was located in the Kilmore Gap, with northerly winds and a history of bad fires in the Mount Disappointment area. In his opinion it was a fire ‘of very high potential’.146 Mr Waller held the opinion on 7 February that once the fire crossed the Hume Highway ‘it was going to run’ and follow a predictable course.147 9.90 Concern about the potential of the Kilmore East fire within the iECC is demonstrated by the evidence of Ms Sarah Henshaw, Information Unit Leader for the CFA at the iECC on 7 February.148 9.91 Ms Henshaw attended a meeting at the iECC at 2:28pm which had been called by CFA State Coordinator, Mr Geoff Conway. At the meeting Mr Conway informed those attending ‘that priority areas for the Kilmore East fire were Whittlesea, Hurstbridge and Kinglake’.149 Also in attendance at the meeting were State Duty Officers of the CFA and DSE and Ms Jennifer O’Beirne from the DSE Information Unit.150 9.92 Ms Henshaw said that Mr Conway wanted priority given to Whittlesea, Hurstbridge and Kinglake in terms of provision of information to those areas — to warn these communities. She was informed with others attending the meeting that messaging needed to come from the ICCs that addressed those priority areas.151 9.93 As a consequence of the meeting with Mr Conway, Ms Henshaw spoke with Mr Alex Caughey who was the Information Officer for the Kilmore East fire at the time. To the best of her recollection she raised Whittlesea, Hurstbridge, Kinglake for the purpose of having the Information Unit prepare messaging for those areas.152 Despite this, the first time Kinglake received a warning by reference to the CFA website was at 5:55pm.153 9.94 Between 3:11pm and 3:30pm fire behaviour analysts at the iECC produced a hand drawn prediction map of the Kilmore East fire.154 The map incorporated information from the aircraft surveillance unit at 3:30pm that the fire was spreading faster than anticipated.155 The prediction map indicated the fire potentially spreading to Hurstbridge and close to Kinglake, with spotting extending considerably further as far as Flowerdale and Toolangi. The hand drawn map is reproduced below.

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Figure 9.5: Hand drawn map created at 3:11pm

Source: Exhibit 122 – Statement of Sutton, Attachment 9 (DSE.CD03.0001.0035)156

9.95 The prediction map was distributed at approximately 4:30pm.157 It was not produced in its electronic form until 5:43pm.158 9.96 The potential effect of the south-westerly change on fires was appreciated at the iECC. Ms Henshaw described a conversation with Mr Conway at 5:49pm during which he informed her that Mr Rees and Mr Waller were concerned that the wind change had the potential to impact on fires in south, eastern and central Victoria and Gippsland. Mr Conway expressed the need to get information to the public about the wind change.159 9.97 Ms Henshaw drafted a web article concerning the fires and the wind changes that was signed by Mr Rees.160 It was then decided that the article should be redrafted as an urgent media release. The information went to the Media Officers to prepare a media release. Ms Henshaw was not sure if it was ever issued.161 9.98 The web article prepared by Ms Henshaw (which was ultimately never released) was signed by Mr Rees at 6:09pm. It referred to erratic winds accompanying the change and the potential for unpredictable fire behaviour.162 9.99 The Commission, as yet, has not received evidence from Mr Conway.

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Kilmore EAST fire information conclusions 9.100 Not all the evidence describing the information and intelligence that was available concerning the Kilmore East fire on 7 February received to date has been referred to in this report. However, the evidence referred to establishes the following significant matters:

■■ Within 20 to 30 minutes of the time of ignition of the Kilmore East fire (11:49am) it was a fire out of control with no prospect of being contained. It could not be fought.

■■ By 1:00pm, when the Hume Highway was closed to traffic and the fire had entered the pine plantation on the western side of the Highway, there was an appreciation that the fire would likely cross the Hume Highway and enter the Mount Disappointment area. This carried with it the high risk that the fire would impact on populated areas.

■■ When the fire crossed over the Hume Highway just prior to 2:00pm, those experienced in fire behaviour must have anticipated its potential for destruction.

■■ Between 2:00pm and 2:30pm the fire had been reported as running at speeds of between 20 and 30 kilometres per hour, with erratic fire behaviour and heavy spotting.

■■ Fire prediction undertaken at various locations between 1:30pm and 2:45pm showed that residents in and surrounding Flowerdale, Kinglake West, Kinglake, St Andrews, Strathewen, Steels Creek, Humevale, Christmas Hills, Toolangi and Whittlesea were at risk.

■■ In addition to running at great speed, the fire was expected to crown in forested areas, spot long distances (up to 20 kilometres), and have flame heights up to 30 metres.

■■ The cold front approaching from the south-west would have a major impact on the Kilmore East fire, converting the eastern flank of the fire to a much broadened firefront, adding significantly to the fire’s activity and potential devastation.

■■ By at least 2:28pm, there was an appreciation at the iECC amongst senior officers of both fire agencies, of the grave potential of the Kilmore East fire to impact on communities and townships including Whittlesea, Hurstbridge and Kinglake.

Kilmore ICC warnings 9.101 Mr Caughey from the Seymour RECC acted as Information Officer for the Kilmore East fire until approximately 4:00pm. He had not previously allocated the Kilmore ICC its own Information Officer because he was not aware it would be activated as a level 3 ICC.163 It was an unusual situation for him, as an Information Officer, to be remote from the ICC and the immediate information concerning the fire coming into the ICC.164 9.102 After being appointed Information Officer to the Kilmore ICC, Mr Caughey remained under pressure due to responsibilities of his other pre-arranged tasks. He was supervising three untrained administrative officers at the Seymour RECC who were inundated with calls from people seeking fire information, and he personally was overwhelmed with calls over the course of the afternoon.165 9.103 Mr Caughey maintained the role of Information Officer, working from Seymour, until Ms Leonie Hunter, a CFA volunteer officer, arrived at the Kilmore ICC at approximately 4:00pm.166 Up until that time he had responsibility for preparing messages and warnings concerning the Kilmore East fire. The messages and warnings were issued from the Seymour RECC. They were not seen or signed by the Incident Controller at Kilmore.167 There was a Media Officer at Kilmore providing information to Mr Caughey concerning the fire. On a number of occasions Mr Caughey spoke to the Incident Controller.168 9.104 An awareness message timed at 12:30pm was posted to the CFA website at approximately 12:40pm. The message was prepared at the iECC and advised that the fire was burning in a south-easterly direction and the communities of Wandong and Clonbinane should be ‘aware of this fire’. The message was authorised by the CFA State Duty Officer, Mr Paterson.169

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9.105 Mr Caughey partially prepared an ‘awareness message — initial advice’ concerning the Kilmore East fire at or about 12:50pm. The message described a wildfire burning in a southerly direction. The advice stated the fire was not currently posing a threat to communities but provided a smoke and ember warning for the communities of Wandong, Heathcote Junction and Upper Plenty. This warning was not released because Mr Caughey said he was answering telephone calls at the Seymour RECC and with the passing of time the fire information contained in the message became out of date.170 9.106 Mr Caughey prepared an alert message at 1:10pm. This message was authorised by the Regional Coordinator at Seymour, Mr Creak. The message stated the fire was ‘not posing a threat’ to communities of Wandong, Heathcote Junction and Upper Plenty but those communities ‘should be aware that fire activity in the area has increased’. This alert message was not posted to the CFA website (release 1). Mr Caughey said he had ‘real problems’ sending this message out particularly to ABC Radio. 171 9.107 An urgent threat message was prepared by Mr Caughey at 1:50pm. The message advised that ‘the communities of Wandong may be directly impacted by the fire within ten minutes’. This urgent threat message was authorised by Mr Creak.172 This release was not uploaded on the CFA website until 2:40pm (release 2). Mr Caughey commented in his statement ‘The fire’s behaviour was such that our messages were really chasing the fire instead of the fire chasing our messages’.173 9.108 Mr Caughey prepared a further urgent threat message nominally timed at 2:05pm, which he believed was distributed within ten minutes of its preparation to ABC local radio and to the iECC for uploading. This release authorised by Mr Creak, advised communities of Heathcote Junction and Upper Plenty they ‘may be directly impacted by the fire within 30 minutes’.174 This was designated as release number 3 of the Kilmore East fire messages. This message was not uploaded to the CFA website.175 9.109 Ms Henshaw, the CFA Information Unit Leader at the iECC, stated that a facsimile had been received at the iECC at 1:53pm from the Seymour RECC (Mr Caughey) which included releases 1 to 3 for the Kilmore East fire. However, it was not received by the Information Unit at the iECC until sometime after 2:21pm, taking at least 28 minutes to be distributed within the iECC’s Information Unit.176 9.110 From 12:40pm, no information was posted to the CFA website concerning the Kilmore East fire, until 2.25pm, when a message was initiated at the iECC, authorised by Mr Paterson.177 The message stated that the fire was ‘not currently posing a threat to communities, however, the communities of Kilmore East, Wandong and Clonbinane need to be aware of this fire’. It went on to state that the fire had jumped the Hume Highway, was significantly spotting and that it was ‘impacting on the outskirts of the Wandong township’. This confusing message was issued at the iECC because it was considered important to upgrade the information from an awareness message to an alert message and because the iECC Information Unit had at that stage not received any information from the RECC or ICC.178 At 1:53pm the iECC had received information that Wandong, Heathcote Junction and Upper Plenty were under imminent threat. It is difficult to understand why this was not put in the iECC drafted warning or why the message did not carry the importance of an urgent threat message, (further analysis of this message is in Chapter 4). 9.111 At 2:40pm, release 2 (prepared by Mr Caughey at 1:50pm) stating that ‘Wandong may be directly impacted by the fire within ten minutes’ was uploaded onto the CFA website.179 The information was redundant and conflicted with the earlier posted message concerning Wandong. 9.112 Mr Caughey prepared an urgent threat message at 2:45pm (release 4). This message advised the community of Hidden Valley that they ‘may be directly impacted upon by the fire within 60 minutes’.180 This message was uploaded to the CFA website at 3:05pm.181 9.113 No updated information concerning the Kilmore East fire was uploaded to the CFA website between 3:05pm and 3:52pm.182 At 3:30pm Mr Caughey prepared an urgent threat message authorised by Mr Creak, which advised that ‘the community of Whittlesea may be directly impacted upon by this fire within two hours’.183 This message was emailed to the iECC at approximately 3:45pm and was uploaded to the website at 3:53pm.184

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9.114 At 4:05pm an urgent threat message for Hidden Valley was updated by the iECC to include the words ‘urgent threat messages for Wandong, Heathcote Junction and Upper Plenty remain current’.185 Ms Henshaw informed the Commission that the reason for this update was that Kilmore release 3, the 2:05pm message, which warned these communities, had not been uploaded to the website, and therefore the urgent threat message on the website did not include Wandong, Heathcote Junction or Upper Plenty.186 9.115 Due to his location and the pressure of his work commitments it was not possible for Mr Caughey to properly perform the responsibilities of Information Officer for the Kilmore East fire. He did not have access to the Planning or Situation Officers. He had no direct access to any fire prediction or analysis taking place at the Kilmore ICC. He had no direct opportunity of interacting with the Planning Unit or other key members of the IMT to obtain an ‘understanding of the potential [of the fire] to impact on communities’ or for obtaining ‘information needs’ concerning the fire.187 9.116 Earlier, at about 2:00pm, Ms Hunter was tasked to take over the responsibility of Information Officer from Mr Caughey and be located physically at the Kilmore ICC.188 She had to travel to Kilmore from the Alexandra CFA group headquarters.189 She took over Information Officer duties at the Kilmore ICC at approximately 4.00pm.190 9.117 Information release 6 for the Kilmore East fire was prepared by Ms Hunter at 4:10pm. This release was signed by the Incident Controller, Mr Murphy.191 The urgent threat message stated in part:

The communities of Clonbinane, Mt Disappointment, Kinglake, Heathcote Junction and Upper Plenty, Hume Vale, Reedy Creek, Strath Creek may be directly impacted upon by this fire. 192

9.118 This warning is the first acknowledgement in an information release of the potential of the fire to impact as far as Kinglake. The evidence discloses the following course of events in relation to this warning:

■■ It took ten minutes (after 4:10pm) to be signed off at the Kilmore ICC because the Incident Controller was very busy.193

■■ There was a problem with the fax machine at the Kilmore ICC. The urgent threat message could not be sent so arrangements were made to email it to Mr Caughey at Seymour RECC. This was done at 4:24pm.194

■■ Mr Caughey then emailed or faxed the urgent threat message to three email addresses at the iECC, (the CFA and DSE information desks and the Victorian Bushfire Information Line), to 774 ABC Radio and to local radio stations (Star and UGFM).195

■■ The urgent threat message was received at the iECC at 4:35pm.196

■■ The message was not uploaded to the CFA website. Upon investigation by Ms Henshaw after 7 February it was noted the email was not flagged as having been actioned by iECC staff responsible for uploading information to the website.197 9.119 The 4:10pm threat message was read over 774 ABC Radio at 4:43pm by Mr John Haynes, Deputy Chief Officer of the CFA.198 However, the 4:10pm message was not repeated on ABC Radio. This may have been because the announcers were relying on information available on the CFA website.199 The next occasion on 774 ABC Radio when the Kilmore East fire was mentioned, was at approximately 5:10pm. The announcer, Mr Steve Martin, referred to a grass and scrub fire burning four kilometres east of Kilmore. He referred to Hidden Valley as the community that may be directly impacted by this fire.200 9.120 Mr Martin at this time referred to a ‘Whittlesea’ fire. This was a reference to an urgent threat message (described in the next paragraph) that was prepared at the iECC and confusingly nominated the fire as a Whittlesea fire. 9.121 An urgent threat message referring to Whittlesea, nominally authorised by Mr Creak but authored at the iECC, was uploaded to the CFA website at 4:35pm (bearing a time stamp of 4:40pm).201 This message referred to a bushfire burning in the Mount Disappointment area and noted that the communities of 248 Whittlesea, Humevale, Arthurs Creek, Nutfield, Eden Park and Doreen may be directly impacted by the fire. Incident Management: A Case Study

9.122 At 5:41pm an urgent threat message from the Kilmore ICC bearing the time of 5:20pm was received at the iECC. This message gave an urgent threat warning to communities from Kinglake to Flowerdale informing them of the potential of direct impact by the fire. This was posted to the CFA website at 5:55pm, but contained a review time of 5:50pm.202 9.123 The above examination of the information and warnings prepared for communities in the path of the Kilmore East fire between 12.00noon and 6.00pm reveals that the information and warnings were not timely and did not accurately reflect the fire information that was available.

KANGAROO GROUND ICC Warnings 9.124 At the Kangaroo Ground ICC staff were concerned about the potential of the Kilmore East fire. Ms Serafina Munns, an experienced volunteer member of the CFA, had been rostered to work in the Information Unit on 7 February. Ms Munns had never worked in an ICC Information Unit prior to 7 February.203 As early as 12:17pm she recorded in her log a report from a Kinglake West CFA member who could see the smoke column of the fire over Mount Disappointment. At that stage the fire was most likely in the Wallan area.204 9.125 In preparation for information releases from the Kangaroo Ground ICC, Ms Munns used templates for releases and gathered information from the CFA radio, telephone calls and discussions with the ICC personnel, particularly the Information Unit and the Planning and Mapping Departments concerning the predicted path of the Kilmore East fire.205 The Kangaroo Ground Fire Tower Operator, Ms Keating, also frequently reported matters concerning the fire to Ms Munns.206 9.126 At 1:30pm Ms Munns recorded in her log a concern that the fire could burn into and around Mount Disappointment and burn towards Kangaroo Ground.207 The Information Unit prepared an awareness message for release concerning this potentiality. The Information Unit was informed that it was inappropriate to release this message because the fire was not in the Kangaroo Ground ICC area of responsibility.208 9.127 Mr Lawrence, Kangaroo Ground ICC Incident Controller, did not initiate direct contact with the local brigades in areas mentioned in the urgent threat messages that were not released, and was unaware of any attempt within the Kangaroo Ground ICC to do so.209 9.128 At 2:19pm there was a briefing of Kangaroo Ground ICC staff addressed by Mr Lawrence and Mr Barca, Deputy Incident Controller, concerning the Kilmore East fire. The meeting was informed that the fire was burning one kilometre from Wandong, and heading towards Kangaroo Ground, although there was an understanding this information might have been out of date. Members of the Information Unit again asked if fire information could be released from Kangaroo Ground. Mr Lawrence informed them this could not occur because ‘it was not our fire’, meaning the Kilmore ICC had responsibility for issuing such information.210 9.129 At 2:40pm, despite prior phone calls and investigations, the Kangaroo Ground ICC could not ascertain who was the Incident Controller at Kilmore. It appears there was some confusion amongst the Kilmore IMT as to who had this role. Mr Barca spoke to a person at the Kilmore ICC at 2:46pm who informed Mr Barca that the Incident Controller at Kilmore was either Mr Greg Murphy or Mr Peter Creak. Mr Barca was unable to contact either individual.211 9.130 A phone call was received by Mr Barca at the Kangaroo Ground ICC at 2:40pm from the Kilmore ICC. Mr Barca was informed of the south-easterly spread of the fire. He then undertook an exercise of predicting the fire spread. Mr Barca predicted that the fire could potentially impact on Kinglake, Kinglake West, Strathewen, St Andrews, Steels Creek, Flowerdale, Humevale and surrounding towns and areas. 212 9.131 Following this analysis, at around 3:00pm, Mr Barca spoke with Mr Lawrence about the need to draft a threat message.213 Mr Barca asked the Information Unit to draft a message for Kinglake and surrounding communities.214

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9.132 At 3:02pm an alert message was drafted.215 The information contained in the message was that the fire was estimated to be over 1000 hectares and that it was near Wandong heading in a south-easterly direction. It further stated:

Even though the fire is not currently posing a threat, the communities of Kinglake West, Kinglake, Pheasant Creek, Strathewen, Arthurs Creek, Doreen, Yan Yean, Woodstock, Mernda, Nutfield, Mittons Bridge, Hurstbridge, St Andrews, Panton Hill, Arthurs Creek, Smiths Gully, Christmas Hills need to be aware that fire activity in the area has increased and has the potential to impact directly.216

9.133 The 3:02pm alert message represents an accurate and timely warning concerning the potential of the Kilmore East fire. It was the combined work of the Planning Unit and the Information Unit at the Kangaroo Ground ICC.217 It demonstrates what could have been achieved by way of information and warning to those who were in the path of the Kilmore East fire. It also demonstrates the time at which information could have been released to the community. 9.134 However, the draft alert message of 3:02pm was not released. According to Mr Lawrence it was not released because ‘the fire was being controlled by the Kilmore ICC and it was their responsibility to issue information messages be they urgent messages or otherwise’.218 This message was not released by the Kangaroo Ground ICC because the Kilmore ICC, not the Kangaroo Ground ICC, continued to have control of the fire.219 9.135 Mr Lawrence stated in evidence that he attempted to contact the Kilmore ICC to pass the information on, without success. He did not know whether the Kilmore ICC was releasing this type of information.220 Mr Lawrence was not monitoring the CFA website to see what information was being released but, in any event, he reiterated: ‘not being the controlling ICC for that fire at that time, I was not able to issue those information releases regardless’. 221 9.136 Mr Barca stated that the unauthorised release of fire information may have caused confusion. He understood the draft threat message was forwarded to the Kilmore ICC for approval and release.222 It is apparent that personnel at the Kangaroo Ground ICC were not aware that the Information Officer for the Kilmore ICC at that time was based at the Seymour RECC, not at Kilmore. 9.137 Mr Barca spoke with Mr Bernard Barbetti, the DSE Regional Duty Officer at Box Hill, at approximately 2:50pm. Mr Barca told Mr Barbetti of his concerns for the potential of the Kilmore East fire and the threat to Kinglake and surrounding areas. He raised the need for a threat message and Mr Barbetti said he would check with the iECC about the status of issuing messages. Mr Barbetti phoned back at 3:13pm to advise no threat messages had been issued. 223 9.138 Mr Barca stated that continuing attempts were made by Kangaroo Ground personnel to contact the Kilmore ICC to check on the issuing of threat messages for the fire.224 Requests were made by the Kangaroo Ground ICC to take control of the fire as fire was burning rapidly into the Kangaroo Ground ICC area. Mr Barca recorded in his log at approximately 4:00pm:

Kinglake needs threat message ASAP – confirmation of responsibility lack of information and threat messages. CFA in a mess. 225

9.139 Mr Barca made this entry because of his frustration concerning the failure to release threat messages and because Kangaroo Ground had not been made ICC for the fire.226 9.140 Even though Kangaroo Ground was not the controlling ICC, Mr Lawrence had a conversation with Mr Armstrong, CFA Region 13 Operations Manager, at 4:00pm to discuss what firefighting resources could be allocated to the protection of SP Ausnet power transmission lines at Kinglake.227 At 4:08pm Mr Lawrence advised Mr Armstrong that Kangaroo Ground did not have sufficient resources to defend the Kinglake power assets. Mr Armstrong advised he would liaise with SP Ausnet.228 9.141 There is an incongruity in this situation. SP Ausnet, responsible for power line infrastructure in and around Kinglake, was advised of the threat and the inability of the CFA to defend that infrastructure. The township and residents of the same area received no warning information posted to the website, because of a 250 perceived necessity to comply with the Chief Officer’s Standard Operating Procedure (January 2005). Incident Management: A Case Study

9.142 At 5:20pm Mr Lawrence, against CFA procedure, did authorise an urgent threat message concerning the Kilmore East fire to be released from the Kangaroo Ground ICC. It featured the same communities that were the subject of the 3:02pm threat message that was never released.229 The release of this message occurred despite Kangaroo Ground not being the ICC for the fire. The reason given for the release was the continuing inability to make contact with the Kilmore ICC and a recognition that it was ‘a priority to issue those messages’.230 Mr Barca was not aware that Mr Lawrence had unilaterally issued this message.231 9.143 Evidence indicates Mr Lawrence did make contact with the Kilmore ICC during the course of the afternoon. He spoke with Mr Murphy at 3:50pm and at 4:50pm he spoke with Mr Peter Hayes, Operations Officer at the Kilmore ICC. 232 This conversation with Mr Hayes occurred only 14 minutes after Ms Munns had spoken with Mr Lawrence about issuing an urgent threat message. Ms Munns had raised the need to issue an urgent threat message at the Kangaroo Ground ICC with Mr Lawrence yet again because she, ‘didn’t believe that our communities at the southern end of the fire were being warned while we knew the fire was coming into the area’.233 There is no evidence that Mr Lawrence raised the issue of the release of the warnings during his conversations with Kilmore IMT members. 9.144 In the context of this contact with senior officers of the IMT at the Kilmore ICC, it is difficult to accept that Mr Lawrence was in fact giving priority to the issuing of threat messages from the Kangaroo Ground ICC. At this stage, the Commission recognises that the evidence is incomplete. The CFA should investigate whether there are any lessons to be learned, in light of comments made about communication problems at the Kilmore ICC. 9.145 It is an unsatisfactory situation that only the Incident Controller in control of the fire authorises information releases and that a firefighting officer can be in possession of information that could save lives but not release such information because of rigid divisions of responsibility. 9.146 It is noted that the Kangaroo Ground Divisional Command issued a red flag warning for firefighting personnel without authorisation of the Kilmore ICC.234 Authorisation for release of a red flag warning by the Incident Controller is not required, because it is an urgent message aimed at ensuring that fireground personnel ‘receive timely and accurate information relevant to their safety’.235 The same approach should apply to the release of bushfire warnings to the public. 9.147 Mr Rees indicated in evidence that AIIMS as a system is ‘immature’ and he thought this may explain the rigid approach to its operation.236 While this may be the case within the CFA, the Commission notes the system was adopted by them almost 20 years ago.237 Concerning the issue of the Kangaroo Ground ICC being prevented from releasing warnings, Mr Rees went on to say that there was a need for flexibility and ‘we … weren’t as flexible as what we should have been’.238 Mr Rees said you have to give people ‘the capability to break through [the system] when it is not working’.239 The Commission strongly supports this approach. 9.148 Mr Rees indicated that there was an ability to work through to the regional level when the Kangaroo Ground ICC was incapable of contacting the Kilmore ICC.240 Yet even though both Mr Lawrence and Mr Barca were in contact with their respective regional headquarters, the warnings were still not released. 9.149 On 7 February for communities in the path of the Kilmore East fire, the core responsibility of the CFA of providing accurate and timely fire information was not met. Supporting and promoting ‘safe, self-reliant and resilient communities’ able ‘to make informed decisions about their own safety’, was not achieved.241 The information for appropriate, timely warnings was available but not delivered to the community.

RECOMMENDATION 9.3

The CFA and DSE ensure that where a level 3 Incident Controller or officer of equivalent ranking is satisfied that a bushfire warning is required, then such Incident Controller is authorised to release a warning where the designated Incident Controller is temporarily unavailable

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iECC warnings 9.150 The evidence presented to date highlights the inadequacy of the warnings provided to threatened communities in the path of the Kilmore East fire. The process of monitoring warnings was also deficient. 9.151 The evidence discloses a widespread appreciation of the need for timely and accurate community warnings in bushfire events, discussed in Chapter 4. Ensuring that this widespread appreciation is matched by practice is another matter. There is a void in the responsibility for the issuing of bushfire warnings in Victoria, with no legal obligation falling on any person to issue warnings. As indicated by Mr Rees in his evidence, no person or authority in Victoria is charged with a legal or formal procedural responsibility for issuing warnings to the community concerning the risk of bushfire.242 9.152 The Commission acknowledges this. The CFA has, in practice, provided information and warnings to communities for many years. The creation, jointly with DSE, of the Victorian Bushfire Information Line acknowledges this. 9.153 The CFA and DSE have participated with AFAC in the evolution of AIIMS over the last 20 years.243 They have seen the role and responsibilities for information and warnings gain importance and consequence within the AIIMS structure.244 The CFA and DSE have been aware that fire information is required by Incident Controllers, both to manage and protect their own firefighting resources and to warn and protect communities under threat. 9.154 The provision of advice and warnings to the community has been a basic role of the fire authorities for many years and a fundamental expectation of the community. 9.155 To put the issue beyond doubt, the Commission considers it desirable to specify in legislation, a person who must shoulder direct responsibility for ensuring appropriate warnings during bushfire incidents. The Chief Officer of the CFA already possesses statutory power and authority concerning fires and, more particularly, for the protection of life, and is the largest fire agency in relation to bushfire in Victoria. 9.156 However, as some fires are under the control of a DSE Incident Controller, without any involvement of the CFA, it is appropriate that there also be a standing delegation allocating responsibility to the DSE Chief Fire Officer for providing information and issuing warnings.

RECOMMENDATION 9.4

The State amend the Country Fire Authority Act 1958 to provide that the Chief Officer has responsibility to issue warnings and provide information to the community concerning the risk of bushfires.

RECOMMENDATION 9.5

The CFA effect a standing delegation of the responsibility for providing information and issuing warnings to the DSE Chief Fire Officer where a fire is directed to be under the control of a DSE Incident Controller.

WARNINGS — CONCLUSIONS 9.157 By 2:00pm on 7 February the fire agencies understood that the Kilmore East fire was burning out of control with high potential to endanger life and property. Observations and reports made of the fire by experienced CFA personnel amply demonstrated its severity and its great potential to cause substantial damage, although it is unclear to the Commission at this time if all of these were received at the ICCs. The subsequent threat messages failed to convey this information, failed to communicate warnings in 252 a timely fashion and failed to identify towns and communities in the likely path of the fire. Incident Management: A Case Study

9.158 The Commission awaits an explanation as to why the Kilmore ICC was without any ICC personnel at the outbreak of this fire. In particular, the fact that the Information Officer was located at the Seymour RECC and distracted from his duties created a void in information. As indicated in evidence by Mr Rees, such an arrangement negatively impacts on the flow of information to the community from the ICC.245 This occurred on 7 February. 9.159 Despite knowledge held by senior personnel at the iECC as to the potential danger of the Kilmore East fire, there was an absence of timely and accurate warnings and oversight of the ICC. The meeting attended by Ms Henshaw at 2:28pm with the State Coordinator of the CFA and the State Duty Officers of the CFA and DSE identified areas including Whittlesea and Kinglake as priority areas for information. The identification of these particular towns at that time reflects the high degree of concern of senior officers in both agencies that this fire, following a predictable course, would impact on communities and populated areas. That information sent by the Kilmore ICC for uploading onto the website at the iECC was not uploaded is indicative of the level of breakdown on the day. 9.160 No warning concerning the Kilmore East fire included information as to the anticipated impact of the south- westerly change on the fire. Fires in the Western Districts had already demonstrated to the iECC the well known impact of the change on a smaller scale. The wind change did create the expected ‘horror’ situation with the Kilmore East fire.246 9.161 The consideration given by Mr Rees and Mr Waller at the iECC at approximately 6:00pm to the south- westerly change’s impact on the fires was consideration after the event. The impact of the change was always an eventuality that needed to be carefully monitored and should have been taken into consideration earlier. control of the kilmore east fire 9.162 Over the course of the afternoon of 7 February the firefront of the Kilmore East fire moved south into the area of the Kangaroo Ground ICC footprint. It was the strategic assessment of Mr Lawrence and the IMT at Kangaroo Ground, by mid afternoon, that the fire would be more efficiently managed by Kangaroo Ground. 247 9.163 Mr Barca raised the issue of the most appropriate ICC to control the Kilmore East fire with Mr Barbetti, DSE Coordinator Box Hill, at around 2:50pm. Mr Barbetti indicated he would contact the iECC on this matter and also concerning the issuing of threat messages about the Kilmore East fire.248 At 3:45pm Mr Barbetti informed Mr Barca it was still a Kilmore ICC controlled fire.249 9.164 The appropriateness of the ICC continuing at Kilmore was raised a number of times over the course of the afternoon of 7 February with Mr Graham Armstrong, Operations Manager Region 13, by both Mr Barca and Mr Lawrence. On all occasions they were informed that the fire would continue to be managed by the Kilmore ICC.250 9.165 At 4:30pm Mr Stewart Kreltszheim, a career firefighter with the CFA since 1993 and Operations Manager Region 23 based in Benalla, ‘instructed’ Mr Lawrence and Mr Barca that the Kangaroo Ground ICC was to be officially set up as a Divisional Command under the control of the Kilmore ICC.251 In large fires, areas of the fire are identified as Divisions with a ‘Divisional Commander’ to assist with span of control. The Divisional Commander (in this instance Mr Lawrence) normally reports through the Operations Officer of the IMT to the Incident Controller and receives advice regarding operational objectives.252 9.166 At 5:45pm Mr Armstrong advised Mr Lawrence he would confer with the State Duty Officer, CFA, as to whether Kilmore or Kangaroo Ground should run the fire.253 At 6:32pm Mr Armstrong advised Mr Lawrence no decision had been made. In this conversation Mr Lawrence informed Mr Armstrong he was unable to contact the Kilmore ICC.254 9.167 At 10:00pm, at a command meeting at the Kangaroo Ground ICC, Mr Lawrence indicated that Mr Armstrong had stated Kangaroo Ground was to assume command of part of the fire.255 The Kilmore ICC was telephoned, but there was a new Incident Controller on duty who indicated he knew nothing of any such transfer.256 253 2009 Victorian Bushfires Royal Commission—Interim Report

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9.168 It was not until between 5:00am and 6:00am on 8 February that Kangaroo Ground was in fact given control of the fire.257 9.169 The Chief Officer’s Standard Operating Procedure 8.04 (January 2005), provides a procedure for the transfer of incident control or command.258 The Incident Controller, a more senior Brigade Officer, an Operations Manager or State Coordinator may initiate a transfer of Incident Controller. The Standard Operating Procedure provides that, where appropriate, the transfer should have the agreement of the incumbent Incident Controller.259 9.170 The Commission will not speculate as to why the transfer did not occur earlier. It acknowledges the challenges of transferring incident control in the midst of rapidly moving fire operations. The communication issues raised in evidence are summarised below. 9.171 Mr Lawrence and Mr Barca maintained there were continual difficulties in making contact with the Kilmore ICC on 7 February.260 Evidence set out earlier indicates this was the reason why urgent threat messages prepared at Kangaroo Ground were not released — they could not be authorised by the Kilmore ICC. 9.172 Mr Barca stated that after Kangaroo Ground was appointed as a Divisional Command Centre, it received no instructions. Indeed ‘after numerous attempts to contact the Kilmore ICC by telephone (the phone rang out or was not answered)’ he said that Kangaroo Ground was unable to obtain instructions.261 Mr Barca stated after the 4:30pm communication with Mr Kreltszheim, he was unable to make contact with the Kilmore ICC again until 11:45pm.262 9.173 The Kilmore ICC received an ‘unbelievable amount of phone calls … and a large amount of radio traffic as well’.263 Mr Kreltszheim described communications as being stretched on the day. However, he was not aware of any problem with the communication system or the faxing or sending of urgent threat messages.264 He said there was a link with Mr Lawrence established by a Liaison Officer at the Kilmore ICC using a mobile phone.265 9.174 The evidence of Mr Lawrence indicates he did communicate with the Kilmore ICC at 3:50pm, 4:30pm and 4:50pm.266 9.175 Ms Hunter, Kilmore ICC Information Officer, stated that she had no difficulty communicating by telephone with the Kangaroo Ground ICC although she acknowledged that there were problems with getting threat messages through.267 9.176 The Kilmore fire station is not a permanent ICC and the telecommunications infrastructure did not match that of the Kangaroo Ground ICC. An area of the multipurpose room in the Kilmore fire station was partitioned off, in preparation for use as an IMT work centre on the night of 6 February.268 However, when Ms Hunter arrived at the Kilmore ICC on the afternoon of 7 February, she was allocated a room away from where the rest of the IMT were working and eventually was forced into the reception centre of the fire station.269 There was initially no computer or printer for her to use; she used her own notebook computer.270 There was a problem with the fax machine and an urgent threat message had to be phoned through to the Seymour RECC.271 9.177 Other evidence indicates a lack of communication and understanding between firefighting personnel in the field and the ICCs at Kilmore and Kangaroo Ground:

■■ Mr Williamson, the CFA Captain at Whittlesea who made important observations of the fire at around 2:00pm, commented: ‘we couldn’t talk to them [Kilmore] on the day’, the lack of communication had ‘a major impact’.272

■■ Mr McGahy, Captain of the Arthurs Creek/Strathewen Brigade, had no communication with the Kilmore ICC at all on the day.273

■■ Mr Hendrie, Captain of the Kinglake Brigade, had no communication with the Kilmore ICC. He believed Kangaroo Ground was ICC for the fire.274

■■ Mr Cooper, Deputy Group Officer at Kangaroo Ground, was involved in operational aspects of the management of fires at St Andrews and then involved in relief activities in Kinglake. All his observations concerning the fire were related to the Kangaroo Ground Divisional Command — he thought they would 254 be managing the fire as the ICC.275 Incident Management: A Case Study

THE iECC 9.178 The Report of the Inquiry into the 2002–03 Victorian Bushfires recommended ‘a single state-of-the-art all hazards State Emergency Operations Centre be established for Victoria’.276 The recommendation accepted that the implementation of the centre may need to develop in stages incorporating initially the CFA, DSE, the Metropolitan Fire and Emergency Services Board (MFB) and the State Emergency Aircraft Unit.277 9.179 A preliminary trial of one week was undertaken in February 2008 where the SECC functions of the CFA were relocated to the DSE Fire Emergency Coordination Centre at Nicholson Street, East Melbourne. This trial was apparently successful and in August 2008 a full scale trial, to run until 30 June 2009, was commenced with all the CFA State coordination functions transferring to the iECC.278 9.180 The CFA left ‘well developed SECC facilities and operational capacity at Burwood’.279 Lack of facilities at the Nicholson Street iECC meant some CFA support capacity was left behind but, in the main, Mr Rees said the operational capacity all went to Nicholson Street. 280 9.181 The objective in moving to the iECC was to integrate the CFA and DSE firefighting structures. When asked what was integrated during this trial period, Mr Rees referred to the Information Desk, the Situation Unit and the Mapping Section having both CFA and DSE people working side by side.281 Mr Rees said that information collection was ‘as integrated as possible’, but noted that integration was made harder by the fact that the CFA and DSE run different systems.282 Significantly each agency took their own command and control structures to the iECC ‘what we call the command function or the command cell are separate functions of the agencies’.283 9.182 Mr Rees indicated that the duplication of command structures at the iECC did not sit well with integration. He stated that ‘we need to understand that we can make better use of the key people and avoid the current parallel we are running’.284 The CFA and DSE ran separate websites providing different fire information from different sources.285 The CFA and DSE have different mapping tools or systems. There was an attempt to share capability but ‘the mapping systems … are not the same simply because the CFA is not DSE. We are not the same’.286 9.183 Mr Rees stated that the move to the iECC worked well and was a success.287 On the other hand, the CFA’s State Duty Officer on 7 February, Mr Paterson, pointed to a significant drop in the CFA’s operational capacity. He stated:

If the incident [7 February 2009 fires] had been run from the SECC [Burwood] we would have had up to ten CFA Situation Officers on duty. Instead we had two CFA Situation Officers on duty due to lack of space.288

9.184 As Mr Paterson stated, the function of the Situation Unit is ‘vitally important’ to maintaining regular and up to date information about fires.289 9.185 There were no operating procedures for the functions, role or work of the agencies at the iECC.290 A two page iECC Guideline was produced on 6 February 2009 and endorsed by officers of Victoria Police, the CFA and DSE, in consultation with the MFB and State Emergency Services.291 The guideline has little detail. It describes the role of the iECC as follows:

To support information sharing, enable intelligence gathering and joint situation analysis between agencies, to inform fire control and coordination, and agency command actions related to the management of the fire event.292

9.186 At the iECC there was no one person in charge. Neither the Chief Officer of the CFA nor the Chief Fire Officer of DSE filled such a position. Mr Rees stated that control of the iECC was a partnership between the CFA and DSE State Duty Officers: ‘they sit side by side and work together’.293

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9 INCIDENT MANAGEMENT: A CASE STUDY

9.187 Importantly, there is no procedure or protocol that allocates responsibility for issuing or monitoring community warnings in the event of fire to someone in the iECC. The events and circumstances of 7 February discussed above show this is a significant omission. While the Commission recognises the attempt at integrating the ‘different systems’, at this stage the evidence supports a conclusion that the main function of the iECC was limited to ‘where the two fire agencies have come together to work together in the coordination of the fires as two agencies with like outcomes’. Mr Rees stated that the iECC is not ‘a state coordinative centre for the management of disasters’.294 Just how the CFA move to the iECC impacted on operational capacity of the CFA on 7 February is not clear on the limited evidence the Commission has received. To date, however, the iECC appears more like co-location rather than integration. 9.188 Later hearings of the Commission will examine aspects of the organisation and structure of the CFA and DSE and the use of AIIMS, along with the cultural issues that inevitably impact on such co-locations.

Preliminary observations — Key iECC roles 9.189 The CFA Chief Officer possesses authority and power that may be exercised for the purpose of ‘extinguishing or restricting the spread of the fire’ or ‘protecting life or property’.295 The Chief Officer may delegate, by written instrument, powers and authorities conferred upon him under the Country Fire Authority Act 1958.296 The statutory role of Chief Officer is an operational role. Mr Rees described himself as the senior operations commander of the CFA.297 Mr Rees described his overall responsibilities as follows:

The Chief Officer has the ultimate responsibility for the suppression of fires and other incidents as prescribed by the Act. My role as Chief Officer is to ensure that the performance of CFA is in accordance with plans and the situation as it develops, and that appropriate inter-agency high level consultation and liaison occurs so that effective coordinated response can occur. My role is further to ensure that both in and outside of CFA, particularly to government, and ultimately to the Minister of Police and Emergency Services, the current fire situation is appropriately being communicated and that strategically, that CFA is working in accord with all the emergency services agencies.298

9.190 It is an onerous role, as shown on 7 February. To fulfil this role, particularly as it concerns the ‘communication of the current fire situation’, the Chief Officer would need to be kept informed by the most up to date fire intelligence and recognise the potential of major fires. 9.191 At the iECC Mr Rees did not appear to become actively involved in operational issues, even when the disastrous consequences of the fires began to emerge.299 His responsibilities on 7 February included ensuring an IMT was in place for major fires and that he was kept informed of the fire situation so he could inform those above him of the fires in a strategic sense.300 9.192 According to Mr Rees, his responsibilities also included coordination at a ‘State strategic level’.301 Mr Rees described this role as requiring strategic decisions as to the priority of resources on a statewide basis.302 9.193 By 3:30pm Mr Rees was aware the fire was in the Mount Disappointment area, that it was spotting significantly, and that there was fire spotting in the Strathewen area a long way ahead of itself.303 Mr Rees recognised the potential with this type of spotting that a range of communities could be the subject of such fire activity but he could not say if he turned his mind specifically to that.304 9.194 Mr Rees did not look specifically at warnings concerning the Kilmore East fire nor did he, given his knowledge of the spotting potential of that fire, ask anybody to check whether the Kilmore ICC was producing timely warnings.305 He did not do this because he said his ‘approach was state-wide. It was a strategic approach. It was not specifically related to one fire’.306 On 7 February, Mr Rees did not have any personal contact with either the Kilmore or the Kangaroo Ground ICC.307 9.195 Mr Rees was not aware specifically of the presence of Dr Tolhurst in the iECC on 7 February, although he knew fire behaviouralists were there, and had met with fire behaviouralists to be briefed as to the potential impact of the Bunyip fire and the damage it might cause to surrounding areas on 6 February.308 9.196 Mr Rees did not see any prediction maps concerning the Kilmore East fire on 7 February.309 Again, the 256 reason given why he did not inspect prediction maps was the need for a state overview.310 Incident Management: A Case Study

9.197 Mr Waller stated in evidence that in prioritising fires of state significance the potential or prediction for those fires was very important.311 He said that senior management at the iECC, including himself and Mr Rees, were discussing the fires over the course of the day. He agreed that it was not possible to coordinate resources without having some understanding of the potential of the fires.312 The methodology of working out fires, Mr Waller said, involved:

… straight experience, knowing the wind of the day, the fuels where [the fires] have started and particularly what assets, or communities, what built assets or critical assets are in front of that fire.313

9.198 According to Mr Waller, he and Mr Rees discussed both CFA and DSE fires equally.314 9.199 In relation to the Kilmore East fire, Mr Waller knew there was a problem in the containment of the fire very soon after ignition.315 Once the fire had crossed the Hume Highway, Mr Waller had the opinion on the day it would not be able to be pulled up; it would be uncontrollable and factors including the impact of the south-westerly change and its impact on the fires had to be taken into account.316 9.200 Mr Waller also agreed that the evidence before the Commission on the warnings issued on the day for the Kilmore East fire demonstrated that the warnings did not properly address the potential for the fire or the impact of the south-westerly change.317 Mr Waller stated he would have expected (for a DSE fire) that the DSE State Duty Officer would monitor the performance of the ICC in issuing warnings and inform him if he thought things were going wrong.318 9.201 Mr Paterson was the CFA State Duty Officer at the iECC on 7 February. The State Duty Officer is the next most senior CFA Officer to the State Coordinator, who is responsible to the Chief Officer. Mr Conway was the State Coordinator. The Commission has not yet heard evidence from Mr Conway and will examine the role of State Coordinator further in future hearings. 9.202 The functions of the CFA State Duty Officer, effectively transferred to the iECC on 7 February, are set out in Standard Operating Procedures concerning the State Emergency Coordination Centre (November 2007).319 The CFA State Duty Officer ‘will be the first point of contact for Regional Duty Officers for all operational matters requiring State notification or action in relation to incidents at which CFA personnel are engaged, or where state coordination of resources may be required’.320 9.203 The CFA Standard Operating Procedures concerning the SECC (iECC on 7 February) described without prioritisation the various roles of the SECC, including:

■■ monitor and advise the Chief Officer via the State Coordinator, of incidents occurring that have the potential to escalate to have significant effect on communities, CFA and government or on other agencies …

■■ provide support to Incident Management Teams in regions …

■■ ensure that suitable information is received by local communities to enable them to take appropriate actions to increase their safety.321

9.204 However, Mr Paterson stated to the Commission that:

■■ he did not see it as one of his tasks in coordinating resources to make an assessment of a fire’s capacity to cause substantial damage or loss of life322

■■ fire spread prediction was not important to him at a state level in terms of ‘resources strategy’323

■■ he did not see any fire prediction maps in relation to the spread of the Kilmore East fire and he did not discuss fire prediction at all with the State Coordinator or the Chief Officer. He saw no information on the day as to the likely area in which the Kilmore East fire would burn324

■■ he did not form a belief as to whether the Kilmore East fire was capable of suppression, nor did he discuss that issue with the State Coordinator or Chief Officer325

326 ■■ he did not prioritise the major fires on the day in terms of coordination 257 ■■ he was not aware on 7 February there was any difficulty communicating with the Kilmore ICC.327 2009 Victorian Bushfires Royal Commission—Interim Report

9 INCIDENT MANAGEMENT: A CASE STUDY

9.205 The evidence discloses that the most senior and third most senior CFA officers on 7 February made no reference to prediction maps and did not use the services of fire behaviour analysts located at the iECC.328 How the CFA’s responsibility in relation to ‘ensuring that suitable information is received by local communities to enable them to take appropriate actions to increase their safety’ was achieved is difficult to understand.329 9.206 On the basis of the evidence set out above, it is also difficult to understand how Mr Rees could properly carry out a strategic statewide coordination responsibility or how Mr Paterson could carry out the responsibilities of State Duty Officer and the coordination tasks he described. 9.207 The Commission made comment earlier in this chapter on the responsibilities and expectations for the provision of warnings and information. These are preliminary observations because the evidence is not complete and the Commission has not heard from the CFA State Coordinator or the DSE State Duty Officer.

FIRE PREDICTION AND ANALYSIS 9.208 DSE, with the support of various fire agencies Australia-wide, has in recent years conducted a course to train fire behaviour analysts.330 The placement of trained fire behaviour analysts at a state level and in ICCs would enhance timely and accurate warnings to the community.331 9.209 Fire behaviour analysts were located at the iECC during the 2008–09 bushfire season. They were involved in morning briefings at the iECC and prepared prediction maps as tasked.332 On 7 February they were not well positioned within the iECC.333 The flow of information concerning fires was slow and in some cases nonexistent.334 The analyst who was requested to undertake fire prediction for the Kilmore East fire was not provided with the line scans of 12:45pm until sometime after 2:00pm.335 Mr Williamson’s observations about the extreme fire scenario he observed north of Wandong at 2:00pm were not conveyed to the fire behaviour analyst at all.336 9.210 At the iECC on 7 February both the CFA and DSE were undertaking fire prediction and analysis. The communication between the two organisations at this level was not good.337 9.211 Overall the evidence points to fire behaviour analysis and fire prediction at the iECC on 7 February being a secondary consideration not referred to by Mr Rees or Mr Paterson. The flow of information to fire behaviour analysts at the iECC needs to be improved. It could be greatly assisted by locating fire behaviour analysts in a better position at the iECC, where they can readily access fire information as it is received at the iECC. 9.212 At the ICC level, fire prediction in a Situation Unit should be a priority for the Situation Officer. Threat messages need to be based on fire prediction and the Information Officer needs to be aware of fire prediction in the ICC as soon as it is available. 9.213 The Commission acknowledges the desirability of locating trained fire behaviour analysts in Situation Units of ICCs across the State. However, as the evidence of Mr Barca at Kangaroo Ground indicates, incident prediction in the early stages of a bushfire does not require enormous sophistication. The Commission accepts the submission of the Volunteer Fire Brigades of Victoria that it is a relatively straightforward undertaking in the preliminary stages of a bushfire to calculate speed, flame height, spotting distances and present the Incident Controller with ‘likely threats downwind’.338

258 Incident Management: A Case Study

AIIMS and INFORMATION — how it might change 9.214 As the evidence in this chapter reveals, the fire agencies were in possession of information early in the afternoon of 7 February that demonstrated the extreme nature of the Kilmore East fire and its potential. Despite this knowledge, warnings were not released in a timely manner. 9.215 There are a number of factors to explain this failure, some of which have been addressed. The release of information and warnings to the community needs to be made a priority in the ICC and effectively monitored at the iECC. The evidence before the Commission indicates insufficient priority was given to this. 9.216 The evidence the Commission has received to date does not enable it to make a definitive recommendation as to whether the Information Unit should have a separate and more significant identity within the AIIMS structure. The evidence concerning the Kilmore East fire demonstrates that warnings to the community need to be given a higher priority and this necessarily means that, for the 2009–10 bushfire season, the role and status of the Information Unit needs to be elevated. 9.217 Increasing this priority requires scrutiny of the function and the role of the Information Officer. In his evidence, Mr Rees raised the potential of expanding the Information Unit within the IMT by making it a separate function and therefore providing more direct access to the Incident Controller. This change in structure may highlight the function and prioritisation of information to the community.339 9.218 The Deputy Incident Controller is an optional appointment to a level 3 IMT, but in Victoria Deputy Incident Controllers are appointed where DSE and the CFA share responsibility for fire management (such as Kangaroo Ground IMT). A possibility identified by the Commission is to give the Deputy Incident Controller the responsibility in the IMT of authorising and releasing warnings to the community. 9.219 A further option is to make the Deputy Incident Controller responsible for all planning functions within the existing AIIMS structure, including information. Such an adjusted structure would better emphasise the increased priority given to information. 9.220 Alternatively, the information function could be established as a separate and equal function to operations. The Deputy Incident Controller could be delegated responsibility for ‘information’, ensuring information is collected and analysed, predictions are made, and warning advice is disseminated in a timely fashion. 9.221 These options are raised now, in this interim report, in an effort to promote the provision of timely and accurate information to the community. The CFA and DSE may choose to explore and trial such options over the 2009–10 bushfire season. 9.222 The Commission intends to examine this and other matters when it considers organisational aspects of the CFA and DSE in later hearings.

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10 EMERGENCY MANAGEMENT

In this chapter we examine Victoria’s emergency management arrangements and, in particular, the State Emergency Response Plan. In addition to those aspects of the emergency management arrangements dealing with warnings and evacuation, the evidence has highlighted some issues to be considered in reviewing the State Emergency Response Plan. This chapter also looks at issues arising from the guidelines for establishing police roadblocks during bushfires.

VICTORIA’S EMERGENCY MANAGEMENT ARRANGEMENTS 10.1 Victoria’s Emergency Management Act 1986 was enacted following the Ash Wednesday bushfires in 1983, to provide a legislative foundation for emergency management involving an all hazards, all agencies approach, and appropriate coordination of all agencies involved in the response to, or recovery from, an emergency.1 As explained by Mr Bruce Esplin, the Emergency Services Commissioner, the overarching principle underpinning the ‘all hazards, all agencies’ approach is that emergency management entails a whole-of-government approach.2 10.2 The ‘all hazards’ approach to emergency management involves a recognition that all emergencies cause similar problems and that many of the measures required to deal with emergencies are generic. There is also a recognition that one emergency may cause others.3 At the same time, the approach recognises that many risks require specific prevention, response and recovery measures.4 The range of hazards that Victoria’s emergency management arrangements are designed to meet is apparent from the definition of ‘emergency’ in the Emergency Management Act:

… an emergency due to the actual or imminent occurrence of an event which in any way endangers or threatens to endanger the safety or health of any person in Victoria or which destroys or damages, or threatens to destroy or damage, any property in Victoria, or endangers or threatens to endanger the environment or an element of the environment in Victoria including, without limiting the generality of the foregoing – (a) an earthquake, flood, wind-storm or other natural event; and (b) a fire; and (c) an explosion; and (d) a road accident or any other accident; and (e) a plague or an epidemic; and (f) a warlike act …; and (g) a hi-jack, siege or riot; and (h) a disruption to an essential service.5

10.3 The ‘all agencies’ aspect of Victoria’s emergency management arrangements recognises that all agencies have a role in emergency management and protecting the community from identified risks.6 10.4 Victoria’s emergency management arrangements are founded on the key components of prevention, response and recovery. The objectives of the Emergency Management Act refer to the role of each component of emergency management, as follows:

The objectives of this Act are to ensure that the following components of emergency management are organised within a structure which facilitates planning, preparedness, operational coordination and community participation—

(a) prevention—the elimination or reduction of the incidence or severity of emergencies and the mitigation of their effects;

(b) response—the combating of emergencies and the provision of rescue and immediate relief services;

(c) recovery—the assisting of persons and communities affected by emergencies to achieve a proper and effective level of functioning.7

262 Emergency Management

10.5 At the highest level, the Emergency Management Act vests responsibility for emergency management in the Coordinator in Chief of Emergency Management, who is the Minister for Police and Emergency Services.8 The Coordinator in Chief is responsible for ensuring that adequate emergency management measures are taken by government agencies, and for coordination of the activities of government agencies undertaking those measures.9 The Deputy Coordinator in Chief of Emergency Management is the Chief Commissioner of Police.10 The Coordinator in Chief may delegate powers or functions under the Emergency Management Act to the Deputy Coordinator.11 10.6 Section 8 of the Emergency Management Act establishes the Victorian Emergency Management Council (VEMC) to advise the Coordinator in Chief on all matters relating to the prevention of, response to and recovery from emergencies.12 The Council consists of the Coordinator in Chief and representatives of government and non-government agencies involved in response to and recovery from emergencies.13 The agencies currently represented on the VEMC include all the emergency service agencies — the Country Fire Authority (CFA), the Department of Sustainability and Environment (DSE), the Metropolitan Fire and Emergency Services Board (MFB), the Victorian State Emergency Services and Ambulance Victoria — as well as Victoria Police, the Emergency Services Telecommunications Authority, the Bureau of Meteorology, the Department of Defence, the Department of Human Services, the Department of Transport, the Department of Primary Industries, the Department of Premier and Cabinet and the Department of Treasury and Finance.14 The Emergency Services Commissioner is the executive officer to the Council.15 10.7 Section 9 of the Emergency Management Act enables the Coordinator in Chief to establish ‘such committees as are necessary to ensure comprehensive and integrated emergency management’.16 One such committee is the VEMC Coordinating Group, which assists the Coordinator in Chief before or during an emergency to ensure that responsible agencies have taken adequate emergency management measures and to coordinate the activities of those agencies.17 The VEMC Coordinating Group comprises the operational heads of the emergency services, the Deputy Commissioner of Police, and other directors of security and emergency management from relevant government agencies.18 10.8 The emergency management arrangements in place in Victoria are set out in detail in the Emergency Management Manual Victoria (the Manual).19 The Manual was developed and is maintained by the Office of the Emergency Services Commissioner, in consultation with agencies involved in emergency management.20 It contains policy and planning documents for emergency management, and sets out the roles played by the agencies involved in emergency management in Victoria.21 The contents of the Manual are structured as follows: Part 1 — Introduction to the Emergency Management Arrangements Part 2 — Emergency Risk Management and Mitigation in Victoria Part 3 — State Emergency Response Plan Part 4 — State Emergency Recovery Arrangements Part 5 — State and Regional Emergency Management Planning Part 6 — Guidelines for Municipal Emergency Management Planning Part 7 — Emergency Management Agency Roles Part 8 — Appendixes and Glossary Part 9 — Emergency Management Act Part 10 — Emergency Management Contact Directory Part 11 — Index. 22 10.9 Part 3 of the Emergency Management Act requires the preparation and review of a State Emergency Response Plan (SERP), for the coordinated response of all agencies with roles or responsibilities in responding to emergencies.23 The SERP is called DISPLAN in the Emergency Management Act, although that term is now little used.24 The SERP is set out in Part 3 of the Manual.25 It is discussed in detail below.

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10.10 Part 5 of the Emergency Management Act makes provision for the declaration of a State of Disaster by the Premier, in respect of an emergency that ‘constitutes or is likely to constitute a significant and widespread danger to life or property in Victoria’. A State of Disaster may be declared for the whole of Victoria, or for any part of it. Before declaring a State of Disaster, the Premier must consider the advice of the Coordinator in Chief and the State Coordinator — that is, the Minister for Police and Emergency Services and the Chief Commissioner of Police.26 10.11 The effect of the declaration of a State of Disaster is to vest operational control of all agencies in the Coordinator in Chief, thereby streamlining the command structure.27 It also enlivens the powers in section 24(2) of the Emergency Management Act, which include the power to take possession and make use of any property considered necessary for responding to the disaster, the power to control movement in the disaster area and the power to compel evacuation of the disaster area.28 10.12 No serious consideration was given by any witness to advising that a State of Disaster be declared on 7 February 2009, and no witness was aware that this had been considered by anyone else.29 Indeed, Deputy Commissioner Kieran Walshe did not believe that a State of Disaster had ever been declared under the Emergency Management Act, and attributed this to the significant improvements made to Victoria’s emergency management arrangements since the Ash Wednesday fires in 1983.30 This matter will be considered further by the Commission.

State Emergency Response Plan

Roles and structures 10.13 The Coordinator in Chief is responsible for arranging for the preparation and review of the SERP, after consultation with the VEMC.31 This preparation and review of the SERP has been carried out by the Chief Commissioner of Police, on the basis of a delegation under section 7 of the Emergency Management Act.32 10.14 The Chief Commissioner of Police is also the State Coordinator of Emergency Response and has responsibility under the SERP for coordinating emergency response agencies.33 The State Coordinator must appoint a member of the police force to be a Deputy State Coordinator of Emergency Response. Mr Walshe has been the Deputy State Coordinator since 2006.34 During his evidence to the Commission he explained the structure and operation of the SERP. 10.15 The SERP identifies the organisational arrangements for managing the response to emergencies in Victoria. Emergency response management is based on assigning three key management tasks of command, control and coordination. These roles and responsibilities are defined in the SERP as follows:

Command Command involves the direction of members and resources of an agency in the performance of that organisation’s role and tasks. Authority to command is established in legislation or by agreement within an agency. Command relates to agencies and operates vertically within an agency.

Control Control involves the overall direction of response activities in an emergency situation. Authority for control is established in legislation or in an emergency response plan, and carries with it the responsibility for tasking other agencies in accordance with the needs of the situation. Control relates to situations and operates horizontally across agencies.

Coordination Coordination involves the bringing together of agencies and elements to ensure effective response to emergencies. It is primarily concerned with the systematic acquisition and application of resources (agencies, personnel and equipment) in accordance with the requirements imposed by emergencies. Coordination relates primarily to resources and operates throughout the management of response or recovery activities.35

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10.16 Figure 10.1 demonstrates the SERP’s command, control and coordination functions in emergency response management arrangements.

Figure 10.1: Emergency response management arrangements

Other agencies and resources Response Co-ordinator

CO-ORDINATION CONTROL Incident Controller

Agency Commander Agency Commander Agency Commander

Supervising Personnel Supervising Personnel Supervising Personnel COMMAND COMMAND COMMAND

Operational Personnel Operational Personnel Operational Personnel

EMERGENCY

Source: Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 017436

10.17 Emergency response agencies are designated as control or support agencies, depending on the kind of emergency.37 The roles and responsibilities of the various agencies with regard to emergency response are set out in Part 7 of the Manual. A control agency is the agency nominated to control the response.38 A support agency, either government or non-government, supports or assists the control agency or another support agency.39 10.18 In relation to fire, the relevant control agencies are the CFA, DSE or the MFB, depending on the location of the fire.40 Section 16 of the Emergency Management Act provides that the chief officers of these agencies may, by agreement, appoint an officer of one of the agencies to have the overall control of the response to the fire.41 The officer appointed becomes the Incident Controller.42 The control agencies on 7 February were the CFA and DSE, and Incident Controllers for each of the fires were appointed by agreement between those agencies.43 10.19 Responsibility for the coordination of emergency response is allocated under the Emergency Management Act to Victoria Police. This is a role performed by Victoria Police for all emergencies, regardless of whether it is the control agency. The coordination function of Victoria Police is discrete from its command and, where applicable, control functions. An independent management structure therefore exists within Victoria Police for the performance of its emergency response coordination function.44

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10.20 In addition to the roles of the State Coordinator and the Deputy Coordinator of Emergency Response, held by the Chief Commissioner and a Deputy Commissioner of Police respectively, section 13 of the Emergency Management Act requires the appointment by the State Coordinator of a member of the police force to be a coordinator of emergency response for each region and municipal district. Mr Walshe explained that there are currently 23 Divisional Emergency Response Coordinators (DERCs) and 56 Municipal Emergency Response Coordinators (MERCs). A DERC is appointed for each of the 23 Victoria Police Divisions, and a MERC is appointed for each of the 56 Police Service Areas, which cover Victoria’s 79 municipalities.45 The Divisional Superintendent is usually appointed as the DERC for that Division, and the role of MERC is usually allocated to a sergeant or senior sergeant in the municipality concerned.46 10.21 Emergency response coordinators have statutory responsibility for directing emergency response agencies on the allocation of resources in responding to an emergency.47 The responsibilities of emergency response coordinators are set out in more detail in the SERP. The principal role of emergency response coordinators specified in the SERP is to:

■■ Ensure that the appropriate control and support agencies are in attendance or have been notified and are responding to an emergency;

■■ Ensure that effective control has been established in responding to an emergency;

■■ Ensure the effective coordination of resources and services having regard to the provisions of s. 13(2) of the Emergency Management Act 1986 (refer also Reserve Powers of Emergency Response Coordinators);

■■ In the event of uncertainty, determine which agency is to perform its statutory response role within a region or other specified area, where more than one agency is empowered to perform that role;

■■ Arrange for the provision of resources requested by control and support agencies;

■■ Review and dispatch situation reports;

■■ Ensure that consideration has been given to:

– Alerting the public to existing and potential dangers arising from a serious emergency direct or through the media; and – Any need for evacuation.

■■ Advise recovery agencies of the emergency;

■■ Consider the additional objectives shown below. 48

10.22 The SERP sets out particular responsibilities of DERCs and MERCs, and the responsibilities of a field emergency response coordinator, usually the senior member of the police force in attendance at the scene of an emergency.49 10.23 There is a corresponding structure of emergency response coordination centres at state, divisional and municipal level.50 Emergency response coordination centres are described in the SERP as:

… the locations where emergency response coordinators and liaison officers of control and support agencies receive, collate and disseminate intelligence, and coordinate the provision of resources. An [Emergency Response Coordination Centre] ERCC/[Emergency Coordination Centre] ECC is established to coordinate the provision of resources and conduct operations ancillary to an emergency operations centre. The ERCC/ECC has no command nor control functions.51

10.24 A diagram of Victoria’s emergency response coordination structure was attached to Mr Walshe’s statement and is reproduced here.

266 Emergency Management

Figure 10.2: Emergency response coordination structure

Co-ordination

SERCC

SERO

DERCC

DERC

MECC

MERC

Relief Centre MERO

Acronym Description Responsibilities

SERCC State Emergency Response The SERCC will access resources from intrastate, interstate Co-ordination Centre or from Federal Departments as the case may be SERO State Emergency Response Officer Sourcing of resources if required from intrastate, interstate or from Federal Departments as the case may be MERC Municipal Emergency Response Normally S/Sgt or Officer in Charge of Station. Co-ordinator Works closely with MERO in sourcing equipment/resources MERO Municipal Emergency Response Officer Normally a council representative. Works closely with MERC MECC Municipal Emergency Maintain communication with fire agencies via [Incident Co-ordination Centre Control Centre] ICC DERCC Divisional Emergency Response Representatives from all Gvt agencies gather to further Co-ordination Centre support MECC DERC Divisional Emergency Response Normally local Superintendent. Will ensure that MECC Co-ordinator are supported with request for assistance

Source: Exhibit 19 — Statement of Walshe, Annexure 3 (WIT.003.002.0044)52

10.25 A municipal emergency coordination centre (MECC) is typically located in a municipal office or public hall.53 One of the responsibilities of a MERC is to attend at the MECC if activated. The Municipal Emergency Response Officer, a council employee, also attends the MECC, together with liaison officers from relevant agencies.54 Divisional Emergency Response Coordination Centres (known as DERCCs or DECCs) are generally located in a police complex.55

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10.26 The State Emergency Response Coordination Centre (SERCC) is located at Victoria Police Centre, and is attended by Victoria Police personnel engaged in emergency response coordination and liaison officers from control and support agencies. The SERCC’s functions are described in the SERP as follows:

When activated, the SERCC is responsible for:

■■ Information collection, analysis of, and dissemination of intelligence to emergency response agencies;

■■ Coordination of the provision of resources required by Divisional emergency response coordinators;

■■ Allocation of resources on a priority basis;

■■ Requesting Commonwealth physical resources;

■■ Briefing the Coordinator in Chief via the State Emergency Response Coordinator;

■■ Dissemination of information to the media and the general public.56

10.27 The level of emergency response coordination depends on the scope of the emergency. In the first instance, the response to an emergency takes place at the municipal level. The MERC will be notified and the MECC may be activated. If the emergency calls for resources beyond those available at municipal level, the emergency response coordination is stepped up to the divisional level. The DERC becomes involved and the DECC may be activated. An emergency that extends beyond the division will be stepped up to the State level, to the State Coordinator and the SERCC.57

responsibility for issuing warnings 10.28 The SERP does not state clearly which agency is responsible for alerting the public to danger. The SERP states that:

Upon the request of a control agency to issue a warning, it is the responsibility of the emergency response coordinator to ensure that it is issued both to agencies and the potentially affected community. … For emergencies of major community significance, the warning should be authorised by an emergency response coordinator in consultation with the control agency.58

10.29 In contrast, Appendix 5 of Part 8 of the Manual, which deals specifically with bushfires, states simply that under ‘Victoria’s response arrangements, provision of warnings to the community is the responsibility of Victoria Police’.59 These apparently contradictory statements as to which agency has responsibility for issuing warnings sit side by side with the responsibility of emergency response coordinators to ensure that consideration has been given to alerting the public to dangers arising from an emergency. The warning arrangements under the SERP are understood by Victoria Police to require that warnings are initiated by the control agency and delivered by police.60 10.30 The provisions of the SERP on evacuation are described in Chapter 6. Subject to some specific exceptions, evacuation under the SERP is voluntary and response agencies are limited to recommending evacuation and assisting people to evacuate safely and efficiently. The SERP states that the decision to recommend evacuation rests with the control agency, in conjunction with Victoria Police and other expert advisers, time permitting. Once the decision to recommend evacuation is made, police are responsible for carrying out the evacuation process.61 10.31 Appendix 5 of Part 8 of the Manual deals with evacuation during bushfires and encapsulates the ‘stay or go’ position.62 The appendix notes that, unless people choose to leave well in advance of a bushfire, sheltering in a house will generally be safer than being caught in the open in a car. It outlines the fire agencies’ position that a decision to evacuate or to stay and fight must be made by the individual concerned, well in advance and on the understanding that there should be no last minute change of plan or attempt to evacuate in the face of a fire. Police are counselled against such ‘ad hoc actions’ as advising or directing people inappropriately to leave their homes in the path of a fire. There is no attempt in the SERP, or elsewhere in the Manual, to reconcile this advice with the responsibility of emergency response coordinators to ensure that consideration is given to any necessary evacuation. 268 Emergency Management

10.32 A review of the SERP was commissioned by the Minister for Police and Emergency Services following the 2009 bushfires. This review is being led by Victoria Police and is to be completed by the end of September 2009.63 The Commission looks forward to receiving the findings of that review.

WARNINGS AND relocation 10.33 As discussed above, the SERP does not clearly designate the agency responsible for issuing warnings and recommending evacuations. While the SERP currently only uses the term ‘evacuation’, the Commission has recommended in Chapter 6 that the word relocation be used in preference to the word evacuation (except in cases where evacuation is clearly more appropriate). In addition, the means by which warnings were issued and relocations were carried out on 7 February bore little resemblance to the arrangements in the SERP. 10.34 The considerable body of evidence received by the Commission on warnings issued on 7 February indicated that warnings were issued by the fire agencies directly to the public, without reference to the warning arrangements set out in the SERP. There is no evidence that the fire agencies requested Victoria Police to communicate any warning to the public.64 The fire agencies did not request Victoria Police to authorise the use of the Standard Emergency Warning Signal in connection with any warning.65 Mr Walshe explained that, under the Memorandum of Understanding with the ABC, fire agencies would issue warnings directly to the ABC and would not seek Victoria Police’s assistance in disseminating warnings.66 10.35 Similarly, there is no evidence that the fire agencies requested Victoria Police to carry out any relocations on 7 February. As discussed in Chapter 6, current CFA policy is not to recommend the evacuation of people threatened by bushfire. The relocations that were carried out by individual members of Victoria Police were initiated by them, and not by the fire agencies.67 The evidence of Superintendent Rodney Collins, the State Emergency Response Officer, was that the provisions of the SERP requiring emergency response coordinators to give consideration to the need for evacuation is not appropriate in relation to fires, because it is inconsistent with the ‘stay or go’ policy.68 10.36 Moreover, there is no evidence that Victoria Police emergency response coordinators at any level actively ensured that consideration was given to issuing warnings or to recommending relocation on 7 February. These judgements were left entirely to the fire agencies, and to members of Victoria Police exercising their own initiative.69 The evidence to date supports a conclusion that the responsibility of emergency response coordinators to ensure that consideration is given to warnings and evacuations was not actively discharged on 7 February. 10.37 Victoria Police regards its emergency response coordination role as being concerned primarily with the acquisition and application of resources.70 The responsibility to ensure that consideration is given to warnings and evacuations is apparently not regarded by Victoria Police as central to the role of emergency response coordinators. The lack of emphasis given to this responsibility by Victoria Police is illustrated by its omission from the otherwise detailed outline of emergency response arrangements for the 2008–09 bushfire season circulated by Assistant Commissioner Stephen Fontana in October 2008.71 However, the inclusion of this responsibility in the SERP creates an expectation that emergency response coordinators will take active steps in relation to warnings and evacuations or relocations, an expectation that was not met on 7 February. 10.38 Diffuse or unclear responsibility for warnings and relocation is at best unhelpful and at worst life threatening in an emergency. It is unsatisfactory that the SERP does not designate clearly the responsibilities of agencies and emergency response coordinators to issue warnings and to advise people to evacuate or relocate during an emergency. The SERP should be amended to give clear responsibility to the control agency to issue warnings. So there is no confusion as to which agency is responsible for these matters, emergency response coordinators should no longer be responsible for ensuring that consideration has been given to warnings and relocation.

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RECOMMENDATION 10.1

The State amend the State Emergency Response Plan:

■■ so the control agency for a fire is responsible for issuing and communicating warnings; and

■■ to remove from emergency response coordinators the responsibility of ensuring the control agency gives consideration to alerting the public to dangers and potential dangers arising from an emergency.

RECOMMENDATION 10.2

The State revise the Emergency Management Manual Victoria consistent with the interim report recommendations in relation to the ‘stay or go’ policy, warnings and relocations.

10.39 Other recommendations to amend the SERP and sections of the Manual on warnings and evacuation are made in:

■■ Chapter 4, in which the Commission recommends that the Manual be amended to reflect the changes to the use of Standard Emergency Warning Signal recommended in that chapter

■■ Chapter 6, in which the Commission recommends that in the SERP, the word relocation be used in preference to the word evacuation (except in cases where evacuation is clearly more appropriate), to remove possible confusion resulting from the compulsory or mandatory connotations of ‘evacuation’.

REVIEW OF THE serp 10.40 The evidence heard by the Commission, so far, has raised issues that should be considered in the current review of the SERP, namely:

■■ the feasibility of establishing an ‘all hazards’ operations centre for Victoria and co-locating the SERCC with this operations centre

■■ how the emergency response on 7 February varied from the ‘all hazards, all agencies’ emergency response management arrangements set out in the SERP

■■ clarifying the responsibilities of emergency response coordinators and the SERCC under the SERP

■■ simplifying the emergency response coordination structures. These matters are discussed in turn below. 10.41 One of the issues considered in the Report of the Inquiry into the 2002–2003 Victorian Bushfires was whether Victoria’s emergency management arrangements provided an effective management framework during the 2002–03 fires.72 Chapter 18 of that report assessed the State’s emergency management arrangements. The Commission remains mindful of the recommendations of this review. 10.42 However, the Commission has heard sufficient evidence to highlight the ongoing relevance of the recommendations in Chapter 18 of the Report of the Inquiry into the 2002–2003 Victorian Bushfires concerning state level coordination of emergency response. Those recommendations were:

18.42 That a single state-of-the-art all hazards State Emergency Operations Centre be established for Victoria. This could, if necessary, be implemented in stages, initially incorporating DSE, CFA, MFESB [Metropolitan Fire and Emergency Services Board] and the State Aircraft Unit.

18.43 That the options of co-locating the State Emergency Response Coordination Centre with the new State Emergency Operations Centre be explored.

18.44 That the State Emergency Operations Centre develop and maintain strong and close links 270 with the State Emergency Response Coordination Centre if collocation [sic] is not possible.73 Emergency Management

10.43 Following these recommendations a feasibility study was conducted by the Office of the Emergency Services Commissioner.74 In 2006 Victoria Police declined to participate in the State Emergency Operations Centre (SEOC) or to relocate the SERCC.75 One reason for declining to participate in the SEOC was the security concerns of other agencies that may be involved in responding to a terrorist attack, such as ASIO and the Australian Defence Force. The primary reason, however, was that emergency management is not the day-to-day business of Victoria Police.76 10.44 In 2008 the CFA, DSE, the MFB and Victorian State Emergency Services established the integrated Emergency Coordination Centre (iECC) in East Melbourne as a joint facility for the coordination of emergencies.77 Any emergency for which Victoria Police is the control agency is coordinated from the SERCC at Victoria Police Centre.78 10.45 The establishment of the iECC by some but not all of the emergency response agencies, and the consequent realignment of roles and responsibilities, may represent a departure from Victoria’s ‘all hazards, all agencies’ emergency management arrangements. The feasibility of a SEOC and its co-location with the SERCC, as recommended in the Report of the Inquiry into the 2002–2003 Victorian Bushfires, both warrant reconsideration. 10.46 Despite the establishment of the iECC, the SERCC is retained as a separate centre and operated separately on 7 February.79 At least in the case of emergencies that are coordinated from the iECC, it is unclear why SERCC functions should not be located within the iECC. The evidence demonstrated that, in practice, some of the functions of the SERCC were performed at the iECC on 7 February. 10.47 For example, the SERCC is responsible under the SERP for information collection, the analysis of and dissemination of information to emergency response agencies, and for dissemination of information to the media and the general public.80 On 6 February 2009 a ‘guideline’ was prepared on the roles of the SERCC and the iECC for 7 February. The guideline provided that the iECC rather than the SERCC was to ‘support information sharing, enable intelligence gathering and joint situation analysis between agencies’ — effectively to collect, analyse and disseminate information.81 Superintendent Collins agreed that this involved the transfer of a coordination function from the SERCC to the iECC, where it was performed by the fire agencies rather than Victoria Police.82 10.48 A further example is the emerging role of the State Emergency Strategy Team (SEST) at the iECC. The SEST is not established under the SERP or the Manual, and has evolved from existing arrangements over recent years.83 The SEST is a group comprising senior representatives of the control and support agencies represented at the iECC. It meets regularly during an emergency to: consider how the emergency may impact in the coming days, develop strategies, identify and address deficiencies in coordination and identify stakeholders that should be involved.84 It looks to be an effective vehicle for coordinating emergency response at the State level, particularly for information sharing between agencies. While Mr Walshe and Mr Collins attempted to distinguish between the functions of the SERCC and the iECC, evidence indicates that the role actually performed by the SEST was a true coordination function. 85 10.49 The lack of clarity in the SERP on issuing warnings and recommending evacuation or relocation is discussed earlier in this chapter. In addition, the effect of the guideline of 6 February and the, as yet, undefined role of the SEST meant there was no clarity on which agency was responsible for the function of collecting, analysing and disseminating information among agencies and to the public. It is obvious that the timely flow of accurate information is critical to effective emergency response. The current lack of clarity about responsibility for information flow should be addressed in the review of the SERP. 10.50 It is understood that other (internal to Government) reviews are underway that may have a bearing on the design of Victoria’s future emergency management arrangements.86 The Commission has not had the opportunity to be appraised of these. However, for the 2009–10 bushfire season, it is essential that the State clarify arrangements that should apply before the season starts.

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10.51 In this context the Commission notes that it would have been necessary for the arrangements in place within the iECC during February 2009 to have departed from those set out in the Manual. This reflects an evolutionary development of a co-located, moving to integrated, operational approach to bushfire management. This approach brought the most senior managers of the CFA and DSE together in a joint facility, that had both a strategic operational role and a whole-of-government coordination role. 87 10.52 Unfortunately, because the changed arrangements were under trial, the Manual does not reflect what was occurring in practice, and this led to some ambiguity. There were other protocols and understandings in place but there remained uncertainties, particularly in the responsibilities of Victoria Police vis-a-vis those of the fire agencies.88 10.53 Whichever arrangements the State chooses to follow during the forthcoming bushfire season — and the Commission encourages simplifying existing structures where possible — the Commission intends to examine in detail the emergency management arrangements for bushfires in future hearings. This is necessary to ensure that the lessons from the February 2009 bushfires can be taken into account in confirming the strategic emergency management structure that will best serve Victoria for the future.

RECOMMENDATION 10.3

The State settle the higher level emergency management and coordination arrangements that will apply during the bushfire season, noting that the Commission intends to take evidence on longer-term arrangements during its 2010 public hearings.

RECOMMENDATION 10.4

The State report to the Commission on the outcome of the current review by Victoria Police of the State Emergency Response Plan.

RECOMMENDATION 10.5

Victoria Police, in consultation with CFA and DSE, review the guidelines for the operation of roadblocks during bushfires, including how to:

■■ formulate the terms of a discretion to police on roadblocks to allow entry to: −− residents returning to their homes; −− people delivering relief and aid to residents and to animals; −− essential services crews; and

■■ expedite the exercise of the discretion in favour of persons able to establish their bona fides.

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Roadblocks 10.54 As identified in Chapter 3, roadblocks represented one of the most frequently mentioned grievances at the community consultations conducted by the Commission in March and April 2009. While the Commission is yet to examine in any detail the roadblocks that were put in place on and after 7 February, it has been able to gain a good understanding of the guidelines under which those roadblocks were established, and some of the issues caused by the application of those guidelines. 10.55 Victoria Police is responsible for establishing roadblocks, or ‘traffic management points’, during and after bushfires, either at its own initiative or at the request of the Incident Controller. In consultation with the CFA and DSE, Victoria Police has developed guidelines for the operation of these roadblocks.89 These guidelines were developed in the context of a Coronial Inquest into the deaths of two people in the Grampians fires in 2006, who had been allowed to pass through a police roadblock to return to their property.90 10.56 The guidelines advise Victoria Police officers on roadblocks ‘If in doubt, keep them out’, and give police no discretion to allow anyone other than responding fire agency personnel to pass. Under the guidelines, the discretion to establish a partial road closure rests with the Incident Controller. Victoria Police may institute a total road closure, or may upgrade a partial road closure to a total road closure. Only the Incident Controller may downgrade a total road closure to a partial road closure. 91 10.57 Many witnesses commented about the inflexibility of police roadblocks. Witnesses such as Mr Peter Newman of Buxton and Mr Doug Walter of Taggerty, who had stayed to defend their homes, found that if they left to communicate with family and friends, or to get supplies, they would not be permitted to return through the roadblock.92 Mr Walter said that every time he went through a roadblock he was at the mercy of the police officers stationed there:

We had gone shopping for everybody; we took it in turns with our neighbours to ‘run the gauntlet’. This was very distressing for me as it was very important to be able to get back to my home to defend it from spot fires. 93

10.58 In a similar vein, Mr John O’Neill of Steels Creek experienced a ‘small but frustrating amount of difficulty’ the day after the fire in getting his children past roadblocks to stay with family.94 10.59 Mr David McGahy, the Captain of the Arthurs Creek/Strathewen CFA, reported that a lot of residents had been troubled by the hard line taken by police officers at roadblocks that ‘If you go out, you are not going to get back’.95 Mr McGahy pointed out that residents had been traumatised by the ‘horrendous experience’ they had been through. He said:

So I appreciate [the police] have a difficult job, but there has to be some method by which people can get out and get supplies and, yes, reassure people that they are all right. There has to be some method that is a little bit more humane than what was employed then. 96

10.60 Witnesses who had left their homes found that roadblocks prevented their return in the days after the fire. Both Dr Chris Harvey of Kinglake and Mr Illiya Ananiev of St Andrews were stopped at roadblocks from returning to their homes, and both returned via a back route.97 Their experience was consistent with findings of the Bushfire Cooperative Research Centre’s Victorian 2009 Research Response Interim Report, which notes that many people attempted to return to their properties in the days after the fire, but in many cases were turned away by roadblocks. The majority of interviewees reported circumventing roadblocks by either talking their way through or finding an alternative — often more dangerous — route back to their properties.98

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10.61 A number of witnesses reported that police roadblocks prevented the passage of people assisting in the response to the fires, providing medical assistance and restoring essential services.99 Mr Lou Sigmund of Boolarra, Group Officer in the CFA Morwell Group, said that the debrief process had highlighted that an ambulance, water carriers, bulldozers and firefighters without identification had been stopped at roadblocks.100 Mr John Williams, who was in Yarra Glen on 7 February, was angered that it took five hours before his badly burned friend reached hospital, because the ambulance could not pass through a roadblock.101 He pointed out that the emergency services were trained to be imaginative and resourceful in an emergency, and said:

I think there certainly needs to be a measure of common sense, a measure of compassion in these roadblocks. To have an absolute square box that says, ‘No-one apart from emergency people may proceed any further’ I think is too watertight. It needs some subsidiary boxes on the side.102

10.62 The inflexibility of police roadblocks also caused difficulties for police on the roadblocks. Mr Walshe spoke of members being assaulted, almost run over, and subject to civil litigation. He acknowledged that the guidelines need refinement.103 10.63 One measure that does appear to have worked well in the days after the fires was a system of providing local residents with wristbands and stickers for their cars, so that they could pass freely through the roadblocks.104 This was used to good effect in the Kinglake area, but does not appear to have been universally employed.105 10.64 A report prepared for the Victoria Police Critical Incident Management Review Committee, arising from the Victoria Police bushfire internal debriefing process, identified a need to increase clarity for members and the public around legislative powers and current policy relating to traffic management points prior to, during and after an emergency.106 The Police Association has also sought clarification of roadblock protocols, including clear identification of people who are permitted to pass. While the current guidelines appear clear enough, what they lack is sufficient flexibility for police officers on roadblocks to exercise common sense and good judgement as to who should be permitted to pass, and helpful guidance to assist the exercise of some discretion.107 10.65 Victoria Police should review its roadblock guidelines, in consultation with the CFA and DSE, before the start of the next fire season. In reviewing the guidelines, Victoria Police should consider the matters raised here.

RECOMMENDATION 10.6

The CFA and DSE amend operating protocols to ensure that when an Incident Controller requests Victoria Police establish a roadblock to an area threatened by a bushfire, the Incident Controller simultaneously issues a bushfire warning to residents of that area.

10.66 In addition to issues arising from the inflexibility of the guidelines on roadblocks, some lay witnesses queried why police had established a roadblock restricting access to their area, but had neither warned residents of the area of the approaching bushfires nor advised them to evacuate. 10.67 Ms Jill Kane of Bendigo drove around a police roadblock to reach her brother Mr Mick Kane’s house in Long Gully. Having encountered the roadblock, she assumed that the police had warned residents about the fire danger and advised them to leave, and could not understand why that did not occur.108 10.68 Mr Illiya Ananiev and his family passed a police roadblock at Mittons Bridge as they fled the fire along the Heidelberg-Kinglake Road. He commented:

It looked like it had been there for a while. If we had known that the police had set up a roadblock we would have left much sooner.109

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10.69 Mr David Brown of Strathewen noted that a roadblock had been set up on the main approach road to Strathewen, as early as 3.30pm. Police on the roadblock were allowing only local residents through. Mr Brown queried what information had prompted the establishment of the roadblock, and why no warning had been issued to the Strathewen community.110 10.70 These are legitimate questions. A decision made by an Incident Controller to establish a roadblock to an area threatened by fire should be based on the same information that should also prompt the Incident Controller to issue a warning to communities in the path of a fire. In some circumstances, this information should also be used to advise people to leave the area, as recommended in Chapter 6. The fire agencies’ protocols should integrate consideration of whether roadblocks are necessary with consideration of warnings and advice to relocate.

Source: Courtesy of The Herald & Weekly Times

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Source: AAP Image 276 COMMONWEALTH RESPONSE 11 2009 Victorian Bushfires Royal Commission—Interim Report

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Each state and territory is responsible for its own preparation and response to natural disasters. The Commonwealth has no ‘stand alone’ powers in this area. Nonetheless, the Commonwealth plays a role in response to and recovery from disasters. This chapter explores the existing and potential role of the Commonwealth in natural disaster response and recovery and the role it played on 7 February.

Division of responsibilities

CommonweaLth Attorney-General 11.1 At the Commonwealth level, the Attorney-General is responsible for disaster-related matters. The Commonwealth Attorney-General’s Department is comprised of three groups, one of which is the National Security and Criminal Justice Group. This Group is divided into six divisions: (1) National Security – Resilience Policy Division (2) Emergency Management Australia (EMA) (3) National Security – Capability Development Division (4) National Security – Law and Policy Division (5) Criminal Justice Division (6) International Crime Cooperation Division.1

11.2 EMA is responsible for ‘the coordination of the operational responses to all hazards including natural disasters, terrorism and pandemics’.2 EMA describes its role as follows:

EMA is responsible to the Attorney-General for the coordination of physical emergency and disaster assistance provided by the Australian Government. Such assistance results from a formal request from a State or Territory if government and commercial resources are unable to cope with an emergency or disaster. The Director-General of EMA, after obtaining approval from the Attorney-General, can call on the resources of any other Australian Government Department or Agency, and can request assistance from other States or Territories.3

11.3 EMA’s operations centre, the Incident Management Facility (IMF), coordinates requests for assistance. The IMF has a surge capacity that can be activated during ‘events’.4 11.4 The Attorney-General’s Department Coordination Centre (AGDCC) monitors all emergency management and counter terrorism matters around the country. The AGDCC operates 24 hours a day, 7 days a week.5 11.5 EMA also has responsibility for the national security hotline, the AGDCC, the Natural Disaster Relief and Recovery section, dignitary protection and protective security.6 It has been noted that EMA does not have a legislative mandate, or Cabinet endorsement: ‘the delivery of EMA functions for the most part is the result of goodwill on behalf of other agencies’.7 11.6 At the time of the February 2009 fires, EMA had carriage at the Commonwealth level for warnings. Subsequently, on 2 March 2009 (in response to a review of the Department undertaken in 2008) the responsibility for warnings was transferred to the National Security Resilience Policy Division.8

Intergovernmental Committees 11.7 In addition to the role of these agencies, there are intergovernmental committees with representation drawn from the states and territories and Commonwealth, with responsibilities in relation to emergency management, disaster response and security. 11.8 The Ministerial Council for Police and Emergency Management — Emergency Management is chaired by the Commonwealth Attorney-General. It meets annually. 11.9 The Australian Emergency Management Committee (AEMC) comprises the executive officers of each of the state and territory emergency management councils, and chaired by the Secretary of the Commonwealth Attorney-General’s Department.9 It usually meets twice a year. 278 Commonwealth Response

11.10 A number of working groups have been formed to support the work of these committees:

■■ The Strategic Management Group supports AEMC in the strategic conduct of its role.

■■ The National Community Safety Working Group is a sub-group of AEMC. It considers ‘broad ranging community safety issues, such as public education, communication strategies and development of tools that could be used to assist the community to understand emergency management issues’.10

■■ The National Risk Assessment Advisory Group comprises representatives from the states and territories, GeoScience Australia and the Bureau of Meteorology. It ‘looks at advancing the capacity to conduct risk assessment and from that, then to be able to plan for mitigating the impact of events’.11 There is also a separate National Flood Risk Assessment Advisory Group.

■■ The National Spatial and Information Management working group provides support in respect of counter terrorism and critical infrastructure work.12

THE ‘all hazards’ approach TO Natural disasters 11.11 The Commonwealth’s approach to natural disasters is an ‘all hazards’ approach that aims to ensure that Australia is as prepared for natural disasters (including bushfires) as for other threats to national security and safety.13 This is an appropriate approach, given the enormous cost and impact natural disasters have on the Australian community. 11.12 A number of significant reviews and reports have been produced over the years in relation to natural disasters generally and bushfires, in particular, including:

■■ House of Representatives Select Committee into the Recent Australian Bushfires,A Nation Charred: Report on the Inquiry into Bushfires (October 2003).14 See also the Australian Government Position, which records the response of the Commonwealth to the recommendations in that report.15

■■ Council of Australian Governments (COAG) National Inquiry on Bushfire Mitigation and Management (March 2004).16 11.13 There have also been two significant Commonwealth reports on the issue of national preparedness for natural disasters. 11.14 In 2002, COAG commissioned the Natural Disasters in Australia: Reforming Mitigation, Relief and Recovery Arrangements Report.17 This report identified a framework of 12 reform commitments and made 66 recommendations. The Report also noted the increase in the incidence of natural disasters in Australia:

Australian Natural Disaster Trends Reliable information on the frequency of disasters in Australia extends only from 1967. Analysis of disasters between that year and 1999 shows that Australia typically encounters approximately eight disasters each year, where the total cost per event is greater than $10 million. However, since 1980, the average number of disasters of that magnitude has been tending to increase. The worst year was 1998, with 17 recorded events over a $10 million damage threshold. … [The] number of natural disasters in Australia, 1967–99, shows an upward trend in disaster frequency over the period. While just over 30 years is a relatively short time frame in which to discern trends, the Bureau of Transport and Regional Economics (BTRE) considers the trend statistically significant.

Across Australia, populations and the built environment continue to develop in hazard-prone areas. Major urban development, particularly in coastal and river valley locations, has continued sometimes without reference to hazard risk assessment and consideration of appropriate mitigation measures, with the result that certain urban developments and essential infrastructure that supports significant populations is at risk of damage from natural disasters.18

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11.15 The report also called on governments to engage in a ‘paradigm shift’ and to embrace mitigation, rather than focusing on recovery from natural disaster:

The HLG [High Level Group that authored the report] considers that a key to an improved national system for disaster management in Australia is a paradigm shift towards increased, cost effective investment in disaster mitigation by all levels of government.

The HLG also considers it is in the national interest, and the interest of all communities, that each level of government accepts responsibility within its own jurisdiction for natural disaster mitigation in relation to land, property and the environment, assets and infrastructure, agencies and programmes, because of the benefits that can be achieved through mitigation.

State and Territory Governments have the principal role in natural disaster mitigation within their respective jurisdictions. They set the legislative and policy frameworks in key areas such as land use planning and emergency management, and set the policy parameters for investment in infrastructure and for many funding programmes. They have a key role in providing leadership in, and establishing priorities for, disaster mitigation.

Local Government has a vitally important role to play at the community level in assessing risk, determining local investment priorities, and planning and implementing disaster mitigation measures to achieve more sustainable communities, and reduce the loss of life, damage and cost to communities from disasters.

The Commonwealth also has a continuing role in:

■■ providing national leadership on mitigation strategies and assessment

■■ providing financial assistance to State, Territories and Local Government for cost-effective, priority disaster risk management

■■ providing financial assistance to States, Territories and Local Government to assist them in meeting their disaster mitigation responsibilities

■■ leading to an overall reduction in damage and costs, thereby benefiting all Australians and all levels of government. In addition, the Commonwealth is considering means by which it might take into account disaster mitigation provisions of States and Territories.19

11.16 This report was supported in principle by COAG in December 2003.20 Mr Tony Pearce, Director-General, EMA, indicated that to date, 55 recommendations and eight reform commitments have been implemented, progressed as far as possible or are ‘being incorporated into emergency management practices’. The remaining recommendations and reform commitments are still being progressed.21 Further detail on this progress is contained in the Report on Progress on Recommendations of COAG Natural Disaster Related Reports.22 11.17 In October 2005, the Catastrophic Disasters Emergency Management Capability Working Group prepared a report, Review of Australia’s Ability to Respond to and Recover from Catastrophic Disasters.23 The recommendations made in this Report on the need for a national warning system are discussed in Chapter 4.

COMDISPLAN and commonwealth aid 11.18 The Commonwealth’s role in response to and recovery from disasters includes the provision of resources, including funding, to the states and territories for disaster preparedness. Programs administered by the Commonwealth include the Bushfire Mitigation Program, the National Emergency Volunteer Support Fund, the Natural Disaster Mitigation Program and the National Aerial Firefighting Strategy.24 11.19 The Commonwealth also provides additional assistance when the total resources of a state or territory affected by disaster or an emergency cannot reasonably cope.25 The Commonwealth Disaster Response Plan (COMDISPLAN) provides the framework for addressing state and territory requests for Commonwealth assistance arising from a disaster or emergency.26 280 Commonwealth Response

11.20 COMDISPLAN is prepared and maintained by EMA. Coordination of assistance delivered under the plan is organised from the EMA Incident Management Facility.27 11.21 Defence resources may also be provided to states and territories without the need for activating the COMDISPLAN. This is done through Defence Assistance to the Civil Community (DACC). DACC1 applies to assistance provided when immediate action is necessary to save human life, alleviate suffering, prevent extensive loss of animal life or prevent widespread loss of or damage to property in a localised emergency. DACC1 assistance may be approved by a local commander using local resources for a period of 24 hours. In principle, DACC1 aid is to be used only until ‘state resources can be deployed to the site of the emergency or DACC2 or DACC3 level assistance is sought’.28 Support at the DACC2 or DACC3 level can be provided only by an activation of the COMDISPLAN via an approach to EMA.29 11.22 Once requests are made by a state or territory to the Commonwealth for assistance, the necessary liaison with the Attorney-General is able to be executed quickly, and response times are swift.30 11.23 The Natural Disaster Relief and Recovery Arrangements are administered by EMA. Under this program, the Commonwealth partially reimburses states and territories for expenditure in relation to a range of natural disaster relief and recovery measures. If a state or territory’s costs in respect of a natural disaster event exceed $240,000, the Commonwealth reimburses 50 per cent (up to threshold limits determined by reference to the state and its revenue). The calculation of this cost is inclusive of eligible personal hardship and distress expenditure (including expenses for food, clothing, accommodation, emergency repairs to housing and replacement of essential household items and personal effects) and psychological and financial counselling expenditure.31 11.24 The Commonwealth suggested in its submissions that assistance from Defence organisations can only be provided ‘where it is requested by a State or Territory and for response to an actual emergency, not in advance of a possible emergency. In any event, Defence assets may not be available at the time of a request for assistance by a State or Territory’.32 11.25 This is certainly the current structure of COMDISPLAN and appears to be the philosophy that underpins the use of Commonwealth resources in aid to the states and territories. However, it is possible that the Commonwealth, states and territories could develop a more cooperative approach to sharing resources in a manner that would prevent and minimise risk, rather than focusing exclusively on response and recovery from disasters at a stage when the disaster is already unfolding. Possible approaches are discussed in more detail below.

Commonwealth RESOURCES For detecting, tracking and suppressing fires 11.26 The Commonwealth has access to a range of resources that could be used to detect, track and suppress fires. 11.27 The Commonwealth was asked to provide information on its capacity to provide ‘facts, data, images, whether obtained or analysed by means of sentinel bushfire monitoring, satellite imagery, infrared technology, mapping tools or other means capacity of providing information in relation to the risk, location and spread of bushfires in Victoria’.33 In evidence, Mr Pearce was asked about the capacity of Defence, the Defence Imagery and Geospatial Organisation (DIGO) and GeoScience Australia to assist states and territories to detect and track bushfires.

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11.28 Mr Pearce attested that he did not know precisely what Commonwealth assets were available that might be deployed to assist in detecting, tracking or suppressing fires. He explained that if ever he is approached by a state or territory about their possible deployment, he is obliged to approach other Commonwealth departments to ascertain whether any assistance might be available.34 Mr Pearce stated that the provision of Commonwealth assistance works in the following manner: states and territories identify the function that they need carried out, and make an approach to EMA. EMA then identifies Commonwealth organisations, including the Australian Defence Force and DIGO, which may have the requisite capacity. Mr Pearce said:

I couldn’t tell you what they have in regard to assets, all I can tell you is what I put to the agencies is a request for this outcome as been received. They will then identify they have an asset that can achieve the outcome. I wouldn’t necessarily know what it is or how they require it, and that could be in an imagery sense [mapping] or otherwise. ... I am not saying [that I don’t know what they can do], I am saying I know the Commonwealth can provide support in a whole raft of areas including imagery but what elements or imagery, what technical solutions they use to actually deliver it I don’t know, and nor do I have to.35

11.29 The Commission heard limited evidence about Commonwealth resources that are available on mapping and imagery. For example, GeoScience Australia’s satellite generated mapping tool products are available on public websites and are already provided to the Department of Sustainability and Environment. There was discussion also of the Australian Army’s 1TopoSurvey Squadron, where members briefed Ms Edwards (of the Australasian Fire and Emergency Service Authorities Council), after the 7 February fires on their ‘rapid response’ capacity in mapping.36 It appears that there is scope for the Commonwealth and the states and territories to liaise more actively on how resources might be used more effectively during bushfire response and recovery. 11.30 Section 6B of the Intelligence Services Act 2001 (Cth) provides that one of the functions of DIGO is ‘to provide to … State authorities ... (i) imagery and other geospatial products ...; (ii) assistance in relation to the production of such imagery or products; (iii) assistance in relation to the performance by those authorities or bodies of emergency response functions’. Emergency response functions are defined under the Act as including the ‘response to natural disasters’. 11.31 DIGO’s assistance was not sought by Victoria on 7 February.37 This is surprising, given that the magnitude of the disaster unfolding in Victoria was clear by mid-afternoon. A question that may be considered in further hearings is whether the Victorian fire services should have sought Commonwealth aid including the assistance of DIGO or Defence imagery during the day. There may also, of course, be a question as to the availability and utility of particular Commonwealth resources at that time. 11.32 The approach adopted thus far to Commonwealth support to natural disasters appears to have been more reactive than proactive. The overarching philosophy is focused on state and territory resources being exhausted prior to any requests for Commonwealth assistance being made. As a result, the Commonwealth does not engage with the states and territories in planning for high fire risk days, nor do the states and territories ask the Commonwealth to pre-position resources on days of predicted extreme fire danger. 11.33 There is room for greater engagement between the states and territories and the Commonwealth on the steps that might be taken before and during disasters. For bushfires, in particular, more planning is needed to consider what resources might be requested by the states and territories during the fire season and whether they are likely to be available or appropriate. The annual bushfire season provides a focus, and a guide, on when action is more likely to be required.

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11.34 In this regard, the Commonwealth proposed in submissions the following recommendations:

■■ The Commonwealth in partnership with Victoria and other high fire risk jurisdictions should facilitate discussions between relevant Commonwealth agencies (including EMA, Defence and GeoScience Australia) and state and territory fire services to identify ways in which appropriate Commonwealth resources might be applied more effectively in bushfire emergencies, including investigating the potential for these resources to be used for detecting, tracking and suppressing bushfires.38

■■ The Commonwealth, through EMA, provide twice yearly briefings to state and territory agencies regarding arrangements to support jurisdictions in times of seasonal emergencies including bushfire. These briefings should include the arrangements for all relevant Commonwealth agencies, including Defence. State and territory representatives should advise their relevant Ministers and agency Chief Officers (including fire services) of the outcomes of these briefings.39 11.35 The suggested approach is appropriate, and recognises that there is room for greater cooperation and planning between governments in responding to bushfire risk in Victoria. The Commission welcomes this development.

RECOMMENDATION 11.1

The Commonwealth facilitate discussions between relevant Commonwealth agencies (including Emergency Management Australia, Defence, Defence Imagery Geospatial Organisation and Geoscience Australia) and state and territory fire services to identify ways in which Commonwealth resources might be applied more rapidly and effectively during extremely dangerous bushfires, including investigating the potential for these resources to be used for detecting, tracking and suppressing bushfires.

RECOMMENDATION 11.2

The Commonwealth, through Emergency Management Australia, provide briefings at least once a year to state and territory agencies regarding arrangements available (including through Defence) to support jurisdictions during disasters and emergencies, including bushfires. State and territory representatives should advise relevant Ministers and the Chief Officers of emergency services (including fire services) of the outcomes of these briefings.

commonwealth involvement UP TO AND on 7 february

Lead up to 7 february 11.36 During late January and early February 2009, EMA was monitoring and responding to a number of significant events around Australia including bushfires in Victoria, South Australia, New South Wales and Western Australia, severe flooding in south-east Queensland, a major oil spill off the coast of south-east Queensland, tropical cyclones off the coasts of Queensland and Western Australia and a major telecommunications infrastructure failure due to flooding in Western Australia.40 As a result, the IMF had already been activated and was operating. Its role on 7 February involved monitoring developments (including the bushfires in Victoria) and communicating with the states and territories where disasters and emergencies were occurring. 11.37 The role of the AGDCC on 7 February was to gather information on various emergencies unfolding around the country, provide reports to senior national decision makers and provide support to EMA as required.41 The IMF prepared event briefings during the day, aimed at informing Commonwealth agencies about the heatwave and potential for bushfires.42 It also prepared national bushfire situation updates which it issued 43 on a number of occasions during early February. 283 2009 Victorian Bushfires Royal Commission—Interim Report

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Events of 7 February 11.38 At 6:41pm, a DACC1 request for assistance for bulldozers was made by direct approach to the Australian Defence Force. At 7:01pm this was updated to an urgent request by the Divisional Emergency Response Coordinator at Bendigo, to assist with the Redesdale fire. The Police Forward Command log notes that a response to this request had not been received by 7:32pm.44 At 8:40pm, the Australian Defence Force was informed the bulldozers were no longer required.45 11.39 At 10:52pm, the AGDCC issued a hazard impact event notification to individuals in the Attorney-General’s Department, Prime Minister and Cabinet, and other Commonwealth Departments with responsibility for disaster management and support (including Centrelink, Defence and Health). The notification advised that there had been fatalities in the Victorian bushfires.46 11.40 At 11:00pm Mr Pearce attended Parliament House and met with the Prime Minister and the National Security Advisor to brief them on the events in Victoria and to advise on the Commonwealth resources that might be made available to Victoria. The Prime Minister told Mr Pearce that he ‘expected EMA to ensure that all requests for Commonwealth Assistance from Victoria were expedited’.47 11.41 The Prime Minister contacted the Victorian Premier that evening. It was agreed the Prime Minister would attend Victoria the next morning and visit affected areas.48 11.42 At 11:38pm, Mr Greg Lovell, Director of Planning and Coordination for EMA contacted the Victorian State Emergency Response Coordination Centre (SERCC) to request approval to send an EMA liaison officer to the SERCC. That request was approved.49 Mr Pearce was asked whether consideration had been given to getting a liaison officer to the SERCC during the day on 7 February. He said, ‘[w]e weren’t asked to provide one. So therefore, had we not requested [that] we actually put one in there for their benefit and ours, we wouldn’t have had one there at all’.50

Activation of comdisplan on 8 February 11.43 At 6:19am on 8 February, the Attorney-General authorised Mr Pearce to activate COMDISPLAN in response to a request from Victoria. The first formal request was for 150 mattresses and portable beds for use in an emergency relief centre in the Shire of Baw Baw.51 11.44 In the days and weeks that followed, the Commonwealth was involved in the deployment of considerable resources directed to the recovery effort in Victoria. Assistance provided ranged from: heavy machinery; field and temporary accommodation; Defence personnel and others to assist in search and recovery efforts; specialist forensic assistance including odontologist support; services to sustain displaced people including through Centrelink and the Department of Families, Housing, Community Services and Indigenous Affairs; and subsequently bushfire researchers. 52 EMA also managed the international offers of assistance made to Victoria.53 11.45 The Commission notes the provision of considerable resources by the Commonwealth to the bushfire recovery effort — commencing in the hours after the fires and continuing to the present, including through the Office of the Parliamentary Secretary for Victorian Bushfire Recovery.

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This chapter discusses Victoria’s current emergency call service arrangements, the performance of these services on 7 February, and their interaction. National as well as state systems are reviewed, as both support Victoria during major bushfires. The chapter examines how both can better prepare and provide Victorians with the best possible service when placed under extreme pressure. Considerations for ‘surge’ capacity are given particular focus.

TRIPLE ZERO 12.1 There are two entities involved in answering Triple Zero calls in Victoria — Telstra and the Emergency Services Telecommunications Authority (ESTA). Each provides a vital component of the service. 12.2 Telstra Triple Zero is the ‘front end’ for taking emergency calls. Telstra Triple Zero operators, located in two national call centres (one in Melbourne and the other in Sydney), answer all Triple Zero calls for fire, ambulance or police. When the caller is located in Victoria, Telstra operators transfer those calls to one of three ESTA call centres — Ballarat, Tally Ho (Burwood) or the World Trade Centre (City of Melbourne).1 12.3 ESTA operators are trained as call takers, dispatchers, or both. They provide the essential interface between the public and the emergency services, including the fire services — the Country Fire Authority (CFA) and the Metropolitan Fire and Emergency Services Board (MFB). ESTA staff operate a Computer Aided Dispatch (CAD) system which permits the caller’s request to be translated into immediate dispatch of emergency services.2 12.4 The Triple Zero service suffered significant strain on 7 February. Many calls to the service went unanswered. Telstra staff were often unable to transfer emergency calls through to ESTA. Both the Telstra and ESTA staff on duty operated under extraordinary pressure, dealing with callers who, in many instances, were frightened and distressed.3 12.5 The system for handling Triple Zero calls and their presentation to ESTA involves some complexity. A great deal of the information presented in the hearings was in the form of data and statistical analysis. 12.6 Despite the complexity of the system, the difficulties experienced on 7 February come down to a number of simple propositions:

■■ there were insufficient ESTA operators to answer the large number of calls being presented by Telstra Triple Zero operators to ESTA centres

■■ Telstra Triple Zero operators were ‘tied up’ waiting on the line trying to put through calls to ESTA centres

■■ while occupied, Telstra Triple Zero operators were unable to take other calls from the public

■■ thousands of calls (10,768 calls in the national queue over 24 hours and 7824 in the Victorian queue from 2:08pm to 9:00pm) were abandoned before Telstra Triple Zero operators could answer4

■■ it is likely that the vast majority of the abandoned calls were made by those affected by the fires in Victoria, though calls from anywhere in Australia relating to life-threatening circumstances might have also been abandoned

■■ Telstra’s Triple Zero Service was not staffed to capacity on the day, nor was ESTA. An increase in the number of Telstra Triple Zero operators may have increased the number of calls initially answered. However, it would not have increased the speed of presentation of calls to ESTA, without a commensurate increase in ESTA staff taking calls. 12.7 There are lessons to be learned from these events. Improvements are needed as presently there is insufficient capacity to ‘scale up’ to handle the significantly larger number of calls expected in a large-scale emergency.5

286 Emergency Calls

Source: Emergency Services Telecommunications Authority

Telstra’s Emergency Service Answer Point 12.8 Ms Jane Elkington, Manager of Telstra’s Emergency Services Answer Point, explained the role Telstra plays.6 Telstra’s operation of the emergency call service is governed by determinations made by the Australian Communications and Media Authority under Commonwealth telecommunications legislation.7 Telstra is obliged to ensure that each emergency call is ‘received and appropriately handled’ and that it is transferred to the appropriate emergency service organisation.8 12.9 Telstra has responsibility for one aspect of the Triple Zero service as part of its licence conditions and is not remunerated for it.9 Telstra transfers Triple Zero calls to approximately 75 centres of emergency service organisations around Australia.10 12.10 Telstra Triple Zero operators who answer calls use a set script. When the caller is using a fixed land line, their address automatically appears on the operator’s screen, and the Telstra operator will say: ‘Emergency – Police, Fire or Ambulance?’ When the Telstra operator receives a response, they transfer the call to the appropriate emergency services organisation answering point. That point is automatically identified by the computer system that Telstra Triple Zero operators use, and with reference to the caller’s number and phone address.11 12.11 The Telstra Triple Zero operator only hangs up when the call is connected and the caller and the operator at the emergency service organisation are in conversation.12 The ‘overlap’ is usually a matter of three or four words, which the Telstra operator is required to hear before they press ‘disconnect’ and move to their next call.13 The role performed by the Telstra Triple Zero operator usually lasts less than 30 seconds. 12.12 Calls made from mobile phones are handled slightly differently. Because they do not operate from a fixed locality, the Telstra operator needs to establish the state and town where the emergency is. In all other respects, mobile calls are handled in the same way as calls from a fixed line.14

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12.13 The Telstra Triple Zero service maintains two key procedures:

■■ Operators are required to stay on the line with the caller until emergency service operators answer the call

■■ Operators are trained to complete and transfer calls rapidly, engaging in minimal interaction with callers — the involvement of Telstra Triple Zero operators usually lasts less than 30 seconds, and operators use set scripts when speaking with callers.15 12.14 The Telstra Triple Zero service is required to ensure that:

■■ 85 per cent of calls are answered by a call taker within five seconds of the call reaching Telstra’s answering point

■■ 95 per cent of calls are answered within ten seconds after the call reaches Telstra’s answering point.16 12.15 Calls to Triple Zero go into a national queue. The queue directs the longest waiting call to the first available Telstra Triple Zero operator at either Melbourne or Sydney. The call centres are staffed 24 hours a day, seven days a week.17 12.16 The Telstra Triple Zero operator presents the incoming call to the first priority number for the emergency service organisation that is automatically selected by the system. The way this works for ESTA is addressed in more detail below.

TELSTRA’S CAPACITY AND ROSTERS 12.17 The Melbourne and the Sydney call centres each have 25 call taker terminals. As a result, the maximum number of operators who can take Triple Zero calls at any one time across Australia is 50.18 12.18 Telstra’s rosters are generally prepared nine days ahead of time and are based on historical data on the likely number of calls. In each bushfire season, Telstra takes into account the potential for an extreme event that might increase call volume. Telstra’s historical data demonstrate that Friday and Saturday evenings are usually its busiest nights.19 12.19 Ms Elkington said it was extremely rare for the call centres to operate at maximum capacity. Telstra does roster 50 staff to work each New Year’s Eve, as experience has demonstrated that a large number of calls (many of which are not genuine) are received.20 12.20 Telstra is not able to compel staff to work additional shifts or hours.21 When preparing rosters Telstra personnel need to ensure that there is sufficient staff available for subsequent shifts.

RECORDED VOICE ANNOUNCEMENTS USED BY TELSTRA 12.21 Recorded voice announcements are used by Telstra in a number of instances.

■■ The front-end recorded voice announcement. This announcement is heard by all callers (since December 2008): ‘You have dialled Emergency Triple Zero. Your call is being connected’. This announcement is directed at reducing the high number of inadvertent and non-genuine calls received by Triple Zero.22

■■ The ‘short delay’ recorded voice announcement. This is automatically activated if any call to Triple Zero is not answered within 30 seconds. It is activated every 30 seconds thereafter. The caller hears the following message: ‘You have dialled the Emergency Triple Zero Number. Due to an unprecedented high volume of calls being received by Triple Zero, we are experiencing short delays in answering. Please stay on the line and you will be answered by the next available operator’.23

■■ The generic ‘extreme event’ recorded voice announcement. This was introduced in 2004 and is used when Telstra experiences high call volumes during an extreme event such a bushfire or major storm. The caller hears the message: ‘You have dialled Emergency Triple Zero. If you require police, fire or ambulance please stay on the line. If you require your local State Emergency Service please hang up and dial 1223 — that’s 1223 — as this service cannot be connected through Triple Zero’.24 When this announcement is activated, it is used in place of the front-end announcement.

■■ The ESTA-tailored extreme event recorded voice announcement. When authorised to do so by ESTA, Telstra uses an announcement tailored to the particular extreme event. In 2006, for example, ESTA authorised Telstra to use an announcement in the following terms: ‘Emergency Triple Zero in 288 Victoria is extremely busy due to bushfires. For emergency assistance please hold. For bushfire information, call 1800 240 667’ (this number is for the Victorian Bushfire Information Line (VBIL)).25 Emergency Calls

12.22 Ms Elkington explained that the tailored extreme event recorded voice announcement is designed to reduce traffic volumes on Triple Zero by directing callers to VBIL.26 However, the ESTA-tailored extreme event recorded voice announcement was not used on 7 February.27 12.23 It seems likely that even if it had been used, it would have had little impact in reducing the difficulties on the day. Evidence suggests that many callers rang Triple Zero and the VBIL on the day (Chapter 5), and a number of callers rang each number multiple times. The stress on both systems was extreme, with neither able to cope. Cross referrals by each service appear to have simply contributed to the problems.

THE ROLE OF eSTA 12.24 ESTA is a statutory authority established under the Emergency Services Telecommunications Act 2004 (Vic). ESTA’s central function is to provide emergency telecommunications and other communication services. It operates a call-taking and dispatch service. It is not responsible for early warnings or general information to the public about catastrophic events.28 12.25 ESTA’s operations are governed by administrative arrangements developed in conjunction with the emergency services organisations and the Office of the Emergency Services Commissioner (OESC). The arrangements presently in place were implemented in June 2005 and include performance standards determined by the OESC.29 12.26 ESTA is funded pursuant to an arrangement under which it is paid a fixed fee by each emergency services organisation.30 12.27 Since its inception in July 2005, ESTA has experienced a 28 per cent increase in the number of Triple Zero calls it answers and a 20.8 per cent increase in the total number of all calls it has answered; but the average funding increase has only been 2.5 per cent per year. 31 Mr Neil Foster, the Chief Executive Officer of ESTA, confirmed that the increase in call activity has not been matched by increases in funding.32 12.28 An additional $3 million was made available in 2009–10 to support ESTA.33 ESTA has made submissions arguing for a move from a fixed-fee funding arrangement to an activity-based funding arrangement. The Department of Justice has agreed that this review should take place.34 12.29 ESTA is responsible for managing Triple Zero emergency calls, non-Triple Zero emergency calls, non-emergency calls and associated communications for the dispatch of the following emergency services organisations:

■■ Victoria Police — only Metropolitan Melbourne, outer suburban area and Geelong

■■ Ambulance Victoria — only Metropolitan Melbourne and outer suburban area

■■ Country Fire Authority — all designated areas

■■ Metropolitan Fire and Emergency Services Board — all designated areas

■■ Victorian State Emergency Service — all designated areas.35 12.30 ESTA is not currently responsible for managing calls and communications for Victoria Police beyond metropolitan Melbourne and the outer suburban area and Geelong. Likewise, ESTA is not responsible for managing calls and communications for Ambulance Victoria beyond metropolitan Melbourne.36 12.31 ESTA also answers:

■■ emergency calls made directly to the State Emergency Communications Centres (SECCs), not through Triple Zero

■■ a number of non-emergency calls on low priority directory numbers. The non-Triple Zero emergency calls are typically made directly to ESTA by the emergency services organisations or from high-risk premises like prisons or petrochemical facilities.37

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12.32 ESTA also operates the Emergency Alerting System (EAS). This is a dedicated pager messaging system used by the emergency services staff and volunteers of the CFA, the Victorian State Emergency Services (VICSES) and Ambulance Victoria (Rural). It operates over the whole of Victoria by means of 212 radio transmitter sites linked to a message switching centre and a leased satellite service.38 12.33 ESTA’s three SECCs are:

■■ the World Trade Centre, which takes calls for Victoria Police for the greater metropolitan area and Geelong, and for VICSES for the metropolitan area

■■ Tally Ho, which takes calls for Ambulance Victoria for the greater metropolitan area, for the MFB and for CFA metropolitan area

■■ Ballarat, which takes calls for CFA Regional, VICSES Regional and Victoria Police Metropolitan.39 12.34 Mr Foster was asked whether there is any rationale for the manner in which calls for particular emergency services organisations are divided between the three call centres. He said it was partly ‘historical’. He agreed that ‘clearly the ideal position would be to have all emergency communication centres answering and managing all calls for all the centres. In that way you finish up with a much better redundancy option’.40

Esta staffing LEVELS 12.35 As at February 2009 ESTA employed 442 operational staff (excluding administrative and auditing staff) located at its three SECCs.41 12.36 All call takers and dispatchers employed by ESTA must achieve Certificate II or Certificate III in Call Centre Operation (Public Safety) or Certificate II or Certificate III in Emergency Communications.42 All staff have a primary area in which they work (Fire, Police or Ambulance). Only a small proportion of the staff is skilled to operate across multiple areas. To maintain the appropriate skill level, staff are rostered once a fortnight to do a shift in an area other than their primary area.43

PRESENTATION OF EMERGENCY CALLS TO ESTA 12.37 Mr Owen Kiernan, ESTA’s Operations Manager (Support), described the emergency call processes between Telstra Triple Zero and ESTA. Calls are presented by Telstra Triple Zero operators to directory numbers provided by ESTA’s centres. The Triple Zero presentation sequence is an agreed protocol between ESTA and Telstra. It requires that calls be presented by Telstra Triple Zero operators to ESTA using a designated presentation sequence, commencing with the first choice Triple Zero directory number. If that call is not answered within 75 seconds, the Telstra Triple Zero operator withdraws the call from the first choice directory number and re-presents it to ESTA on the second choice directory number. If that call is not answered within a further 75 seconds, the Telstra Triple Zero operator withdraws the call and re-presents it to a third choice directory number. If the call remains unanswered by the time presentation is made to the final choice directory number, the Telstra operator withdraws the call and commences the sequence again.44 12.38 All calls to ESTA’s first choice directory number are assigned a priority of two. The second presentation is given the priority of one. Third and subsequent presentations are assigned the highest priority of zero.45 12.39 In normal circumstances, callers to Triple Zero remain on the line until connected to ESTA, but sometimes the caller may be disconnected. This might be due to the call dropping out, the caller hanging up by choice, or by reason of illness, or the nature of the emergency that is occurring. In such a case, the Telstra operator is trained to stay on the line and announce the Caller Line Identification to the ESTA operator. Where appropriate ESTA will initiate a call back to the caller and/or dispatch assistance in any event. The Telstra Triple Zero operator is sometimes able to supply more information to ESTA, which assists in this process, for example, the last words used by the caller before the call ended.46 12.40 Prior to 7 February, Telstra and ESTA agreed on a new process whereby during periods of extreme call activity, this procedure would be ‘relaxed’ so that the Telstra operator would not remain on the line after a disconnected call, but rather retain the Caller Line Identification data and pass it to an ESTA supervisor via a Telstra supervisor. The intention was to free up the Telstra operator to take more Triple Zero calls.47 290 Despite this agreement and the intention that it be used on 7 February, it was not deployed uniformly.48 Emergency Calls

12.41 As noted in paragraph 12.3, ESTA operates a CAD system that enables operators to record call details, nominate and verify incident location, and determine the event type and the emergency responses that should be allocated to that event.49 When an ESTA call taker receives a call about a new fire, they ‘create’ an event in the computer system and record all relevant information provided by the caller. If a subsequent call is determined by the ESTA call taker to be about the same fire, it is added to the information already recorded in the system about that event.50 The CAD system effectively ‘chooses’ the means by which dispatch of emergency resources occurs. The CAD system assigns the resources.51 ESTA is required to dispatch the resources ‘recommended’ by the system.52

PREPARATION FOR 7 FEBRUARY 12.42 ESTA was formally notified of the severe fire risk in the lead up to 7 February. It was provided with Significant Incident Situation Reports from the OESC.53 ESTA’s General Manager attended a meeting of the Victorian Emergency Management Council Coordination Group on 5 February 2009.54 The meeting discussed the forecasts for the weekend and plans, including by ESTA, for the predicted extreme fire danger.55 ESTA made efforts to ensure that additional staff were rostered at Tally Ho and Ballarat, although ultimately its operations are restricted by the number of work stations available.56 12.43 In the week leading to 7 February, Telstra Triple Zero had already experienced increased demand because of the heat wave in South Australia and Victoria, and floods in Queensland.57 12.44 Ms Elkington explained that neither she nor anyone within Telstra’s Triple Zero service was formally notified by the CFA, the Department of Sustainability and Environment or the Bureau of Meteorology of the predicted weather and fire conditions for 7 February. Indeed, there is no formal notification system by which Telstra is alerted to predictions of bad weather or fire risk.58 Telstra staff, including Ms Elkington, monitor the Bureau of Meteorology website to assist with planning.59 She agreed it would be helpful to receive formal notification of fire risk or of Total Fire Ban days.60 It would be beneficial for the OESC to provide significant incident situation reports to Telstra at the same time as it provides them to ESTA. This would assist Telstra with its planning and rosters, and promote closer liaison between ESTA and Telstra in the lead up to predicted days of extreme fire danger. This, in turn, might improve the planning for extreme events.

RECOMMENDATION 12.1

The Office of the Emergency Services Commissioner formally advise the Emergency Services Telecommunications Authority and Telstra Triple Zero of forecast severe fire risk days and particularly days where there is a risk of extremely dangerous bushfires.

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ESTA staff levels and resources for 7 February 12.45 As at 7 February, ESTA had ‘on its books’ 62 full-time and 13 part-time operational call takers and dispatchers at the Tally Ho centre. At Ballarat, it had 64 full-time operational call takers and dispatchers, two part-time call takers and four casuals.61 As ESTA operates 24 hours a day, seven days a week, these staff are required to be rostered in a manner that allows for appropriate shifts and breaks.62 12.46 ESTA has a limited number of work stations and equipment for its staff to take and dispatch emergency calls for fire services. On 7 February:

■■ at Tally Ho, there were 58 work stations, but only 15 were configured for fire service call-taking and dispatch

■■ at Ballarat there were 25 work stations available, but only 13 were configured for fire service call-taking and dispatch.63 12.47 Arrangements were made in the lead up to 7 February for additional staff to work. Additional staff were rostered and staff were contacted and asked to work overtime over the weekend.64 12.48 At Tally Ho during 7 February, there were between eight and 18 fire operators working at all times. Between 2:00pm and 8:00pm, there were between 14 and 18 fire operators working.65 At Ballarat, there were between eight and 19 fire operators working at all times. During the period 2.00pm to 8.00pm, there were between 16 and 19 working.66 However, the numbers of staff who worked on that day ‘in excess’ of the available work stations (namely 15 at Tally Ho and 13 at Ballarat) were unable to take calls and instead performed administrative or support roles.67 12.49 Modelling by ESTA suggests that in order to answer the volume of calls received on 7 February within the benchmark service standards, ESTA would have required 30 staffed call taker positions at Tally Ho centre and 21 staffed call taker positions at Ballarat. This translates (allowing for leave, rostered breaks, etc.) into a requirement for 186 full-time staff at Tally Ho and 130 full-time staff at Ballarat rostered on an ongoing basis — a significant increase on current staff numbers.68 12.50 Mr Kiernan accepted in evidence that it would be possible to keep ‘in reserve’ a body of appropriately trained call-taking staff who might be otherwise engaged (for example, at other centres like VBIL or VICSES) and be made available during fire danger periods to provide for greater surge capacity during extreme events.69 This suggestion was not supported by the State.70

TELSTRA’s Staffing and rosters for 7 February 12.51 Ms Elkington confirmed the total staff numbers who worked over the 24-hour period on 7 February, who were available to take Triple Zero calls were:

■■ Melbourne call centre 5071

■■ Sydney call centre 4572 12.52 The records produced by Ms Elkington indicate that the highest number of staff working and taking Triple Zero calls at any one time at Melbourne was only 19 (this occurred during three separate 15-minute intervals at 7:15pm; 8:15pm and at 10:30pm).73 Telstra did not operate at maximum capacity for any part of 7 February.

292 Emergency Calls

Events of 7 February 12.53 At 12:40pm on 7 February when call volumes were increasing, a decision was made to extend the shifts of Telstra agents to require them to work through breaks. A recall list was activated.74 12.54 At 1:50pm the assistant manager of the Ballarat ESTA call centre contacted Ms Elkington requesting that an ESTA-tailored extreme event recorded announcement be used, but he requested that only callers for the fire service hear the message. Ms Elkington advised him that this was not technically possible, as prior to any call to Triple Zero being answered, it is not known whether the caller is seeking fire, ambulance or police assistance. The assistant manager indicated he would discuss the issue with his own management and advise Telstra if ESTA wished the tailored extreme event announcement to be activated for all calls in Victoria. No such advice was received. As a result Telstra instead activated the generic extreme event announcement from 2:08pm.75 12.55 By 2:00pm the call volume was extreme, and Ms Elkington decided to isolate the Victorian call traffic from the national Triple Zero call queue. Therefore, after 2:08pm all calls originating in Victoria were answered by the Melbourne centre and all calls originating outside Victoria were answered by the Sydney centre. All Victorian callers from that time onwards heard the generic extreme event recorded announcement.76 12.56 At 3:30pm, monitoring of call traffic indicated an unexpectedly high rate in the national queue being handled by Sydney. Investigations revealed that fire services calls originating from Victoria were still coming through. This occurred because the overflow and queue thresholds for the Victorian queue were set at 900 seconds (15 minutes). The threshold for ‘wait time’ in the Victorian queue was adjusted to 30 minutes.77 The need to alter the ‘overflow’ threshold to 30 minute wait time (in relation to a service whose benchmark is a matter of seconds) underscores the extreme delay being experienced. 12.57 Further steps were taken in an attempt to deal with the crisis through a further increase in the number of terminals made available to Victorian fire calls.78 Call volumes in the Victorian queue did not return to ‘close to normal’ until approximately 9:00pm.

Call volume and abandonment rate 12.58 Telstra and ESTA experienced unprecedented demand on 7 February. Telstra experienced (at the peak of the demand on that day) three times the normal call volume.79 Charts produced by Mr Kiernan depicted a large spike in Triple Zero calls on 7 February compared with regular Saturdays during the months of January and February 2009.80 On 7 February ESTA received a total of 6974 Triple Zero calls.81 It answered 6905 Triple Zero calls via its Automatic Call Distribution System.82 12.59 At the peak of demand, ESTA call presentations exceeded 450 calls in a 30 minute period, which translates to a presentation every four seconds. This represented an increase of 450 per cent on typical call activity when compared with the four preceding Saturdays.83 During the height of the activity, ESTA call takers answered a call on average every 12 seconds.84 Fire services normally account for 10 per cent of the Triple Zero calls to ESTA. On 7 February the Triple Zero presentations for fire services accounted for 48 per cent of all Triple Zero emergency calls presented to ESTA.85 For ESTA, the increase in fire call activity for 7 February was about 92 per cent above the next busiest day for ESTA (4202 calls compared with 2185 calls on 22 January 2006).86 12.60 There were very high rates of abandoned calls on 7 February. Abandoned calls are those calls which are abandoned or terminated by the caller before the call can be answered by a Telstra operator.87 There are two important features of the data for 7 February:

■■ The analysis proceeds on the basis that the Victorian calls were only isolated from the national queue at 2:08pm.88 Thus, there are two relevant sets of figures: national figures for the entire 24-hour period, and figures for the Victorian queue from 2:08pm (Tables 12.1 and 12.2).

■■ Care must be taken in analysing the data for abandoned calls, as each abandoned call does not necessarily represent a different caller. It is likely that many callers rang Triple Zero a number of times on 7 February, perhaps hanging up and dialling again in the erroneous hope that they might increase their chances of getting through.89 293 2009 Victorian Bushfires Royal Commission—Interim Report

12 EMERGENCY CALLS

Table 12.1: National queue 24-hour call data, 7 February Calls made to Triple Zero in the national queue 41,88290 Calls answered by Triple Zero in national queue 31,20491 Calls abandoned in national queue 10,67892 (25.49%)

Source: Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]–[119] 93

Table 12.2: Victorian queue, 2:08pm to 9:00pm, 7 February Calls made to Triple Zero in the Victorian queue 10,87694 Calls answered by Triple Zero in the Victorian queue 305295 Calls abandoned in Victorian queue 782496 (71.93%)

Source: Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123], Elkington tender (TEN.044.001.0001)97

12.61 More detailed statistics (broken down into 15 minute intervals) demonstrate that the ‘peak’ in abandonment rates occurred at approximately 5:00pm, as is illustrated in Figures 12.1 and 12.2.

Figure 12.1: National Triple Zero emergency call data by 15 minute intervals — 7 February

1200

1000

800

600 Number of Calls

400

200

0 12:00 am 3:00 am 6:00 am 9:00 am 12:00 pm 3:00 pm 6:00 pm 9:00 pm

Time Calls Abandoned Calls Answered

Source: Graph based on data at Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [119] 98

Note: this graph shows calls abandoned and calls answered. The sum of these figures equals calls presented in Ms Elkington’s statement for all 294 periods except for between 5:45pm and 6:00pm, where an additional 18 calls have been listed. Emergency Calls

Figure 12.2: Victorian Triple Zero emergency call data by 15 minute intervals — 7 February

900

800

700

600

500

400

Number of Calls 300

200

100

0 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm 8:00 pm 9:00 pm

Time Calls Abandoned Calls Answered

Source: Graph based on data at Exhibit 117 – Statement of Elkington, Attachment 22 (WIT.5003.001.0424); (WIT.5003.001.0431); (WIT.5003.001.0438) 99

Note: this graph shows calls abandoned and calls answered. The calls answered figures were obtained by adding together the figures contained in WIT.5003.001.0424 and WIT.5003.001.0431. The calls abandoned figures were obtained by summing together the figures contained in WIT.5003.001.0438 and WIT.5003.001.0445.

12.62 These statistics are disturbing. Nearly 73 per cent of calls in the Victorian queue were abandoned during the afternoon and evening of 7 February.100 It is not known why these calls were abandoned. The reasons might include a decision by a caller that the call was not urgent; a caller needing to flee from danger; and the caller being overwhelmed or even injured. There is every likelihood that during this period many callers were in fear for their lives when they abandoned their call. Further, while many of the abandoned calls no doubt related to the bushfires in Victoria, it is not known, nor is it now possible to ever know, how many in that group (particularly in the national queue) may have been calling Triple Zero for other serious personal circumstances, including life-threatening illness.101 12.63 Much lower rates of disconnection occurred after Telstra Triple Zero operators answered the calls. Mr Trevor Ives, Manager, Management Information Services, explained that 6974 Triple Zero calls were answered by ESTA and 368 were disconnected after the call was answered by Telstra, but before it was answered by ESTA. This tends to suggest that the overwhelming majority of callers who got through to Telstra waited on the line and spoke to an ESTA call taker.102

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Wait times 12.64 All Triple Zero calls are recorded. During the hearings, examples were played of two standard or typical calls to Triple Zero that were made on 7 February. These were calls during which the caller requested a fire service and the Telstra Triple Zero operator transferred the call within 12 to 20 seconds.103 12.65 The Commission heard a harrowing recording of a caller from Kinglake. The call was answered by a Telstra operator at 8:15pm on the evening of 7 February. In that call, the Telstra operator was on the line with the caller for 3 minutes and 55 seconds waiting for ESTA to answer.104 The distress and mounting panic of the caller was evident. Telstra operators received many calls like this on 7 February. 12.66 The statistics set out below in Table 12.3 were supplied by Telstra. Mr Ives explained that the ‘wait time’ does not always indicate that a member of the public was also waiting on the line. The caller may have disconnected for some reason; however, the Telstra Triple Zero operator was waiting on the line to convey the caller’s Caller Line Identification details to ESTA. The final figures in the table (wait times of 20 minutes for 12 calls) are an example of this and need to be treated with caution. For 11 of these 12 calls, the Telstra operator waited on the line after a caller had disconnected in order to pass on the Caller Line Identification details to ESTA. Only in one instance was a caller waiting on the line for in excess of 20 minutes.105 12.67 With that caveat in mind, the statistics still illustrate the long wait times experienced on the day.

Table 12.3: Triple Zero call transfer data, time delays

Period of time waiting for a call to be answered by an ESTA operator Number106

1 minute 1944 2 minutes 1360 5 minutes 272 10 minutes 68 15 minutes 28 20 minutes 12

Source: Elkington T3859:27–T3860:29; Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [43]–[44] 107

12.68 ESTA reported non-compliance with its call answer speed benchmark. Only 24.5 per cent of calls were answered within five seconds and a further 32.2 per cent were answered within 30 seconds.108 The applicable benchmarks are 90 per cent and 95 per cent. 12.69 Mr Kiernan conceded that ESTA did not have the staff or work stations to handle the unprecedented call activity on 7 February.109

Triple Zero Calls presented to ESTA for fire services 12.70 Of the 4202 fire-related calls, 3310 were emergency calls from Telstra Triple Zero. Of these 3310 emergency calls:

■■ 660 were presented to MFB (640 of which were answered by ESTA)

■■ 1249 were presented to CFA Regional (1238 of which were answered by ESTA)

■■ 1401 were presented to CFA Metropolitan (1368 of which were answered by ESTA). These figures come to a total of 3246 calls answered (of the 3310 calls presented).

296 Emergency Calls

bottleneck IN EMERGENCY calls Presented to esta 12.71 Telstra’s data indicate that it presented 3299 calls to Victorian fire services on 7 February.110 Of these, approximately 46 per cent (1534 calls) had to be re-presented to alternative directory numbers at ESTA before an operator was available to take the call.111

Table 12.4: Triple Zero call referrals for fire services, 7 February

Calls presented by Telstra Triple Zero Number

Calls presented for a Victorian fire service over 24 hours 3299112 Calls presented to more than one number for a Victorian fire service over 24 hours 1534113 Calls presented for a Victorian fire service between 12:14pm and 9:00pm 7 February 2393114 Calls presented to more than one number for a Victorian Fire Service between 12:14pm and 9:00pm 1450115

Source: Exhibit 117 – Elkington tender (TEN.044.001.0001) 116

12.72 There was a ‘bottleneck’ created as a result of Telstra operators being unable to put through calls to an emergency service organisation. Ms Elkington emphasised that Telstra Triple Zero is ‘absolutely reliant’ on the emergency services picking up the calls being presented.117 She said:

I think an analogy I might use is that I can have a 15-lane freeway going into a two lane tunnel. I can increase that to 100 lanes, but if it is still going into a two lane tunnel there is very little I can do about it.118

12.73 Ms Elkington also said that although it is possible for Telstra to respond to predictions of high fire danger, they would not respond by staffing to the maximum level for two reasons: first, there are many days of high danger in Australia; and second, Telstra is able to turn around calls quickly, due to its short handling times, but is restricted by the fact that it cannot connect those calls if the emergency service organisation is unable to take the call.

So as I mentioned earlier, I could have 25 positions, I could have 50. It is still not going to help me get those calls through to where they need to be more quickly.119

12.74 Given the high abandonment rate of calls (prior to them being answered by Telstra), it is possible that if more emergency calls had been answered by Telstra operators, it may have served to reduce the phenomenon of callers hanging up and making multiple calls. Further, the ‘comfort’ of a caller being connected, even if waiting, may be beneficial. 12.75 The Commission acknowledges, however, that there is a tension and difficult balance, between providing additional call takers for very occasional high volume days, and having many more staff than are required. It is anticipated that if bushfire information and warnings are better prepared, disseminated and understood, the demand on Telstra Triple Zero and ESTA call takers will be less on extreme bushfire days.120 Regrettably, there are always likely to be some delays when call volumes peak on some occasions and the Commission is hopeful that if other measures that are recommended in this interim report are actioned, this will mitigate the impact of any delays.

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Lay evidence 12.76 A number of witnesses described being unable to get through on Triple Zero, and noted the distress this caused. Mr Denis Spooner spoke of his wife and son trying Triple Zero without success while trapped in their home at Strathewen.121 Ms Jill Kane tried to reach Triple Zero after her brother was overcome and collapsed near his home in Bendigo.122 Similarly, Mr David Brown’s son tried calling Triple Zero three times from Strathewen when the family was threatened by fire and sheltering in their home. He could not get through.123 Ms Anastasia Scott attempted to call Triple Zero from Marysville around 7:00pm and could not get through.124 12.77 Mrs Carol Matthews tried to call Triple Zero to obtain aid for her son who was trapped in his home at St Andrews as fire approached. Mrs Matthews could not get through, which was a source of great distress. A friend kept trying for her, and eventually got through but received incorrect information about the attendance of appliances near the Matthews’ home.125

EMERGENCY ALERT SYSTEM 12.78 As noted in paragraph 12.32, ESTA operates a dedicated pager messaging system (the EAS) used by emergency services staff and volunteers of the CFA, VICSES and Ambulance Victoria (Rural). It operates over the whole of Victoria by means of 212 radio transmitter sites linked to a message switching centre and a leased satellite service. 12.79 EAS also experienced unprecedented demand. The total number of pager messages recorded in the emergency pager system log for 7 February is 13,899 messages. By comparison, the system usually transmits between 2000 and 3000 messages a day.126 12.80 A total of 12,111 messages were sent from 11:50am to midnight. This equates to one message every 3.5 seconds.127 4349 of these were emergency messages; 93.2 per cent of which were delivered within 30 seconds. There were 7649 non-emergency messages and 1901 administrative messages transmitted.128

Cross referrals 12.81 The Standard Operating Procedures that apply to ESTA staff provide that if a caller is making an inquiry about (rather than reporting) a fire, or is seeking incident information, the caller is advised to ring VBIL. VBIL staff who receive calls from members of the public who are reporting new fires and/or are in life- threatening circumstances advise them to call Triple Zero (Chapter 5). 12.82 On 7 February, ESTA did not have any information about the capacity of VBIL to take calls referred to it, or any information about the volume of calls being experienced at VBIL’s call centre. 129 These cross-referrals no doubt contributed to the difficulties the VBIL call centre experienced. Mr Kiernan agreed that having information about the impact on VBIL may be helpful in reviewing ESTA’s procedures.130

IMPROVING THE coordination and capacity of emergency call services

IMPLICATIONS OF The 2008 windstorm report 12.83 ESTA’s performance during extreme events was the subject of a review by the OESC in August 2008. The OESC investigated the operational response to the extreme storm which occurred on 2 April 2008, including aspects of ESTA’s operations. The report, Review of the April 2008 Windstorm Melbourne (the 2008 Windstorm Report), identified areas for improvement.131 12.84 During the storm in April 2008, Telstra experienced a surge in demand to its Triple Zero service. As occurred on 7 February, Telstra implemented a recorded voice announcement and isolated Victorian traffic from the national queue during the afternoon.132 Large numbers of calls went unanswered.133 12.85 A number of the recommendations made in the 2008 Windstorm Report refer to:

■■ streamlining the Telstra–ESTA handover process

■■ reviewing the interface between the CFA Brigade communication systems and the ESTA CAD system

■■ reviewing and improving call queue arrangements and paging systems. 134 These recommendations appear to focus directly on the shortfalls that became apparent (again) 298 on 7 February 2009. Emergency Calls

12.86 A draft of the report was supplied to ESTA in October 2008, but the report and the Government’s response were not released publicly until April 2009, after the Royal Commission was established.135 The Government’s response to the 35 recommendations indicates that for some matters it is ‘currently implementing the recommendation … to be further considered in light of any findings of the Royal Commission’. For others it ‘intends’ to implement the recommendations but notes ‘it will need to be further considered in light of any findings of the Royal Commission’. 12.87 It is a matter of concern to the Commission that as recently as August 2008 issues pertaining to the system’s capacity to cope with extreme events was the subject of a detailed review by the OESC, yet a number of the failings evident in the operational response to the windstorm in August 2008 were replayed during 7 February. 12.88 It has also emerged that although aspects of the 2008 Windstorm Report directly concerned arrangements between Telstra and ESTA, the report was not brought to the attention of Ms Elkington until it was released publicly.136 She accepted it was possible the report had been supplied to other sections within Telstra, but she had not been consulted.137 More frequent liaison between Telstra Triple Zero and ESTA might contribute to a more organised response by both entities to extreme events. telstra and the triple zero service 12.89 Telstra has been investigating alternatives to the requirement that its Triple Zero operators stay on the line in all circumstances until a three-way conference is established. This is being considered because of the desire to ‘free up’ operators more quickly during major events. Thus far, Telstra’s capacity to implement change has been constrained by the technical limitations of some emergency service organisations not having queuing facilities. As a result, the strict requirement has been maintained.138 12.90 This matter will require dedicated effort and resources from all jurisdictions, including the Commonwealth, if change is to be implemented in a way that preserves the integrity of the Triple Zero service and its important Caller Line Identification information. The Commission encourages all governments to work together to progress these options. 12.91 In this context, Telstra has also promoted the introduction of national technological solutions. Telstra has made representations to the Commonwealth Attorney-General, calling for a ‘holistic, coordinated approach to emergency response policy development’.139 Ms Elkington said in her evidence that Telstra is concerned that there is no single authority that manages the end-to-end emergency call service. Telstra would like to see ‘an overarching review of the emergency call service so that there is some accountability on an authority that will lead the strategic direction, the operational direction of the end-to-end service’.140 The Commission welcomes this approach and notes Ms Elkington’s words in relation to the importance of the Triple Zero service:

The role that we play as the emergency call person we take very, very seriously. This is not just a job for us. We are very passionate about it. These numbers are very concerning and frustrating for us. There is not a great deal that we can do at the moment around that bottleneck to improve that. We have tried on occasions to put different processes in place and there has been a number of reasons why they have not been supported by the emergency services. We continue to raise our concerns with the federal government, the Australian Communications and Media Authority and the emergency services themselves, to explain that we can only do so much at what we call the uphill end of this service … we need the assistance from the backend, the downhill end, which is the ECC [the emergency call centre] of the emergency service organisation … because I certainly don’t want these figures. I mean, my aim is to answer every call as quickly as we can and connect so the person gets the relevant response.141

12.92 In its written submissions Telstra called for the Commonwealth Government, in consultation with the state and territory governments, to ‘set the agenda for the emergency call service, by taking strategic and operational responsibility’.142 12.93 There are obvious practical barriers to the Commonwealth setting ‘the agenda’, as each state and territory has its own emergency services to which Triple Zero calls are presented, each with its own operational demands and capabilities. However, the Commission does support Telstra’s suggestion that the Commonwealth and the State of Victoria work together to improve the end-to-end Triple Zero process (including resourcing and infrastructure). The aim ought to be to reduce the ‘bottlenecks’ which occur at emergency service organisations’ answering points.143 299 2009 Victorian Bushfires Royal Commission—Interim Report

12 EMERGENCY CALLS

ESTA RESOURCES AND FUNDING 12.94 The State accepted, in its written submissions to the Commission, that there should be a recommendation to increase ESTA staff. However, it did not accept that there ought to be any related recommendation on funding. It noted that additional funding had already been provided to ESTA in the 2009–10 Budget. The State said the following:

An additional $3 million has been made available, in addition to a 3% (CPI) [consumer price index] related increase in revenue for base Computer Aided Dispatch (CAD) services in 2009/10. ESTA will receive $46.6 million for core CAD fees from consolidated revenue in 2009/10, up from $42.6 million for core CAD fees from consolidated revenue in 2008/09. These core CAD fees excluded funding provided by the CFA for ESTA’s operations at Ballarat as these are not funded by the State and are separately funded by ESTA (from its reserves) and the CFA. ESTA will use the additional funds to partly fund the proposed recommendation as to staffing and capacity. In addition, the State has funded the commissioning of call taking capacity for an additional 15 work stations at ESTA’s Ballarat call centre. Off duty staff will be recalled to duty on high demand days to staff these additional work stations to assist ESTA to deal with anticipated surges in emergency calls.

Options in addition to increasing staff are being pursued by the State to address the delays experienced on 7 February, such as training more staff to be ‘multi-skilled’. For example, there would be an effective increase in numbers of staff available to take calls for fire, if police call takers at the Ballarat centre could handle the fire related calls on busy days. To this end ESTA has already commenced the cross training of existing police staff at Ballarat.

The State also considers that long term goals and business models must be implemented such as:

(a) a revision of ESTA’s infrastructure, staffing arrangements and operating procedures so as to allow its call takers to answer calls for multiple emergency services organisations regardless of which State Emergency Communications Centre they were located in;

(b) splitting ESTA’s call taking interface with the public from a single Triple Zero point of contact into an emergency and non emergency call taking interface via two different telephone numbers (for example, Triple Zero and 333) allowing ESTA to initially prioritise calls prior to them being answered by an ESTA call taker.144

12.95 The question of broader reform in the nature of ‘splitting’ ESTA’s functions between its emergency and non-emergency functions is a matter for the State to explore in the longer term. The Commission welcomes the indication that steps will be taken immediately to tackle the question of staffing levels and increased multi-skilling prior to the coming fire season. 12.96 Although it accepted the need for increased staffing levels, the State rejected a proposed recommendation to the effect that there be established a pool of reserve staff available to work in ESTA centres. In so doing, it emphasised the specialised training provided to ESTA staff and the need to maintain standards.145 The Commission accepts this, and proposes increasing the work stations available at ESTA centres.

RECOMMENDATION 12.2

The State ensure the Emergency Services Telecommunications Authority (ESTA) is funded to provide greater surge capacity during extreme events, including establishing additional work stations for fire calls at ESTA centres.

RECOMMENDATION 12.3

The State further promote, through the Council of Australian Governments, more effective emergency call service arrangements throughout Australia. 300 Next steps 13 2009 Victorian Bushfires Royal Commission—Interim Report

13 NEXT STEPS

13.1 The Commission is required to deliver a final report on 31 July 2010. A further 28 weeks of public hearings are scheduled to examine the issues specified in the Commission’s terms of reference. 13.2 The dates that the Commission has tentatively set aside for public hearings are set out below: Hearing Block 2 — 24 August to 24 September 2009 Hearing Block 3 — 5 October to 5 November 2009 Hearing Block 4 — 16 November to 17 December 2009 Hearing Block 5 — 1 February to 4 March 2010 Hearing Block 6 — 15 March to 1 April 2010 Hearing Block 7 — 12 April to 13 May 2010 13.3 The Commission will normally sit from Monday to Thursday of each week. The Commission’s usual hearing hours will continue to be from 9:30am to 4:30pm, with a lunch recess between 1:00 and 2:00pm.1 Details of the public hearings will be published on the Commission’s website. 13.4 When the Commission resumes hearings on 24 August, its initial focus will be an examination of building standards in bushfire prone areas. This will include matters such as materials used in construction, fire- resistant house features, and designs for building bushfire bunkers. 13.5 It will then hear evidence about the structure and regulation of the electricity industry in Victoria, after which the Commission will then investigate each of the following fires:

■■ Kilmore East

■■ Coleraine

■■ Pomborneit-Weerite

■■ Horsham

■■ Beechworth-Mudgegonga

■■ Murrindindi

■■ Bunyip

■■ Churchill

■■ Bendigo

■■ Redesdale

■■ Narre Warren

■■ Delburn. 13.6 During the forthcoming hearing blocks, time will be set aside to examine progressively the circumstances surrounding the deaths of the 173 people who died in the 2009 Victorian bushfires. 13.7 In this interim report, the Commission makes 51 recommendations, focused on changes that can be implemented prior to the 2009–10 bushfire season. The Commission requests the various authorities and agencies responsible for each recommendation to report back to the Commission about matters raised in this report. 13.8 Specifically, parties are to provide to the Commission:

■■ an Implementation Plan by 30 September 2009 — being a brief advice setting out the proposed response, allocated responsibilities and schedule to implement a recommendation; and

■■ a Delivery Report by 31 March 2010 — being a more detailed report on the progress made towards implementing each recommendation and, where appropriate, the outcomes and effectiveness of the response.

302 Next steps

13.9 In respect of each recommendation, the Commission is seeking a single report. Where a number of parties are responsible for a recommendation, the Commission would appreciate one party coordinating a single, consolidated report. Further, with respect to Recommendations 6.4 and 8.2, the Commission requests the Municipal Association of Victoria to coordinate the Implementation Plan and Delivery Report, consolidating the responses by relevant individual municipal councils. 13.10 Evidence as to the extent and effect of implementation by parties of the recommendations made in this report will be heard at an appropriate stage during future hearings. 13.11 Other topics the Commission currently plans to address include:

■■ climate change and fire weather

■■ psychological trauma among bushfire survivors

■■ methods for prevention, detection and management of arson

■■ demographic changes and growth in the rural/urban interface

■■ land use planning for private land, including vegetation management and defendable space

■■ public land management, including fuel management, prescribed burning and roadside clearing

■■ operational and organisational issues for Victoria’s fire agencies, and emergency management generally

■■ essential services

■■ insurance

■■ the economic cost of the fires

■■ recovery

■■ education

■■ terminology for fires

■■ emergency procedures, such as refuges. 13.12 To complement the public hearing process, some of these topics will be pursued using different methods for obtaining relevant information, including expert panels. The Commission will continue to seek out and receive evidence from researchers and other experts, and further research and analysis being conducted by the Bushfire Cooperative Research Centre into the 2009 Victorian bushfires will be considered. The Commission will identify priorities for future bushfire research in Australia. 13.13 The overarching focus of the work of the Commission will remain on the protection of human life. Matters to be addressed for the final report are derived from the Commission’s terms of reference. Recommendations to minimise the likelihood of a recurrence of the tragedy of February 7 will be provided to the people of Victoria in memory of family and friends lost to the bushfires.

303 2009 Victorian Bushfires Royal Commission—Interim Report

Source: AAP Image 304 APPENDIX 1 2009 Victorian Bushfires Royal Commission—Interim Report

1 appendix – PARTIES GRANTED LEAVE TO APPEAR

Leave Granted in Relation to the following Terms Party1 of Reference:

ACE Radio Broadcasters Pty Ltd 1, 2, 3, 10

Australasian Fire and Emergency Service Authorities Council 2 – Preparation and planning in relation to ‘stay or go’; (AFAC) (22 April 2009) building in bushfire prone areas; use of fire shelters/ refuges; community warnings; bushfires and use of vehicles; prescribed burning; and 3 – Response to fires including AIIMS ICS; volunteerism in emergency management; agency inter-operability

Australian Broadcasting Corporation (ABC) 1, 2, 6, 9, 10

Australian Institute of Architects Victorian Chapter 6, 7, 8

Australian Workers Union 1, 2, 3

Commonwealth of Australia Unconditional Leave

Housing Industry Association (1 May 2009) 6, 7, 8

Insurance Council of Australia 6, 7, 8

Master Builders Association of Victoria 6, 7, 8

Municipal Association of Victoria (and 77 Councils) Unconditional Leave

Police Association Victoria 1, 2, 3, 4, 6, 9, 11

Powercor Australia Limited (1 May 2009) 1 & 2 – Causes and circumstances of the fires insofar as they relate to power assets and the preparation and planning for fires in relation to power assets

SP Ausnet (24 April 2009) 1 & 2 – Causes and circumstances of the fires insofar as they relate to power assets and the preparation and planning for fires in relation to power assets

Standards Australia (22 May 2009) 2, 6, 8

State of Victoria (including Department of Sustainability and Unconditional Leave Environment, Emergency Services Telecommunications Authority, County Fire Authority, Victoria Police, Department of Premier and Cabinet, and Department of Justice)

Telstra Corporation Limited 1, 2, 3, 6, 9, 10

United Firefighters Union of Australia 1, 2, 3

Utility Services Corporation Limited, trading as Utility Asset 1 & 2 – Causes and circumstances of the fires insofar Management (UAM) (7 May 2009) as they relate to power assets and the preparation and planning for fires in relation to power assets

Victims of fires (represented by Tobin – Maddens) 1 – Causes and circumstances of the fires insofar as they (3 July 2009) relate to power assets and 3

Victims of fires (represented by Tobin – Nevin Lenne & Gross) 1 – Causes and circumstances of the fires insofar as they (3 July 2009) relate to power assets and 3

Victims of fires (represented by Tobin – Slidders/Maurice 1 – Causes and circumstances of the fires insofar as they Blackburn Cashman) (3 July 2009) relate to power assets and 3

Victims of fires (represented by Tobin – Hunter Newns) 1 – Causes and circumstances of the fires insofar as they (3 July 2009) relate to power assets and 3

Volunteer Fire Brigades Victoria Inc. 1, 2, 3

354 1 Where a party was granted Leave to Appear after the initial directions hearing, the date of the granting of leave is noted in brackets. APPENDIX 2 2009 Victorian Bushfires Royal Commission—Interim Report

2 appendix – HEARING DAYS AND WITNESSES

Day Date Witness name

1 11 May 2009 Mr Luke Andrew Corbett (Operations and Planning Officer, CFA) Mr Russell James Rees (Chief Officer, CFA) Mr Ewan Waller (Chief Officer, Fire and Emergency Management, DSE)

2 12 May 2009 Mr Ewan Waller (Chief Officer, Fire and Emergency Management, DSE) Mr Russell James Rees (Chief Officer, CFA) Ms Jesse Monica Odgers (Lay witness) Mr Bruce Esplin (Emergency Services Commissioner, State of Victoria)

3 13 May 2009 Mr Bruce Esplin (Emergency Services Commissioner, State of Victoria) Mr Peter Graham Newman (Lay witness)

4 14 May 2009 Mr Brian David Patten (Lay witness) Dr Katharine Augusta Haynes (Centre for Risk and Community Safety, RMIT University, Risk Frontiers, Macquarie University)

5 15 May 2009 Mr Denis John Spooner (Lay witness)

6 18 May 2009 Mr Bruce Esplin (Emergency Services Commissioner, State of Victoria) Mr Kieran James Walshe (Deputy Commissioner, Victoria Police) Mr Kenneth George Rogers (Lay witness)

7 19 May 2009 Mr Kieran James Walshe (Deputy Commissioner, Victoria Police) Dr Mark Williams (Meteorologist, Bureau of Meteorology) Mrs Joan Frances Davey (Lay witness) Mr Anthony Stephen Griffiths (Acting Manager, Fire Information & Systems Group, DSE)

8 20 May 2009 Mr Anthony Stephen Griffiths (Acting Manager, Fire Information & Systems Group, DSE) Mr Paul Hendrie (Kinglake Brigade Captain, CFA) Mr Lou Mario Sigmund (Group Officer, Morwell Group, CFA) Dr John Walton Ferguson (Lay witness)

9 21 May 2009 Mr Simon Matthew Langdon (EyeFi) Dr Kevin Gerard Tolhurst (Senior Lecturer, Fire Ecology and Management, Department of Forest and Ecosystem Science, University of Melbourne) Ms Jillian Gay Kane (Lay witness)

10 25 May 2009 Dr Kevin Gerard Tolhurst (Senior Lecturer, Fire Ecology and Management, Department of Forest and Ecosystem Science, University of Melbourne) Mr Daryl Roger Hull (Lay witness) Mr Kieran James Walshe (Deputy Commissioner, Victoria Police)

11 26 May 2009 Mr Gregory Peter Murphy (Kilmore Brigade Captain, CFA) Mr Stewart Duncan Kreltszheim (Region 23 Operations Manager and Incident Controller at Kilmore Incident Control Centre, CFA) Ms Christine Mandie Glassford (Lay witness) Mrs Serafina Yvette Munns (Facilitator and Fire Ready Presenter for Region 13 and Member of Information Unit, Kangaroo Ground Incident Control Centre, CFA) 356 Appendix 2

Day Date Witness name

12 27 May 2009 Mr Anthony Charles Pearce (Director General, Emergency Management Australia) Mr Bevan Brett Gobbett (Lay witness)

13 28 May 2009 Mrs Serafina Yvette Munns (Facilitator and Fire Ready Presenter for Region 13 and Member of Information Unit, Kangaroo Ground Incident Control Centre, CFA) Mr John David Brown (Lay witness) Mr Paul Gerard O’Halloran (Detective Inspector, Victoria Police) Mr Jason Robert Lawrence (Operations Officer and Incident Controller at Kangaroo Ground Incident Control Centre, CFA) Mr Alexander Caughey (Community Education Coordinator and Information Officer at Seymour Regional Emergency Coordination Centre, CFA)

14 29 May 2009 Ms Leonie Jane Hunter (Information Officer at Alexandra Group Headquarters and Information Team Leader at Kilmore Incident Control Centre, CFA) Dr Kevin Gerard Tolhurst (Senior Lecturer, Fire Ecology and Management, Department of Forest and Ecosystem Science, University of Melbourne)

15 1 June 2009 Ms Samantha Ross Stayner (Acting Program Director, 774 ABC Melbourne) Mr Peter Geoffrey Olorenshaw (Lay witness) Mr Russell James Rees (Chief Officer, CFA)

16 2 June 2009 Mr Neil Francis Foster (Chief Executive Officer, ESTA) Mr Owen Michael Kiernan (Operations Manager (Support), ESTA) Mr Kenneth James Dwight (Lay witness)

17 3 June 2009 Mr Rodney William Collins (Superintendant, Victoria Police) Dr Christopher Harvey (Lay witness) Mr David Victor McGahy (Arthurs Creek Brigade Captain, CFA)

18 4 June 2009 Prof Douglas Paton (Chair in the School of Psychology, University of Tasmania) Mr Christopher Leonard William Casey (Lay witness)

19 9 June 2009 Mr Russell James Rees (Chief Officer, CFA) Ms Sharon Lisa McCulloch (Lay witness)

20 10 June 2009 Mr Russell James Rees (Chief Officer, CFA) Mr Douglas Elliot Walter (Lay witness)

21 11 June 2009 Mr Russell James Rees (Chief Officer, CFA) Ms Naomi Patricia Brown (Chief Executive Officer, AFAC) Mr John Bryan Gledhill (Chief Executive Officer and Chief Officer, the Tasmania Fire Service) Mr Illiya Joseph Ananiev (Lay witness) Mr Simon Anthony Seear (Member, Walhalla Brigade, CFA)

22 12 June 2009 Mr Stuart Andrew Lawson (Deputy Chief Officer, Country Fire Service of South Australia) Ms Jillian Patricia Edwards (Manager Strategy and Knowledge, AFAC) Ms Anastasia Scott (Lay witness) Ms Naomi Patricia Brown (Chief Executive Officer, AFAC) 357 2009 Victorian Bushfires Royal Commission—Interim Report

2 appendix – HEARING DAYS AND WITNESSES

Day Date Witness name

23 15 June 2009 Mr Norman John Free (Manager of the State Fire Management Planning Support Team hosted by the CFA) Mr Andrew Edmond Willans (Mt Gordon Fire Tower Operator, DSE) Dr Lachlan Clyde Fraser (Lay witness)

24 16 June 2009 Prof John William Handmer (Disaster Management Expert) Mr John Colin O’Neill (Lay witness) Ms Colleen Mary Keating (Kangaroo Ground Fire Tower Operator, CFA)

25 17 June 2009 Mr David Anderson Cooper (Group Deputy Officer Lower Yarra Group, CFA) Mr Alexander Caughey (Community Education Coordinator and Information Officer at Seymour Regional Emergency Coordination Centre, CFA) Mr Alan Norman Rhodes (Manager, Community Safety Research and Evaluation, CFA) Ms Gwendoline Mary Alice Barber (Lay witness) Mr Alan Norman Rhodes (Manager, Community Safety Research and Evaluation, CFA)

26 18 June 2009 Dr Sarah Mariah McCaffrey (Research Forester/Social Scientist at the US Department of Agriculture Forest Service, Northern Research Station in Evanston, Illinois) Mr Rocky Joseph Barca (Manager, Werribee Park, Parks Victoria and Deputy Incident Controller at Kangaroo Ground Incident Control Centre) Mr Peter Ross Brown (Lay witness) Mr Alan Norman Rhodes (Manager, Community Safety Research and Evaluation, CFA) Mr Grant Alan Johnstone (General Manager of ACE Radio’s Traralgon-based TRFM and Gold 1242)

27 22 June 2009 Mr Robert John Beresford (Director, Service Delivery for the Southern Region of Telstra and Chairman, Telstra’s Regional Emergency Council for Victoria) Mr John Lawrence Cowan (National Networks Manager for the Managed Radio Networks Group Enhanced Operations at Telstra and Planning Office at Kangaroo Ground Incident Control Centre, CFA) Mr David John O’Halloran (Lay witness)

28 23 June 2009 Mrs Carol Ann Matthews (Lay witness) Ms Jane Louise Elkington (Emergency Service Answer Point National Manager, Telstra) Mr Michael Domenic Consolo (General Manager, Telstra) Mr Maxwell Roland Jennings (Director – Wireless Network Engineering, Telstra)

29 24 June 2009 Mr Maxwell Roland Jennings (Director – Wireless Network Engineering, Telstra) Mr David Roy Packham (Adjunct Senior Research Fellow in Geography and Environmental Science, Monash University) Ms Karen Ann Ward (Lay witness) Mr Michael William Sutton (Manager of the Forest Resource Analysis and Modelling Section of the Forest and Parks Division, DSE) Mr Gavin Daniel McCormack (Kangaroo Ground Fire Tower Operator, CFA)

358 Appendix 2

Day Date Witness name

30 25 June 2009 Mr Robert Norman Spence (Chief Executive Officer, Municipal Association of Victoria) Mr John Joseph Williams (Lay witness) Mr Gregory Alan Paterson (State Duty Officer, CFA)

31 26 June 2009 Mr Gregory Alan Paterson (State Duty Officer, CFA) Mr Timothy Sholl (Strath Tower Fire Operator, Melbourne Water) Mr Ewan Waller (Chief Officer, Fire and Emergency Management, DSE) Mr Kenneth Robert Williamson (Whittlesea Brigade Captain, CFA)

32 29 June 2009 Mr John David Nicholson (Consultant, Community Safety Services Pty Ltd) Ms Jacqueline Ann Hainsworth (Lay witness) Dr Kevin Gerard Tolhurst (Senior Lecturer, Fire Ecology and Management, Department of Forest and Ecosystem Science, University of Melbourne)

33 30 June 2009 Ms Kathryn Irene Venters (Manager of Customer Services, DSE) Ms Christine Ann Millington (Manager of Customer Liaison and Education, Customer Service Centre, DSE) Ms Carolyn Hogg (Deputy Chief Executive Officer of Centrelink) Mr Tony Robert Cook (Deputy Secretary for the Office for Planning, Strategy and Coordination, Department of Education and Early Childhood Development)

34 1 July 2009 Ms Sarah Margaret Henshaw (Instructional Designer, Learning and Development and Information Unit leader at iECC, CFA)

359 ENDNOTES 2009 Victorian Bushfires Royal Commission—Interim Report

INTRODUCTION Overview of 7 february 2009

1 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [18] 2 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0033 3 M Williams T721:8–T721:10 4 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [24]–[25] 5 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [29] 6 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0038 7 Tolhurst T992:12–T992:16 8 Exhibit 32 – Statement of Tolhurst, Expert Report (EXP.003.001.0017) at 0026 9 Exhibit 3 – Statement of Rees, Annexure 21 (WIT.004.001.0479) at 0479 10 Teague – Chairperson’s Opening Remarks, Directions Hearing 20 April 2009 11 Williamson T4441:27–T4442:6; Lawrence T1600:15–T1600:19 12 McGahy T2252:14–T2252:23 13 Exhibit 32 – Statement of Tolhurst, Expert Report (EXP.003.001.0017) at 0029 14 D O’Halloran T3695:13–T3695:14 15 Tolhurst T996:25–T996:26 16 Exhibit 139 – Report of Victorian Bushfire Reconstruction and Recovery Authority, 100 Day Report (TEN.046.001.0001) COMMISSION PROCESS

17 Ferguson v Cole (2002) 121 FCR 402 [18] 18 Dixon v Canada (Commission of Inquiry into the Deployment of Canadian Forces in Somalia – Letourneau Commission) (1997) 149 DLR (4th) 269 at [14], per Marceau J (Federal Court of Appeal) 19 R v War Pension Entitlement Appeals Tribunal; Ex Parte Bott (1933) 50 CLR 228, 256 (Evatt J) the interim report

20 Appendix 2 presents a schedule and list of witnesses in the first round of public hearings. 21 Exhibit 81 – Report of the Royal Commission into the Bushfires of January 1939 (TEN.028.001.0001) at 0005 22 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [21]

1 THE FEBRUARY 2009 FIRES Introduction

1 The DSE fire information management system The Weather

2 M Williams T720:12–T720:14 3 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [19], [29] 4 M Williams T721:1–T721:8 5 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [18] 6 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0028 7 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0032 and 0034 8 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0033 9 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0024 10 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0030 11 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0030 12 M Williams T720:17–T720:24 13 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [21] 14 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [22] 15 M Williams T724:9–T724:11; Dipole activity refers to opposites in weather conditions similar to opposite magnetic or electrical charges. 16 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [24]–[25] 17 M Williams T723:24–T723:26 18 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [25] 19 M Williams T724:22–T724:24

306 Endnotes

20 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0042 21 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0042 22 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [27] 23 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [28] 24 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [30] 25 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [30] 26 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [29] 27 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [30]–[31] 28 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [32] 29 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [33] 30 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [33]; M Williams T732:29–T732:30 31 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0043 32 Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0043 33 Exhibit 3 – Statement of Rees (WIT.004.001.0001) 34 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [234.3] 35 Exhibit 32 – Tolhurst Report (EXP.003.001.0017) at 0022 36 Rees T52:11–T52:23 37 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [68] 38 Rees T58:14–T58:28 39 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0053 40 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [34] 41 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [35]–[37] 42 Tolhurst T1760:28–T1761:8 43 Tolhurst T1761:19–T1761:22; Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [35]–[37] 44 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0067 45 Exhibit 22 – Statement of M Williams, Attachment 2 (WIT.013.002.0001) at 0068 46 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [13] 47 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [43] 48 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0067 Fire Behaviour

49 Rees T2574:11–T2574:13 50 Tolhurst T1762:11–T1762:16 51 Tolhurst T1762:17–T1762:28 52 McGahy T2239:25–T2239:26; McGahy T2244:2–T2244:12 53 Tolhurst T1763:23–T1764:8 54 Willans T3030:14–T3030:15; Rees T85:31–T86:6 55 Rees T67:11–T67:19 56 Williamson T4457:21–T4457:26 57 Willans T3030:21–T3030:23; Tolhurst T1026:3–T1026:29; Exhibit 32 – Tolhurst Expert Report (EXP.003.001.0017) at 0027 58 Willans T3032:19–T3032:31 59 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0067 60 Willans T3030:14–T3030:28 61 McCormack T4102:2–T4102:5 62 Tolhurst T1765:20–T1765:22 63 Esplin T374:25–T374:27; Rees T2402:23–T2402:25 64 Exhibit 25 – Hendrie Tender (EXH.025.0001) 65 Exhibit 25 – Hendrie Tender (EXH.025.0001) 66 Tolhurst T1030:14–T1030:24 67 Tolhurst T1030:25–T1031:2 68 Tolhurst T1031:2–T1031:9 69 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0017 70 Tolhurst T1032:1–T1032:12; Waller T105:1–T105:11 71 Rees T81:27–T82:13

307 2009 Victorian Bushfires Royal Commission—Interim Report

Fires Examined

72 Rees T2626:15–T2626:22; T2627:10 73 Rees T2568:29–T2569:6 74 Rees T2627:29–T2627:31 75 Stayner T1805:1–T1805:6 76 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [21] 77 Rees T2628:5–T2628:28 78 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [298] 79 Figure derived from Exhibit 6 – Statement of Waller (WIT.002.002.0001) and Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) 80 Griffiths T824:6–T824:11 81 See for example Murphy T1281:26–T1281:28; Esplin T205:25–T205:29 Fire Activity Prior to 7 February

82 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [255] 83 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [256] 84 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [257] 85 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [265] 86 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [264] 87 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [266] 88 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0048 89 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [269] 90 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [271]; Mineral earth control lines refers to areas where combustible fuel is removed either by hand or machinery. 91 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [281] 92 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [281] 93 To reduce a fire’s rate of spread, aerial bombers lay a retardant mix on vegetation ahead of or adjacent to the fire. 94 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [281] 95 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [340] Bunyip

96 Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 0895 97 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0091 98 Rees T2666:18–T2666:26; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0094 99 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0094; Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0057 100 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0091 101 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0091 102 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [385]; Rees T2570:12–T2570:15; Exhibit 6 – Statement of Waller (WIT.002.002.0001) [321] 103 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0390 104 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [320] 105 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0010 106 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [322] 107 Willans T3021:24–T3021:28 108 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0010 109 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [328] 110 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [330] 111 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0091 112 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [326] 113 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [323] 114 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [323]; Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) at 0525–0526 Delburn

115 Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0093 116 Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0056 [see Community Cluster H] 117 Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0056 [see Community Cluster H] 118 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [7]

308 Endnotes

119 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [9], [12], [20] 120 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [10], [14] 121 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [22] 122 Sigmund T898:8–T898:21 123 Sigmund T899:10–T899:14 124 Sigmund T913:11–T913:22 125 Sigmund T900:6–T900:15 126 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [24]–[25] 127 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [35]–[36] 128 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [38] 129 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [265] 130 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [76] Fire Activity on 7 February

131 Waller T135:29–T136:2 132 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [9], [12], [20] 133 Rees T68:22; T69:9–T69:10 134 Rees T56:4 135 Rees T45:27–T46:10 136 Rees T63:4–T63:9 137 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [77] 138 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0094 139 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [102] 140 Esplin T364:7–T364:8 141 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [113] 142 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [359] 143 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0132 144 Exhibit 11 – Statement of Esplin, Attachment 1 (WIT.005.001.0049) at 0054–0057, 0109, 0113–0122 Kilmore East

145 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0097 146 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) at 0006 147 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0132 148 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0132 149 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [27] 150 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [36] 151 Rees T2569:30–T2570:3 152 Rees T2570:15–T2570:19 153 Murphy T1281:26–T1281:27 154 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0394 155 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [14] 156 Keating T3224:3–T3224:15 157 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0096; Barca T3465:4–T3465:25 158 Rees T89:15–T89.22 159 Murphy T1262:20–T1262:24 160 Murphy T1267:29–T1267:31; Kreitszheim T1284:25–T1284:31 161 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [51], [71] 162 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [35] 163 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [6], [8]; Williamson T4428:8–T4428:10 164 Rees T2670:22–T2670:24 165 Murphy T1260:14–T1260:23; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [15] 166 Murphy T1261:19–T1261:23 167 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [15] 168 Murphy T1279:9–T1279:11 169 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [16]

309 2009 Victorian Bushfires Royal Commission—Interim Report

170 Murphy T1277:1–T1277:15 171 Tolhurst T1736:15–T1736:30; Rees T71:9–T72:16 172 Rees T75:1–T75:11; Murphy T1268:8–T1268:12; Kreltszheim T1305:6–T1305:9 173 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [16] 174 Rees T2671:4–T2671:13 175 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [17] 176 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [17] 177 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [17] 178 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0011 179 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [37] 180 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [37] 181 Keating T3226:14–T3226:17 182 Keating T3229:23–T3229:25 183 Exhibit 98 – Statement of Keating (VPO.001.002.0237_R) at 0241 184 Rees T2674:5–T2674:8 185 Rees T2674:14–T2674:15 186 Keating T3231:7–T3231:21 187 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [19] 188 Rees T2675:18–T2675:19 189 Strike teams may be sent significant distances away from their home locations. 190 McGahy T2245:5–T2245:10 191 McGahy T2245:10–T2245:11 192 McGahy T2246:21–T2246:24 193 McGahy T2248:26–T2248:29 194 McGahy T2251:19–T2251:26 195 McGahy T2253:2 196 McGahy T2253:6–T2253:9 197 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0011 198 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [16], [17] 199 Exhibit 25 – Statement of Hendrie (WIT.027.001.0007) at 0017 200 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [22] 201 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [50] 202 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [20] 203 Rees T81:10–T81:11; Rees T86:11–T86:12 204 Keating T3246:4–T3246:8 205 McCormack T4099:6–T4099:8 206 Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [22], [24], [26] 207 Munns T1369:18–T1369:21 208 Keating T3237:23–T3238:15 209 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [21] 210 Cooper T3261:27 211 Cooper T3261:19 212 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [20] 213 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [354]; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [21]–[22]; Rees T86:30–T86:31 214 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [21]–[22] 215 Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [32] 216 Exhibit 43 – Statement of Glassford (WIT.028.001.0001_R) [16] 217 Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [21] 218 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [24] 219 Rees T78:29 220 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [25]–[26] 221 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [27] 222 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [28] 223 Rees T92:12–T92:13

310 Endnotes

224 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [30] 225 Rees T2672:1 226 Rees T93:1–T93:8 227 Munns T1366:30–T1367:5 228 Kreltszheim T1294:1–T1294:6 229 Munns T1358:20–T1358:31 230 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [31] 231 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [32] 232 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [33] 233 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [34] Horsham

234 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0099 235 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [52] 236 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0098 237 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0098 238 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [49] 239 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [52] 240 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0401 241 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [41]; Rees T56:1–T56:3 242 Barca T3465:4–T3465:25; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0098 243 Rees T62:13 244 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [40] 245 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [42] 246 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [43] 247 Rees T58:3–T58:13 248 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [45] 249 Rees T58:14–T58:19 250 Rees T59:12–T59:14 251 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [47], [48] 252 Rees T58:29 253 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [49] 254 Rees T61:22–T61:24 255 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [50], [51] Coleraine

256 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0101 257 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [64] 258 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0100 259 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0120 260 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [60] 261 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [64] 262 Rees T46:4–T46:12 263 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0100; Rees T52:24–T52:25; Barca T3465:4–T3465:25 264 Rees T52:24–T52:30 265 Rees T46:28–T47:4 266 Rees T47:1–T47:3 267 Rees T47:15–T47:16 268 Rees T47:18 269 Rees T48:12; Rees T50:8–T50:9 270 Rees T52:11–T52:17 271 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [59] 272 Rees T53:12; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [60] 273 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [61], [63]

311 2009 Victorian Bushfires Royal Commission—Interim Report

Pomborneit–Weerite

274 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0103 275 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [75] 276 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0102 277 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [72] 278 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0102 279 Rees T63:4–T63:9 280 Barca T3465:4–T3465:25; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0102 281 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [75] 282 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [65], [67] 283 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [66] 284 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [69] 285 Rees T64:27–T64:29 286 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [70] 287 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [72] 288 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [73] 289 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [74] Churchill

290 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0105 291 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) at 0014 292 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 293 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 294 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 295 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 296 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0388 297 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [77]; Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0011–0012 298 Barca T3465:4–T3465:25; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 299 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 300 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [76] 301 Rees T2663:17–T2663:20 302 Rees T146:3; Rees – Exhibit 4 (WIT.004.002.0001) [82] 303 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [80] 304 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [83] 305 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [84] 306 Rees T2663:27–T2663:29; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [85]–[88] 307 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [86] 308 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [87] 309 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [88] 310 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [89] 311 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [90] 312 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [99] 313 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [100] 314 Rees T2665:17–T2665:22 315 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [91] 316 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [92] 317 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [93] 318 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [94] 319 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [96] 320 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [97]

312 Endnotes

Murrindindi

321 Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 0896 322 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0094 323 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0096; Exhibit 49 – Statement of P O’Halloran, Attachment 1 (WIT.3010.001.0007) 324 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [341]; Exhibit 3 – Statement of Rees (WIT.004.001.0001) [438] 325 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0096 326 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0093 327 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0094 328 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0397 329 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [332]; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [41] 330 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [332] 331 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [43]; Barca T3465:4–T3465:25 332 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0094 333 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [333] 334 Waller T127:24–T127:30 335 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [44] 336 Exhibit 130 – Statement of Waller (WIT.3024.001.0072) [37]; Exhibit 6 – Statement of Waller (WIT.002.002.0001) [334] 337 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [334]; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [44] 338 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [334] 339 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [335] 340 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [51] 341 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [40] 342 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [335] 343 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [335], [336] 344 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [50] 345 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [50] 346 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [59] 347 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [59] 348 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [336] 349 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [338] 350 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0012 351 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [55] 352 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [56] 353 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [340]; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [56] 354 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [318] 355 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [56] 356 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [53] 357 Fraser T3064:26–T3064:30 358 Fraser T3054:7 359 Fraser T3057:25; T3058:5–T3058:8 360 Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [23], [31] 361 Exhibit 13 – Statement of Newman (WIT.009.001.0001_R) [14]; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [53] 362 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [341] 363 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0093 364 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [60] 365 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [60] 366 Hunter T1720:8–T1720:13; T1721:19–T1721:21; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [61] 367 Hunter T1722:7–T1722:8 368 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [61] 369 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [339]; Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [63] 370 Hunter T1723:39–T1724:9 371 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [54] 372 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [64]

313 2009 Victorian Bushfires Royal Commission—Interim Report

Redesdale

373 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0107 374 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) at 0015 375 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 376 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0120 377 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 378 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 379 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [102] 380 Barca T3465:4–T3465:25; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 381 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 382 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [103] 383 Rees T2651:6–T2651:11 384 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [104] 385 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [105] 386 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [106] 387 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [107] 388 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [108] 389 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [109] 390 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [110] 391 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [108] Narre Warren

392 Esplin T364:7–T364:11 Bendigo

393 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0107 394 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0107 395 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) at 0017 396 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 397 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 398 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 399 Rees T2657:27; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 400 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0391 401 Rees T2657:22; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [113] 402 Rees T2658:1–T2658:4; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [120] 403 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [113] 404 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106; Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [112]; Barca T3465:4–T3465:25; Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 405 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [115] 406 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [116] 407 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [118] 408 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [120] 409 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [119]–[120] 410 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [122], [125] 411 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0013 412 Rees T2659:4–T2659:7 413 Rees T2659:18–T2659:26 414 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [123] Beechworth–Mudgegonga

415 Exhibit 6 – Statement of Waller, Attachment 46 (WIT.002.001.0895) at 0897 416 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0101 417 Walsh T669:7–T669:8 418 Exhibit 11 – Statement of Esplin, Attachment 1(WIT.005.001.0049) at 0082 419 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0100 420 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0101

314 Endnotes

421 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [85] 422 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0399 423 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [359] 424 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [359] 425 Barca T3465:4–T3465:25 426 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [365], [371] 427 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [72], [73], [86] 428 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [363] 429 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [77] 430 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [80] 431 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [81] 432 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [368] 433 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [364] 434 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [368] 435 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [370] 436 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [366] 437 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [371] 438 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [372] 439 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [373] 440 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0100 441 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [89] 442 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [367] 443 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [89] 444 Exhibit 130 – Statement of Waller (WIT.3024.001.0073) [90] 445 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0112 446 Rees T2662:23–T2662:27 447 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0112 448 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0112 449 Rees T2660:24–T2660:27 Fire Activity after 7 February

450 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [414] 451 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [408] 452 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [389] 453 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0099 454 Exhibit 6 – Statement of Waller (WIT.002.002.0001) at 0100 455 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [409] 456 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [410] 457 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [415], [418] 458 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [432] 459 Exhibit 3 – Statement of Rees, Attachment 33 (WIT.004.001.0730) at 0730 460 Cook T4751:15–T4751:21; Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [65] 461 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [418] 462 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [435] 463 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [419] 464 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [419] 465 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [391] 466 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [389], [391] 467 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [391] Previous Major Fires

468 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 0999–1001 469 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 0999 470 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1000 471 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1001 472 Exhibit 11 – Statement of Esplin, Attachment 1, (WIT.005.001.0049) at 0111

315 2009 Victorian Bushfires Royal Commission—Interim Report

2 ENGAGING COMMUNITIES Communicating with the Commission

1 Bushfires Royal Commission Enquiries Line 1800 243 650; [email protected]; www.royalcommission.vic.gov.au 2 These three initiatives were established following the fires to assist in the relief and reconstruction process. Fire-Affected Community Consultations

3 Matthews T3784:9–T3784:10 4 Ward T4040:21–T4040:28 5 Spooner T491:29–T491:31 6 D O’Halloran T3717:11–T3717:14 7 Exhibit 108 – Statement of P Brown (WIT.053.001.0001_R) [20] 8 D Brown T3511:27–T3511:30 9 Ananiev T2787:8–T2787:10 10 Fraser T3050:12–T3050:16 11 Gobbett T1504:26–T1504:29 12 Ananiev T2783:26–T2783:28 13 Ferguson T925:17–T925:18 14 Newman T347:24–T347:26 15 P Brown T3545:28–T3545:30 16 Ferguson T951:30–T952:11 17 Exhibit 29 – Statement of Ferguson (WIT.022.001.0001_R) [21] 18 D O’Halloran T3680:24–T3680:27 19 Glassford T1335:8–T1335:13 20 O’Neill T3198:26–T3198:31 21 The terms used during the community consultation reflected fuel reduction in a general sense, rather than its precise technical meaning. 22 Harvey T2201:14–T2202:1 23 Davey T788:27–T788:30 24 Ananiev T2771:23–T2771:25 25 Glassford T1338:7–T1338:10 26 Newman T351:30–T352:1 27 Walter T2593:25–T2593:27 28 Olorenshaw T1903:4–T1903:6 29 Davey T787:17–T787:19 30 J Williams T4233:27–T4233:29 31 D Brown T1649:24–T1649:26 32 D O’Halloran T3719:18–T3719:20 33 Walter T2591:23–T2592:9 34 Rogers T609:29–T610:3 35 Olorenshaw T1903:16–T1903:19 36 Matthews T3789:24–T3789:28 37 Newman T347:1–T347:11 38 McCulloch T2469:5–T2469:11 39 McCulloch T2470:24–T2470:27 40 Matthews T3804:12–T3804:13 41 Gobbett T1505:24–T1505:26 42 P Brown T3546:2–T3546:4 43 Joan Davey is from Warrnambool, and gave evidence in relation to the death of her son and his family in their home at Kinglake. 44 Jill Kane is from Bendigo, and gave evidence in relation to the death of her brother at his home in Long Gully. 45 Daryl Hull is from Blackburn and was working in Marysville on 7 February. 46 John Williams is from Mitcham and was working in Yarra Glen on 7 February 2009.

316 Endnotes

3 SUBMISSIONS THE SUBMISSIONS PROCESS

1 The Commission’s terms of reference are presented at page VII of this report. SUBMISSION Demographics

2 The 12 fires are outlined in more detail in Chapter 1 of this report. Recurring themes in submissions

3 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-031-0369_R at 0379 4 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-037-0102_R at 0107 5 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-028-0178_R at 0214 6 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-1122_R at 1124 7 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-0867_R at 0879 8 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-019-0040_R at 0041 9 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-033-0222_R at 0227 10 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-032-0321_R at 0324 11 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-039-0075_R at 0077 12 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-018-0538_R at 0542 13 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-021-0341_R at 0343 14 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-016-0783_R at 0785 and http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-1302_R at 1306 15 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-0204_R at 0208 16 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-016-0113_R at 0114 17 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-016-0342_R at 0343 18 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-022-0005_R at 0009 19 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0448_R at 0451 20 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-032-0058_R at 0060 21 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-018-0209_R at 0218–0219 22 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-034-0171_R at 0188 23 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-031-0173_R at 0183 24 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-038-0001_R at 0003 25 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-0673_R at 0678 26 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-031-0037_R at 0040 27 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-035-0314_R at 0317–0318 28 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-013-0525_R at 0527 29 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-002-0103_R at 0105–0106 30 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-039-0250_R at 0256 31 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-035-0284_R at 0293 32 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-004-0309_R at 0311 33 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-018-0096_R at 0099 34 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-028-0057_R at 0068 35 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-030-0292_R at 0294 36 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-029-0235_R at 0246 37 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-020-0336_R at 0343 38 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0289_R at 0363 39 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-032-0040_R at 0049 40 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-036-0001_R at 0007 41 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-030-0327_R at 0335 42 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-013-0331_R at 0337 43 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-028-0029_R at 0034 44 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-022-0137_R at 0154 45 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-016-0725_R at 0730 46 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-029-0313_R at 0316 47 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-011-0037_R at 0040

317 2009 Victorian Bushfires Royal Commission—Interim Report

48 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-033-0328_R at 0377 49 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-030-0080_01_R at 0085 50 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-1161_R at 1163 51 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-011-0006_R at 0008 52 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-030-0012_R at 0018 53 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-005-0076_R at 0078 54 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0073_R at 0080 55 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-018-0247_R at 0250–0251 56 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0465_R at 0470 57 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-032-0007_R at 0012 58 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-015-0471_R at 0473 59 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0578_R at 0582 60 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-034-0010_R at 0014 61 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-017-0586_R at 0592 62 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-009-0093_R at 0098 63 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-022-0225_R at 0232–0233 64 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-002-0054_R at 0058–0059 65 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-023-0024_R at 0026 66 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-028-0153_R at 0154 67 http://www.royalcommission.vic.gov.au/Submissions/SubmissionDocuments/SUBM-002-016-0267_R at 0279

4 WARNINGS BUSHFIRE INFORMATION, WARNINGS AND TRIGGERS

1 Esplin T552:19–T553:28 BUSHFIRE INFORMATION AND EDUCATION IN VICTORIA

2 Exhibit 11 – Statement of Esplin, Attachment 29 (WIT.005.001.1957) 3 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [86] 4 Exhibit 11 – Statement of Esplin, Attachment 26 (WIT.005.001.1931) 5 Exhibit 11 – Statement of Esplin, Attachment 22 (WIT.005.001.1816) 6 Exhibit 11 – Statement of Esplin, Attachment 4 (WIT.005.001.0595) 7 Exhibit 11 – Statement of Esplin, Attachment 21 (WIT.005.001.1776) 8 Exhibit 11 – Statement of Esplin, Attachment 28 (WIT.005.001.1949) BUSHFIRE WARNINGS: THE WELL-TRODDEN PATH

9 Exhibit 141 – Report of the Bushfire Review Committee – On Bushfire Disaster Preparedness and Response in Victoria, Australia, Following the Ash Wednesday Fires 16 February 1983 (TEN.048.001.0001) 10 Exhibit 141 – Report of the Bushfire Review Committee – On Bushfire Disaster Preparedness and Response in Victoria, Australia, Following the Ash Wednesday Fires 16 February 1983 (TEN.048.001.0001) [45] 11 Exhibit 141 – Report of the Bushfire Review Committee – On Bushfire Disaster Preparedness and Response in Victoria, Australia, Following the Ash Wednesday Fires 16 February 1983 (TEN.048.001.0001) [152]–[159] 12 Exhibit 141 – Report of the Bushfire Review Committee – On Bushfire Disaster Preparedness and Response in Victoria, Australia, Following the Ash Wednesday Fires 16 February 1983 (TEN.048.001.0001) [157(c)] 13 Exhibit 45 – Pearce Tender (TEN.004.002.0037) 14 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0042 15 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0075–0076 16 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0080–0081 17 Exhibit 143 – Report on Progress on Recommendations of COAG Natural Disaster Related Reports (TEN.045.001.0009) at 0013 18 Exhibit 142 – National Inquiry on Bushfire Mitigation and Management (TEN.049.001.0001) 19 Exhibit 142 – National Inquiry on Bushfire Mitigation and Management (TEN.049.001.0001) at 0187–0188 20 Exhibit 142 – National Inquiry on Bushfire Mitigation and Management (TEN.049.001.0001) at 0187–0188 21 Exhibit 142 – National Inquiry on Bushfire Mitigation and Management (TEN.049.001.0001) at 0188 22 Exhibit 45 – Pearce Tender (TEN.004.002.0285); Statement of Pearce (WIT.032.001.0001) [3]; T1452:26–T1452:30 23 Exhibit 45 – Pearce Tender (TEN.004.002.0285) at 0293 24 Exhibit 45 – Pearce Tender (TEN.004.002.0285) at 0302–0305

318 Endnotes

25 Exhibit 45 – Pearce Tender (TEN.004.002.0285) at 0322 26 Pearce T1455:14–T1455:16 27 Exhibit 83 – Rees Tender (SUMM.022.002.0297) 28 Exhibit 83 – Rees Tender (SUMM.022.002.0297) at 0300 WHAT MAKES A GOOD BUSHFIRE WARNING?

29 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [8]–[26]; T3083:22–T3090:10 30 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027); Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) 31 Exhibit 45 – Pearce Tender (TEN.004.002.0478) 32 Exhibit 90 – Statement of Edwards, Attachment 7 (WIT.039.001.0049); Attachment 8 (WIT.039.001.0053) 33 State of Victoria (SUBM.100.005.0001) [37] 34 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R); T3070:11–T3190:24 35 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [10]–[14] 36 Handmer T3077:13–T3077:21 37 Handmer T3080:25–T3081:4 38 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [30] 39 Handmer T3080:15–T3080:19 40 Handmer T3092:2–T3093:27 41 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) 42 Handmer T3092:9–T3092:21 43 Handmer T3164:10–T3164:29 44 Handmer T3079:10–T3079:17; T3084:28–T3085:10 45 Handmer T3144:9–T3145:1 46 Handmer T3086:20–T3086:30 47 Handmer T3097:18–T3097:23 48 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [24]; Attachment, Communication of Emergency Public Warnings – A Social Science Perspective and State of the Art Assessment (WIT.3004.002.0149) 49 Exhibit 11 – Statement of Esplin, Attachment 8, Ferny Creek Fire Alert Siren Evaluation Report (WIT.005.001.0738); Attachment 9, Halls Gap Fire Risk Management Project (WIT.005.001.0784); Attachment 7, Coode Island Community Warning and Information System (WIT.005.001.0784); Attachment 10, Community Information and Warning System: Report of the Trial and Evaluation (WIT.005.001.0833); Attachment 13, A Report of the Response to an Emergency at Melbourne Airport on 21 February 2005 (WIT.005.001.1462); Attachment 14, Westpoint Chemical Fire Report to the Community (WIT.005.001.1496) 50 Exhibit 11 – Statement of Esplin, Attachment 10 (WIT.005.001.0833) 51 Esplin T214:7–T214:19 52 Exhibit 102 – Rhodes Tender (TEN.036.001.0001) 53 Exhibit 102 – Rhodes Tender (TEN.036.001.0001) at 0003. The article was put to Mr Esplin at T592:9–T594:13 and to Mr Rhodes at T3328:29–T3330:23 54 Exhibit 89 – Statement of Lawson, Attachment 5 (WIT.024.002.0035) at 0036 55 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [28]; Lawson T2840:12–T2840:15. The 2005 paper has been superseded by a new discussion paper dated May 2009; Lawson T2840:16–T2840:19 56 Exhibit 89 – Statement of Lawson, Attachment 5 (WIT.024.002.0035) at 0036 57 Exhibit 89 – Statement of Lawson, Attachment 5 (WIT.024.002.0035) at 0042 58 Exhibit 96 – Statement of Lawson, Attachment 5 (WIT.024.002.0035) at 0042 59 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0088 60 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0096 61 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0097 62 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0098 63 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0100–0105 64 Exhibit 90 – Statement of Edwards, Attachment 9 (WIT.039.001.0087) at 0106 65 Exhibit 45 – Pearce Tender (TEN.004.002.0478) 66 Exhibit 45 – Pearce Tender (TEN.004.002.0478) at 0485 67 Exhibit 45 – Pearce Tender (TEN.004.002.0478) at 0486 68 Exhibit 45 – Pearce Tender (TEN.004.002.0478) at 0486 69 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [33]; T3094:22–T3097:10 70 Edwards T2893:4–T2893:10 71 Pearce T1506:27–T1507:1 72 Rhodes T3299:5–T3299:23 73 State of Victoria (SUBM.100.005.0001) [33]–[37]; Commonwealth of Australia (SUBM.100.007.0002) [13]. The Commission acknowledges the Commonwealth’s caveat that the information in the paper should be considered in conjunction with the expertise of the emergency services in local circumstances.

319 2009 Victorian Bushfires Royal Commission—Interim Report

74 State of Victoria (SUBM.100.005.0001) [36] 75 Edwards T2868:28–T2868:29 76 Edwards T2869:21–T2869:22 77 Exhibit 90 – Statement of Edwards (WIT.039.001.0001) [22] 78 Exhibit 90 – Statement of Edwards (WIT.039.001.0001) [25] 79 Exhibit 90 – Statement of Edwards (WIT.039.001.0001) [21] 80 Exhibit 45 – Pearce Tender, AFAC National Information Exchange Standards: A foundation to establish interoperability within the emergency services September 2007 (TEN.004.001.0217) at 0223–0224 81 Exhibit 45 – Pearce Tender, AFAC Information Exchange Standards: Common Alerting Protocols and Inter-CAD Messaging April 2008 (TEN.004.001.0228) at 0230; See also Exhibit 90 – Statement of Edwards (WIT.039.001.0001) [20]; Annexure 8 OASIS Common Alerting Protocol VI.1, Oasis Standard CAP VI.1 October 2005 (WIT.039.001.0053) at 0054 82 Exhibit 90 – Statement of Edwards, Annexure 9 (WIT.039.001.0087) at 0101 83 Exhibit 90 – Statement of Edwards, Annexure 9 (WIT.039.001.0087) at 0103 84 AFAC (SUBM.100.002.0001) [9] 85 State of Victoria (SUBM.100.005.0001) [36] BUSHFIRE WARNINGS: THE SYSTEM IN VICTORIA ON 7 FEBRUARY

86 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0181 87 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at [196]–[204]; T42:12–T44:13 88 Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [18]; Spooner T473:20–T473:25; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [5]; Ananiev T2775:3–T2775:9; Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [11], [13]; O’Neill T3199:20–T3199:21; Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [13] 89 Glassford T1327:1–T1327:2; Harvey T2195:28–T2195:30; Matthews T3776:29–T3777:6; Newman T336:15–T336:20; D O’Halloran T3683:26–T3684:11 90 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [201]; See also Exhibit 6 – Statement of Waller (WIT.002.002.0001) [105] 91 Exhibit 3 – Statement of Rees (WIT.004.001.0001) 92 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [23]; Attachment F (WIT.033.001.0069) at 0070 93 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [24]–[27] 94 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [23]–[55]; T1809:20-T1813:1; T1802:14–T1842:4 BUSHFIRE INFORMATION DISSEMINATED PRIOR TO 7 FEBRUARY

95 Exhibit 11 – Statement of Esplin, Attachment 29 (WIT.005.001.1957) at 1975–1978 96 Exhibit 11 – Statement of Esplin, Attachment 33 (WIT.005.001.2242) 97 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [140]–[199] 98 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [168] 99 Exhibit 11 – Statement of Esplin, Attachment 42 (WIT 005.001.2304) 100 Exhibit 11 – Statement of Esplin, Attachment 44 (WIT.005.001.2306) 101 Exhibit 11 – Statement of Esplin, Attachment 49 (WIT.005.001.2314) 102 Exhibit 11 – Statement of Esplin, Attachment 50 (WIT.005.001.2316) 103 Exhibit 11 – Statement of Esplin, Attachment 51 (WIT.005.001.2320) 104 Exhibit 11 – Statement of Esplin, Attachment 58 (WIT.005.001.2358) 105 Exhibit 11 – Statement of Esplin, Attachment 59 (WIT.005.001.2359) 106 Exhibit 11 – Statement of Esplin, Attachment 61 (WIT.005.001.2361) 107 Exhibit 11 – Statement of Esplin, Attachment 62 (WIT.005.001.2362) 108 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [184]; Attachment 63 (WIT.005.001.2363) 109 Exhibit 11 – Statement of Esplin, Attachment 67 (WIT.005.001.2370) 110 Exhibit 11 – Statement of Esplin, Attachment 68 (WIT.005.001.2371) 111 Exhibit 11 – Statement of Esplin, Attachment 69 (WIT.005.001.2373) 112 Exhibit 11 – Statement of Esplin, Attachment 71 (WIT.005.001.2376) 113 Exhibit 11 – Statement of Esplin, Attachment 72 (WIT.005.001.2378) 114 Exhibit 11 – Statement of Esplin, Attachment 76 (WIT.005.001.2383) 115 Exhibit 11 – Statement of Esplin, Attachment 77 (WIT.005.001.2399) 116 Exhibit 11 – Statement of Esplin, Attachment 78 (WIT.005.001.2400) 117 Exhibit 11 – Statement of Esplin, Attachment 80 (WIT.005.001.2406) 118 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [101]–[103] 119 Handmer T3083:8–T3083:21 120 Esplin T580:11–T580:14 121 Exhibit 11 – Statement of Esplin, Attachment 24 (WIT.005.001.1860)

320 Endnotes

122 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [101]–[103]; Attachment 24 (WIT.005.001.1860) 123 Handmer T3139:16–T3139:25 124 Exhibit 69 – Statement of Paton (WIT.031.001.0001) [6], [13], [14], [15.2] BUSHFIRE WARNINGS ON 7 FEBRUARY

125 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [28] 126 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [374] 127 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) 128 Exhibit 6 – Statement of Waller, Annexure 37 (WIT.002.002.0108) 129 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [198] 130 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [74]–[75] 131 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [76] 132 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [48] 133 Exhibit 7 – Schedule, 774 ABC Radio Broadcast on 7 February 2009 7.00 AM to 12.00 midnight (SUMM.001.002.0001) 134 Exhibit 79 – Rees Tender (ENDX.0079.001.0001); Exhibit 144 (TEN.052.001.0001) 135 Exhibit 7 – Schedule, 774 ABC Radio Broadcast on 7 February 2009 7.00 AM to 12.00 midnight (SUMM.001.002.2752) 136 Stayner T1816:21–T1816:29 137 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [50] 138 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [53] 139 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [53]-[55] 140 Stayner T1819:15–T1819:28 141 Stayner T1819:29–T1820:7 142 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [93] 143 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [96] 144 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [98]–[100] 145 Exhibit 78 – Rees Tender (EXH.078.0001) 146 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [210] 147 Exhibit 111 – Statement of Johnstone (WIT.7500.001.0001); T3571:1–T3587:28 148 Exhibit 111 – Statement of Johnstone (WIT.7500.001.0001) [34] 149 Exhibit 111 – Statement of Johnstone, Attachment (WIT.7500.001.0016); (WIT.7500.001.0017) 150 Exhibit 111 – Statement of Johnstone (WIT.7500.001.0001) [14] 151 Exhibit 111 – Statement of Johnstone (WIT.7500.001.0001) [34] 152 Exhibit 111 – Statement of Johnstone (WIT.7500.001.0001) [35]–[37] 153 Johnstone T3575:20–T3576:2 154 State of Victoria (SUBM.100.005.0001) [51(b)] HOW DID THE COMMUNITY RECEIVE AND UNDERSTAND THE WARNINGS on 7 february?

155 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) 156 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0079–0114 157 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0083–0085. The second stage of the research, yet to be completed, involves a mail survey of households in bushfire-affected communities. 158 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0094 159 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0095 160 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0096 161 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0096 162 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0096 163 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0096 164 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0098 165 Exhibit 96 – Statement of Handmer (WIT.044.001.0038) 166 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0530–0531 167 Handmer T3111:2–T3112:6 168 Rhodes T3297:17–T3297:21 169 Esplin T587:6–T587:12 170 Esplin T584:14–T584:21; T580:15–T580:30 171 Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [5], [7]–[8], [11]; T3047:14–T3047:21; T3048:15–T3049:10; T3049:25–T3049:31 172 Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [11]; T3196:23–T3196:28; T3199:18–T3199:21; T3201:5–T3201:18 173 Exhibit 103 – Statement of Barber (WIT.046.001.0001_R) [13]; T3339:14–T3339:21

321 2009 Victorian Bushfires Royal Commission—Interim Report

174 Exhibit 61 – Statement of Olorenshaw (WIT.034.001.0001_R) [5]–[7], [23]–[25]; T1873:13–T1873:30; T1877:19–T1877:29 175 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [11]–[13]; T193:3–T193:10 176 Odgers T192:8–T192:30 177 Newman T336:6–T336:14 178 Patten T414:9–T414:13 179 Rogers T605:8–T605:22 180 Rogers T610:22–T610:31 181 Ferguson T930:1–T930:9; T955:24–T956:18 182 Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [18]–[19]; T472:9–T472:27; T474:18–T475:14; T498:25–T499:6 183 Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [21]–[23]; T478:12–T480:28 184 Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [12]; T4534:20–T4534:25 185 Hainsworth T4533:11–T4533:22 186 Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [16]; T2774:29–T2775:5; T2776:12–T2779:27 187 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001) [4]–[5]; T1493:11–T1493:26; T1495:29–T1496:3; T1500:30–T1502:2; T1496:5–T1496:30 188 Exhibit 23 – Statement of Davey (WIT.019.001.0001_R) [1], [8]; T780:22–T780:29 189 Hull T1164:14–T1164:16 190 Gobbett T1495:31–T1496:2 191 P Brown T3511:24–T3511:27 192 Exhibit 70 – Statement of Casey (WIT.035.001.0001_R) [4], [7]; T2355:4–T2355:16; T2356:20–T2357:11 193 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [10], [14]; T2473:16–T2473:23; T2474:12–T2474:22; T2447:14–T2448:6 194 Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [19]–[20]; T2585:21–T2586:3 195 Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [11], [13], [15]; T3683:9–T3683:30; T3684:19–T3685:10; T3687:14–T3687:29 196 Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [8], [11], [18]; T2918:30–T2919:3; T2919:27–T2919:30; T2922:1–T2922:5 197 Exhibit 43 – Statement of Glassford (WIT.028.001.0001_R) [11]–[12]; T1326:14–T1326:29 198 D Brown T1652:9–T1652:27; T1653:12–T1653:22 199 D Brown T1654:29–T1655:8 200 Exhibit 116 – Statement of Matthews (WIT.057.001.0001_R) [19]–[23]; T3778:31–T3780:29; T3785:11–T3785:18 201 Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [15] 202 Harvey T2194:11–T2195:20 203 Harvey T2202:6–T2202:29 204 Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [4]–[8] 205 D Brown T1646:11–T1646:21 206 Exhibit 108 – Statement of P Brown (WIT.053.001.0001_R) [17]–[20]; T3509:14–T3509:30; T3511:5–T3511:14 207 P Brown T3511:15–T3511:23 208 P Brown T3531:20–T3531:30 209 Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [13], [16]; T4031:25–T4031:28; T4033:9–T4034:1; T4038:18–T4039:14 210 Exhibit 125 – Statement of J Williams (WIT.055.001.0001_R) [14]; T4212:26–T4213:5 211 J Williams T4229:3–T4229:15 212 J Williams T4229:19–T4229:23 213 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [13]; T1053:26–T1054:28 conclusions on the construction and content of BUSHFIRE warnings

214 Rees T2532:2–T2532:18 215 Lawson T2847:2–T2847:6 216 Pearce T1514:21–T1514:27 TOWARDS A LONGER TERM APPROACH — A NEW CATEGORISATION SYSTEM

217 P Brown T3529:24–T3532:4 218 Ananiev T2787:8–T2787:17 219 Glassford T1328:11–T1328:26 220 Harvey T2203:27–T2203:30 221 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [58]; T3074:1–T3074:29 222 Exhibit 90 – Statement of Edwards, Annexure 9 (WIT.039.001.0087) at 0105 223 Handmer T3105:20–T3106:1

322 Endnotes

LESSONS FROM THE 2005 WANGARY FIRES AND PROJECT PHOENIX

224 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [8] 225 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [1]–[10] 226 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [14]–[16] 227 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [17]–[18] 228 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [19] 229 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [21] 230 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [24]–[25] 231 Lawson T2834:29–T2835:8 232 Handmer T3116:5–T3116:19 233 Handmer T3182:19–T3182:25 234 Lawson T2823:26–T2824:7 235 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [23], [25] 236 Lawson T2820:17–T2820:24; T2822:1–T2822:4 237 Lawson T2851:1–T2851:14; T2856:6–T2856:13; T2858:10–T2859:2 238 State of Victoria (SUBM.100.005.0001) [37] RETHINKING THE Standard emergency warning signal

239 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [104] 240 Exhibit 11 – Statement of Esplin, Attachment 25 (WIT.005.001.1924) 241 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [105]; Attachment 25 (WIT.005.001.1924) at 1926–1927 242 Esplin T253:14–T254:27; T245:15–T245:17; Walshe T632:24–T632:25 243 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [107]; T256:18–T256:24; Pearce T1447:22–T1448:15 244 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [106]; Esplin Tender (TEN.002.001.0002) at 0037; T243:17–T245:14 245 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [233] 246 Rees T2485:13–T2485:18; T2486:18–T2486:31 247 Exhibit 11 – Esplin Tender (TEN.002.001.0002) at 0037 248 Esplin T245:10–T245:14 249 Exhibit 83 – Rees Tender (SUMM.022.002.0297) 250 Exhibit 83 – Rees Tender (SUMM.022.002.0297) at 0312 251 Exhibit 83 – Rees Tender (SUMM.022.002.0297) at 0312 252 Exhibit 89 – Statement of Lawson (WIT.024.002.0001) [24]–[25]; T2825:26–T2826:3 253 Lawson T2827:6–T2827:15 254 Lawson T2827:16–T2827:20 255 Handmer T3090:21–T3090:27 256 Esplin T317:4–T317:10 257 State of Victoria (SUBM.100.005.0001) [54]–[56]; ABC (SUBM.100.011.0001) [8]–[10] 258 Lawson T2852:26–T2853:23 259 Handmer T3162:26–T3162:28 260 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [112] THE USE OF SIRENS AS A BUSHFIRE WARNING

261 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [81]–[82] 262 Rees T53:23–T53:25 263 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [32]–[33] 264 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [33] 265 Handmer T3101:3–T3101:5 266 Hull T1167:15–T1167:31 267 Fraser T3050:9–T3050:29 268 Exhibit 103 – Statement of Barber (WIT.046.001.0001_R) [18] 269 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) 270 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0742 271 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0742 272 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0748 273 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0739, 0751

323 2009 Victorian Bushfires Royal Commission—Interim Report

274 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0743 275 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0743 276 Esplin T290:13–T290:22 277 Exhibit 11 – Statement of Esplin, Attachment 8 (WIT.005.001.0738) at 0771 278 Exhibit 11 – Esplin Tender (TEN.002.001.0320) 279 Exhibit 11 – Esplin Tender (TEN.002.001.0320) at 0332 280 Exhibit 11 – Esplin Tender (TEN.002.001.0320) at 0333 281 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [2]–[6] 282 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [7]–[36] 283 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [30] 284 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [35]–[36] 285 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [41] 286 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [42]–[43]; T909:13–T909:23; T916:31 287 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [42] 288 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [36] 289 Sigmund T915:1–T915:6; T919:10–T920:7 290 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [49] 291 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [52] 292 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001) [46]; T909:4–T909:5 293 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [32]; T3299:24–T3302:22 294 Lawson T2854:27–T2855:14 295 Lawson T2855:12–T2855:16 296 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [16]–[18] 297 For further information about the operation of these sirens, see Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R); Attachment 3 (WIT.037.001.0023) 298 Dwight T2066:16–T2067:6 299 Esplin T317:28–T318:12 300 Rees T53:23–T54:24 301 Esplin T284:24–T285:10 A TELEPHONY-BASED EMERGENCY WARNING SYSTEM

302 Exhibit 11 – Statement of Esplin, Attachment 10 (WIT.005.001.0833) 303 Exhibit 11 – Statement of Esplin, Attachment 10 (WIT.005.001.0833) at 0849 304 Exhibit 11 – Statement of Esplin, Attachment 10 (WIT.005.001.0833) at 0841 305 Exhibit 11 – Statement of Esplin, Attachment 10 (WIT.005.001.0833) at 0905 306 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [218]; T305:15–T305:17; Consolo T3886:20–T3886:31 307 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [111] 308 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [123]–[164] 309 Refer to evidence set out in Submissions of Counsel Assisting (SUBM.100.001.0001) [2.3.3]; Pearce T1518:24–T1538:18 310 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [164]; Pearce Tenders (TEN.004.002.0541); (TEN.004.002.0527) 311 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [165]; Attachment 17 (WIT.032.001.0261) at 0262 312 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [165] 313 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [102] 314 Exhibit 45 – Pearce Tender (TEN.004.002.0561) 315 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [225]; T309:27–T310:1 316 Exhibit 155 – Brumby Releases National Emergency Warning System Tender Ahead of Bushfire Season (VBRC.002.001.0001) 317 Exhibit 155 – Brumby Releases National Emergency Warning System Tender Ahead of Bushfire Season (VBRC.002.001.0001) 318 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [220]–[222] 319 Exhibit 118 – Statement of Consolo (WIT.5000.001.0001) [11], [81]; T3903:19–T3904:3 320 Exhibit 118 – Statement of Consolo (WIT.5000.001.0001) [83]; T3905:15–T3905:30 321 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [223]–[224]; Esplin Tender (TEN.002.001.0106); Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [113], [118]; Handmer T3128:4–T3128:23 322 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [43]; T3087:2–T3087:7 323 Esplin T215:20–T215:28

324 Endnotes

5 INFORMATION revisiting the fdi and the fire danger rating

1 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [236], [237.4] 2 Exhibit 22 – Statement of M Williams, Annexure 1 – Meteorological Aspects of the 7 February 2009 Victorian Fires, an Overview (WIT.013.001.0012) at 0026 3 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.1] 4 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.4] 5 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.2]; see further Exhibit 22 – Statement of M Williams, Annexure 1 – Meteorological Aspects of the 7 February 2009 Victorian Fires, an Overview (WIT.013.001.0012) at 0021 6 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.5]; see further Exhibit 22 – Statement of M Williams, Annexure 1 – Meteorological Aspects of the 7 February 2009 Victorian Fires, an Overview (WIT.013.001.0012) at 0021 7 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [237.2], [237.5] 8 See Exhibit 3 – Statement of Rees (WIT.004.001.0001) at [236]–[243]; Rees T36:10–T38:18; Tolhurst T1037:26–T1038:7 9 M Williams T749:23–T749:25; M Williams T750:4–T750:9; Esplin T512:28–T513:2 10 Rees T40:8–T40:27; M Williams T714:15–T714:29 11 Rees T40:10–T40:18 12 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [255] 13 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [257] 14 Rees T38:9–T38:30; Rees T38:16–T38:17 15 M Williams T749:26–T749:31; M Williams T751:11–T751:14; Esplin T512:18–T513:5; M Williams T749:23–T749:28; Esplin T513:6–T513:12 16 Exhibit 22 – Statement of M Williams, Attachment 1 – Meteorological Aspects of the 7 February 2009 Victorian Fires, an Overview (WIT.013.001.0012) at 0194–0195; Exhibit 22 – Overview of the Meteorological Aspects of the Victorian Fires (WIT.013.002.0001) at 0074-0075; Exhibit 3 – Statement of Rees (WIT.004.001.0001) [278], [283]–[284], [292] 17 Patten T408:23–T408:30; Rogers T605:8–T605:12; Harvey T2194:13–T2195:26; Gobbett T1493:11–T1493:21 18 Exhibit 3 – Statement of Rees (WIT.001.001.0001) at 0069 19 M Williams T750:10–T750:24 20 Handmer T3102:9–T3102:13 21 Handmer T3104:12–T3104:25; Handmer T3164:18–T3165:3 22 Handmer T3101:27–T3102:13; M Williams T750:10–T750:15; Tolhurst T1036:30–T1038:30 23 Commonwealth of Australia (SUBM.100.007.0002) [41] 24 State of Victoria (SUBM.100.005.0001) [63]–[65] 25 Edwards T2895:3–T2895:30; Edwards T2900:6–T2900:25 26 Australasian Fire and Emergency Service Authorities Council (SUBM.100.002.0001) [47] 27 Exhibit 22 – Statement of M Williams (WIT.013.001.0002) [17] 28 M Williams T748:21–T749:18 29 M Williams T748:29–T749:22 30 M Williams T749:9–T749:15 31 Handmer T3124:4–T3124:8 32 M Williams T756:29–T757:1 33 Odgers T194:15–T194:28; see also Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [33] 34 Rogers T611:11–T611:16 35 Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [10] 36 D Brown T1646:11–T1646:17 37 Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [39]–[41]; Harvey T2195:14–T2195:16 38 Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [41] 39 Rees T41:2–T41:11 40 Rees T41:12–T41:16 41 Counsel Assisting (SUBM.100.001.0001), proposed recommendation 2.3.5(a) 42 State of Victoria (SUBM.100.005.0001) [63], [65] 43 Commonwealth of Australia (SUBM.100.007.0002) [39]–[40] 44 Australasian Fire and Emergency Service Authorities Council (SUBM.100.002.0001) [21] Building A Single, multi-agency bushfire information website for Victoria

45 Exhibit 3 – Rees (WIT.004.001.0001) [211] 46 Exhibit 6 – Waller (WIT.002.002.0001) [113]–[114]

325 2009 Victorian Bushfires Royal Commission—Interim Report

47 Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [18]–[19]; Spooner T473:20–T473:25; Gobbett T1496:27–T1496:31; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [5], [16]; Ananiev T2775:3–T2775:12; Ananiev T2777:1–T2777:23; Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [11], [13]; O’Neill T3199:20–T3199:21; O’Neill T3201:29–T3202:5; Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [13]; D O’Halloran T3683:23–T3683:26 48 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [48.c], [51], [59.c]; Stayner T1815:3–T1815:9 49 Venters T4621:20–T4621:28 50 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0096_R 51 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [67] 52 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [69(v)] 53 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [72]; Handmer T3123:2–T3123:16 54 Caughey T1699:12–T1699:17 55 Venters T4652:1–T4652:20 56 Exhibit 83 – Joint CFA/DSE Review (SUMM.022.002.0297) at 0310–0311 57 Rees T2373:10–T2373:27 58 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [214] 59 Waller T116:24–T116:26; see also Waller T143:14–T143:26 60 State of Victoria (SUBM.100.005.0001) [48] 61 Stayner T1817:12–T1818:2 62 State of Victoria (SUBM.100.005.0001) [50] 63 Handmer T3098:19–T3099:18 64 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [76] 65 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [78] 66 Handmer T3122:26–T3123:1 67 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [74], [77]; Handmer T3123:24–T3124:2 68 Exhibit 58 – Statement of Stayner (WIT.033.001.0001) [94]–[96]; Stayner T1824:21–T1824:28 69 M Williams T757:10–T757:22 The Victorian Bushfire Information Line

70 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [10] 71 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [23], [25] 72 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [9] 73 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [12] 74 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [23]–[25] 75 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [28] 76 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [29] 77 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [13]; Exhibit 6 – Statement of Waller (WIT.002.002.0001) [107]–[108]; Exhibit 11 – Debrief Outcomes Significant Victorian Fires December 2005 and January 2006 (TEN.002.001.0002) at 0024 78 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [14]; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [159] 79 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [82] 80 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [16] 81 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [54] 82 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [55] 83 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [81] 84 Exhibit 137 – Statement of Venters, Attachment 1 (DSE.USB9.0055.0001) 85 Exhibit 137 – Statement of Venters, Attachment 1 (DSE.USB9.0055.0001) at 0014 86 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [17], [20] 87 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [4]–[8] 88 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [9] 89 Exhibit 147 – Statement of Hogg, Attachment A (WIT.6000.001.0015) 90 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [108]; Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [17]; Attachment A (WIT.6000.001.0015) at 0037–0038 91 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [10]; Attachment A (WIT.6000.001.0015) at 0034; Venters T4614:24–T4615:3; Hogg T4705:23–T4705:31 92 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [10]; Statement of Hogg, Attachment A (WIT.6000.001.0015) at 0034–0038; Venters T4618:5–T4618:9 93 Venters T4617:29–T4618:11; Venters T4649:20–T4650:1 94 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [53]

326 Endnotes

95 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [73] 96 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [107], [113]; Annexure 8 (WIT.3024.002.0035) at 0036; Venters T4602:13–T4602:25 97 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [113]; Venters T4602:13–T4602:25; Venters T4604:27–T4605:4 98 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [107]; Venters T4601:24–T4601:26; Venters T4662:10–T4662:22 99 Venters T4662:23–T4662:31 100 Exhibit 137 – Statement of Venters (WIT.3024.002.0001); Venters T4608:3–T4608:23 101 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [52]; Venters T4601:2–T4601:4; Venters T4656:28–T4657:2 102 Venters T4608:9–T4608:12; Venters T4608:24–T4609:17 103 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [49] 104 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [58]–[61]; Attachment 1 (DSE.USB9.0055.0001) 105 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [15], [74]; Tender (DSE.HDD.0016.0722), (DSE.HDD.0016.0738), (DSE.HDD.0016.0762), (DSE.HDD.0016.0560), (DSE.HDD.0016.0627), (DSE.HDD.0016.0690), (DSE.HDD.0016.0698); Exhibit 11 – Debrief Outcomes Significant Victorian Fires December 2005 and January 2006 (TEN.002.001.0002) at 0024; Exhibit 6 – Statement of Waller (WIT.002.002.0001) [109] 106 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [110]; Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [34], [86]–[88]; Venters T4623:21–T4623:30 107 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [75]; Attachment 9 (WIT.3024.002.0038) 108 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [74], [78] 109 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [75], [77] 110 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [78]–[79] 111 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [80], [93]; Venters T4597:28–T4598:5; Exhibit 138 – Statement of Millington (WIT.3024.002.0081) [15] 112 Exhibit 138 – Statement of Millington (WIT.3024.002.0081) [16]–[17]; Annexure 2 (WIT.3024.002.0091); Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [70]; Venters T4635:19–T4637:10; Millington T4675:9–T4678:29 113 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [66] 114 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [67.2] 115 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [68] 116 Exhibit 138 – Statement of Millington, Attachment 1 (WIT.3024.002.0088); Exhibit 147 – Statement of Hogg, Attachment A (WIT.6000.001.0015) 117 Exhibit 137 – Statement of Venters, Attachment 7 (WIT.3024.002.0033); Hogg T4704:12–T4705:6 118 Venters T4612:4–T4612:7; Venters T4612:23–T4613:8; Hogg T4704:12–T4704:15 119 Exhibit 138 – Statement of Millington (WIT.3024.002.0081) [11]; Attachment 1 (WIT.3024.002.0088) 120 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [67.2], [69] 121 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [70]; Attachment 6 (DSE.HDD.0013.2054); Venters T4600:23–T4601:1; Venters T4606:29–T4607:5; Venters T4671:10–T4671:17 122 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [22] 123 Exhibit 138 – Statement of Millington, Annexure 2 (WIT.3024.002.0091) 124 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [26]–[27]; Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [114] 125 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [28] 126 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [29] 127 Millington T4686:26–T4687:3 128 Hogg T4706:29–T4707:3 129 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [18]; Hogg T4701:29–T4702:12 130 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [108], [116]; Venters T4610:18–T4610:21, T4611:26–T4611:27 131 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [29]–[34] 132 Venters T4667:21–T4667:24 133 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [34]; Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [116] 134 Hogg T4701:29–T4702:18; Hogg T4723:16–T4723:26 135 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [88]–[89] 136 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [92] 137 Findings drawn from chart contents, Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [133]–[136]; Tender (INF.007.001.0010) and Venters T4624:12–T4627:2 138 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0096 139 Exhibit 100 – Statement of Caughey, Tender (DSE.HDD.0017.0117), (DSE.HDD.0017.0470), (DSE.HDD.0017.0648) (DSE.HDD.0017.0649), (DSE.HDD.0017.0651) 140 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0143) 141 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0098 142 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0062)

327 2009 Victorian Bushfires Royal Commission—Interim Report

143 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0072) 144 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0100 145 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0070) 146 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0077) 147 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0102 148 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0016.0222) 149 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0016.0244) 150 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0104 151 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0091), (DSE.HDD.0017.0732) 152 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0109) 153 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [331] 154 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0130), (DSE.HDD.0017.0415) 155 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0153), (DSE.HDD.0017.0404) 156 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0162) 157 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0106 158 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0124), (DSE.HDD.0017.0672) 159 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0134), (DSE.HDD.0017.0729) 160 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0154) 161 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0110 162 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0249) 163 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0305) 164 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0321), (DSE.HDD.0017.0491) 165 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0108 166 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0163), (DSE.HDD.0017.0654) 167 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0328) 168 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [139] 169 Exhibit 6 – Statement of Waller (WIT.002.002.0001) [359] 170 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0265), (DSE.HDD.0017.0396) 171 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0017.0278) 172 See endnotes 138 – 171 above 173 Exhibit 138 – Statement of Millington, Annexure 2 (WIT.3024.002.0091) at 0093; Millington T4676:14–T4677:27 174 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [136] 175 Venters T4625:18–T4625:20 176 Note: the figure of 12,819 calls given in Venters statement does not appear to include the 27 calls that elected to use the after-hours automated system. Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [117]; Annexure 17 (DSE.HDD.0016.0118) at 0118 177 Exhibit 137 – Statement of Venters, Annexure 17 (DSE.HDD.0016.0118); Venters T4599:27–T4600:7; Venters T4628:20–T4628:21 178 Exhibit 137 – Statement of Venters, Annexure 17 (DSE.HDD.0016.0118) 179 Exhibit 137 – Statement of Venters, Annexure 17 (DSE.HDD.0016.0118) 180 Exhibit 137 – Statement of Venters, Annexure 17 (DSE.HDD.0016.0118) at 0118 181 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [129]; Venters Tender (DSE.HDD.0016.0136); Venters T4645:1–T4646:7 182 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [104]; Hogg T4696:15–T4696:29 183 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [53(a)]; Hogg T4710:24–T4710:31 184 Exhibit 137 – Statement of Venters, Annexure 14 (WIT.3024.002.0046); Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [48], [51] 185 Exhibit 137 – Statement of Venters, Annexure 17 (DSE.HDD.0016.0118); Venters T4645:25–T4645:27 186 Hogg T4697:30–T4698:17 187 Exhibit 147 – Statement of Hogg, Attachment G (WIT.6000.001.0349) at 0350 188 Exhibit 147 – Statement of Hogg (WIT.6000.001.0001) [40] 189 Exhibit 147 – Statement of Hogg, Attachment I (WIT.6000.001.0354) at 0356; Hogg T4709:28–T4710:1; Venters T4672:16–T4672:20 190 Exhibit 147 – Statement of Hogg, Attachment A (WIT.6000.001.0015) at 0036 191 Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [102]–[103] 192 Exhibit 137 – Statement of Venters, Tender (DSE.HDD.0016.0001_I_01_R) 193 Venters T4635:19–T4640:28 194 Venters T4641:1–T4641:8 195 Exhibit 29 – Statement of Ferguson (WIT.022.001.0001_R) [20]; Ferguson T932:22–T933:11 196 Exhibit 23 – Statement of Davey (WIT.019.001.0001_R) [20]; Davey T782:10–T782:26

328 Endnotes

197 Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [8]; Fraser T3048:22–T3049:10 198 See for example call logged to VBIL at 10:16:23 pm and 10:17:18 pm from caller in metropolitan Melbourne in relation to plans for a barbeque the following day: Exhibit 137 – Statement of Venters (WIT.3024.002.0001) [73]; Statement of Venters, Tender (DSE.HDD.0016.0001_I_01_R) at 0001_I_68_R; Venters T4641:22–T4642:6 199 Exhibit 83 – Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media during Fire Incidents (SUMM.022.002.0297) at 0308–0309 200 Exhibit 137 – Statement of Venters, Tender (WIT.3024.002.0051); Venters T4627:14–T4627:17; Venters T4643:6–T4644:18 201 Submissions of the State of Victoria (SUBM.100.005.0001) [157] 202 Submissions of the State of Victoria (SUBM.100.005.0001) [159] 203 Submissions of the State of Victoria (SUBM.100.005.0001) [157] 204 Submissions of the Commonwealth of Australia (SUBM.100.007.0002) [96]

6 RELOCATION INtroduction

1 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [13]; Munns T1374:12–T1374:19. See also Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [275]; Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [34] 2 Exhibit 16 – Statement of Haynes (WIT.001.001.0001) [25(ii)] 3 Exhibit 49 – Statement of P O’Halloran, Attachment 1 (WIT.3010.001.0007) at 0007. The circumstances in which each person died will be the subject of more detailed investigation in future hearings. 4 Exhibit 49 – Statement of P O’Halloran, Attachment 1 (WIT.3010.001.0007) at 0007. Of the 173 people whose deaths were attributed to the fires on 7 February 2009, 113 were found in houses. the Terminology of evacuation

5 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) 6 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0184 7 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0184 8 AFAC (SUBM.100.002.0001) [28] 9 State of Victoria (SUBM.100.005.0001) [69] 10 AFAC (SUBM.100.002.0001) [28] Legislative and policy framework

11 Emergency Management Act 1986, s. 24 12 A State of Disaster can be declared under s. 23 of the Emergency Management Act 1986. A State of Disaster was not declared on 7 February. Power to compel evacuation can be found under s. 24(2)(e) of the Emergency Management Act 1986. 13 Emergency Management Act 1986, s. 24(7) 14 Emergency Management Act 1986, s. 36B(1)(c) 15 Emergency Management Act 1986, s. 36B(2). There is no evidence that police made any declaration of an emergency area on 7 February. 16 The SERP is Part 3 of the Manual; see Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0184. The provisions of the SERP that relate to evacuation are discussed in Chapter 10. 17 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0184 18 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0176 19 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0442–0443 20 Exhibit 66 – Statement of Collins, Attachment 1 (WIT.3010.001.0025) at 0036 21 Exhibit 101 – Statement of Rhodes, Attachments (WIT.3004.003.0049); Attachment (WIT.3004.002.0864) 22 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [85]; Attachment (WIT.3004.003.0049) at 0049 23 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0049) 24 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [87]–[88] 25 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.002.0864) 26 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.002.0864) at 0867 27 Exhibit 3 – Statement of Rees, Annexure 6 (WIT.004.001.0238) at 0241 28 Exhibit 3 – Statement of Rees, Annexure 6 (WIT.004.001.0238) at 0240 ARGUMENTS AGAINST COMPULSORY EVACUATION

29 State of Victoria (SUBM.100.005.0001) [71(f)]; Esplin T377:12–T377:24; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [292(c)]; Rhodes T3326:1–T3326:4; Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [38]; McCaffrey T3455:16–T3455:29 30 Exhibit 102 – Rhodes Tender, Hazard Warning Systems: Review of 20 Years of Progress (TEN.036.001.0001) at 0003

329 2009 Victorian Bushfires Royal Commission—Interim Report

31 Esplin T381:30–T383:4; Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [36]–[37]; McCaffrey T3453:14–T3453:28; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [290]; Rhodes T3363:18–T3364:9; Nicholson T4492:14–T4492:27; State of Victoria (SUBM.100.005.0001) [71(e)–(f)] 32 McCaffrey T3453:14–T3453:21 33 Exhibit 120 – Evacuation in Wildfires: The Australian Experience (TEN.038.001.0010) at 0011; Volunteer Fire Brigades Inc (SUBM.100.004.0001) [104] 34 Ferguson T955:17–T955:21; Olorenshaw T1901:20–T1901:27; Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [36]; O’Neill T3211:26–T3212:16; P Brown T3547:31–T3548:3 35 Olorenshaw T1901:20–T1901:27 36 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [292(g)]; Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [38]; Exhibit 133 – Statement of Nicholson, Attachment 11 (WIT.056.001.0286) at 0289 37 Ferguson T955:17–T955:21; O’Neill T3212:8–T3212:14 38 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [290], [292(f)]; Volunteer Fire Brigades Inc (SUBM.100.004.0001) [99]–[102] 39 Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [36] 40 Esplin T535:1–T535:5; T545:10–T546:6; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [290], [292(a)]; Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [35]; State of Victoria (SUBM.100.005.0001) [71(d)] 41 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) at 0049 RELOCATION ON 7 fEBRUARY

42 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509), for example awareness message for Saunders Rd, Kilmore East Fire at 0515, awareness message for Bunyip Ridge Fire at 0520 43 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509), for example awareness message for Camperdown–Danedite Road Fire at 0532 44 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509), for example alert message for Bunyip Ridge Fire at 0544 45 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509), for example urgent threat message for Murrindindi Mill Fire at 0567–0568 46 Exhibit 7 – 774 ABC Radio Transcript (SUMM.001.002.0001) at 0012, 0049, 0072, 0122, 0186 47 Exhibit 7 – 774 ABC Radio Transcript (SUMM.001.002.0001) at 0138 48 Exhibit 7 – 774 ABC Radio Transcript (SUMM.001.002.0001) at 0155 49 See Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) at 0528, urgent threat message, Churchill–Glendonald Road Fire for communities of Hazelwood South, Jeeralang, Jeeralang North, Jeeralang Junction 50 Exhibit 7 – 774 ABC Radio Transcript (SUMM.001.002.0001) at 0232 51 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) at 0546, urgent threat message, Kilmore East Fire, for communities of Hidden Valley, Wandong, Heathcote Junction and Upper Plenty 52 Exhibit 7 – 774 ABC Radio Transcript (SUMM.001.002.0001) at 0296 53 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) 54 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) 55 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0104 56 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0104 57 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0105 58 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0105 59 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [6]–[7]; Odgers T190:8–T190:12; Odgers T190:26–T190:29 60 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [30] 61 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [32] 62 Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [10]; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [6]; Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [7]; Exhibit 103 – Statement of Barber (WIT.046.001.0001_R) [12]; Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [7]; Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [9] 63 Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [11]–[12], [24] 64 D O’Halloran T3681:22–T3682:25; T3717:15–T3718:25 65 D O’Halloran T3682:9–T3682:10; T3717:31–T3718:1 66 Hainsworth T4533:19–T4533:22 67 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [124] 68 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [131]–[132]; Walshe T657:25–T658:5 69 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [138]–[139]; Walshe T658:23–T659:9 70 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [140]–[142]; Walshe T659:10–T660:10 71 Exhibit 61 – Statement of Olorenshaw (WIT.034.001.0001_R) [23]–[28]; Olorenshaw T1877:1–T1879:6 72 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [134]–[137]; Walshe T658:6–T658:22 73 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [40]–[50]; Dwight T2067:19–T2072:22 74 Dwight T2068:10–T2068:22

330 Endnotes

75 Exhibit 39 – Statement of Hull (WIT.030.001.0001_R) [14]. Mr Hull took shelter in the lake next to the oval during the passage of the firefront. 76 Exhibit 39 – Statement of Hull (WIT.030.001.0001_R) [15] 77 Dwight T2076:23–T2077:3 78 Dwight T2077:6–T2077:11 79 Walshe T660:10–T660:31 80 Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [30]; Scott T2927:6–T2927:12 81 Compare Exhibit 70 – Statement of Casey (WIT.035.001.0001_R) [7] with Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [9]–[10], [13(2)]; Kane T1057:2–T1057:8 82 Exhibit 28 – Statement of Sigmund (WIT.020.001.0001); Sigmund T893:4–T909:31 protocols for RECOMMENDING timely RELOCATION

83 Waller T109:11–T110:11; Rees T2505:13–T2507:2; Exhibit 22 – Statement of M Williams, Annexure 1 (WIT.013.001.0012) at 0073 84 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [35]; Barca T3471:2–T3471:14; Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [32]; Munns T1356:4–T1357:9; Exhibit 115 – Statement of Cowan (WIT.3004.009.0001) [17] 85 Willans T3035:15–T3036:8 86 Exhibit 66 – Collins Tender (SERO Log) (TEN.020.003.0001) at 0003; Collins T2175:16–T2176:14 87 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [359]–[360]. For further detail on the impact of the wind change, see Chapter 1. 88 See for example Exhibit 42 – Statement of Kreltszheim (WIT.3004.001.0032) [21]–[22]; Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [16], [20], [25]; Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [27]–[22], [33]–[36] 89 Exhibit 42 – Statement of Kreltszheim (WIT.3004.001.0032) [22], [26], [29]; Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [16]–[20]; Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [34] 90 AFAC (SUBM.100.002.0001) [26] 91 See paragraph 6.50 92 State of Victoria (SUBM.100.005.0001) [71(c)] 93 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [6]; Odgers T193:24; Exhibit 39 – Statement of Hull (WIT.030.001.0001_R) [24]; Exhibit 70 – Statement of Casey (WIT.035.001.0001_R) [8]; Casey T2358:5–T3259:13; Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [18]; McCulloch T2451:14–T2452:1; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [22]; Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [18]; Scott T2925:31–T2926:18; Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [22]; D O’Halloran T3690:9–T3690:13; Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [30]; Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [32]; Hainsworth T4540:14 94 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [14]; Gobbett T1500:2–T1500:7; Exhibit 61 – Statement of Olorenshaw (WIT.034.001.0001_R) [109]; Olorenshaw T1898:20–T1898:29; Exhibit 108 – Statement of P Brown (WIT.053.001.0001_R) [40]; P Brown T3525:15–T3525:30 (WIT.034.001.0001_R) [109]; Olorenshaw T1898:20–T1898:29; Exhibit 108 – Statement of P Brown (WIT.053.001.0001_R) [40]; P Brown T3525:15–T3525:30 95 Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [33]; Attachment F (WIT.038.001.0132) at 0135; McCaffrey T3424:3–T3425:5 96 Exhibit 106 – Statement of McCaffrey (WIT.038.001.0001) [33]; McCaffrey T3425:8–T3425:15 97 Details of the State’s proposal is at State of Victoria (RESP.3000.001.0001) [15]–[20] 98 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0315–0317

7 Stay or Go The CURRENT ‘STAY OR GO’ POLICY AS APPLIED IN VICTORIA

1 Exhibit 49 – Statement of P O’Halloran (WIT.3010.001.0001); Attachment 1 (WIT.3010.001.0007) 2 Esplin T376:5–T376:6; State of Victoria (SUBM.100.005.0001) [72] 3 Exhibit 3 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) 4 Exhibit 3 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0030 5 Exhibit 84 – Statement of N Brown (WIT.023.002.0001) [27]–[30] 6 N Brown T2705:21–T2706:11 7 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [83] 8 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0032 9 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0032 10 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0032–0033 11 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0033 12 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0033 13 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [6]–[7]; Gobbett T1498:8–T1498:29; Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [5]–[6]; D Brown T1645:13–T1645:26; Exhibit 61 – Statement of Olorenshaw (WIT.034.001.0001_R) [50]–[88]; Olorenshaw T1884:25–T1890:30 14 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [30] 15 Exhibit 101 – Statement of Rhodes, Annexure B (WIT.3004.002.0110)

331 2009 Victorian Bushfires Royal Commission—Interim Report

16 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0035 17 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [81] 18 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [91]; Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [13]–[19] 19 The quoted catchphrase comes from Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0232) at 0233 20 See for example, Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0147) at 0152 21 Exhibit 9 (TEN.001.001.0102) at 0102 22 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0147); Exhibit 9 (TEN.001.001.0102) 23 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0154) 24 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0130); Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0136–0137 25 Exhibit 9 (TEN.001.001.0102) at 0106 and 0108. In Mount Macedon, where the fires had destroyed 234 of 455 houses and killed 6 people, 89 per cent of attended houses survived whereas only 44 per cent of unattended houses survived (of which one-third were assisted by neighbours, brigades or returning occupants). The Otway Ranges study also concluded that the presence of occupants and their firefighting activities (extinguishing small ignitions before fires became uncontrollable) significantly reduced the relative risk of house destruction (Ramsay, McArthur & Darling). See also Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0137 26 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0147) at 0150–0151 27 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0147) at 0152 28 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0154) at 0160 29 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0136 30 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0015 31 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0216–0217 32 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0219 33 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0176 34 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0219 35 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0219 36 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0040 37 Exhibit 49 – Statement of P O’Halloran, Attachment 1 (WIT.3010.001.0007) 38 Gledhill T2739:6–T2739:14 39 Esplin T376:5–T376:6; State of Victoria (SUBM.100.005.0001) [72] 40 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [247] 41 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0019–0050 42 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0201) 43 Exhibit 16 – Statement of Haynes (WIT.001.001.0001) at 0009 44 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0040 45 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0021; Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0147) at 0152 46 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0026–0027 47 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) [12]–[16]; Haynes T435:23–T439:6 48 Exhibit 9 – (TEN.001.001.0110) at 0119 49 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0042–0043 50 Exhibit 16 – Statement of Haynes (WIT.001.001.0001) [21]; Attachment B (WIT.001.001.0001) at 0043 51 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0046 52 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0046 53 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0042 54 Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0046 55 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [88] 56 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [86]–[88] 57 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0098) at 0122 58 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.002.0685) at 0732–0733 59 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.002.0685) at 0732–0733 60 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [185]–[211] 61 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [29], [81] 62 Exhibit 85 – Statement of Gledhill, Attachment 9 (WIT.025.002.0107) at 0126–0129 63 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.003.0098) at 0123–0124. See also Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [129]–[157]

332 Endnotes

COMMUNITY IMPLEMEnTATION OF THE stay or go policy

64 Exhibit 69 – Statement of Paton (WIT.031.001.0001) [18]–[19]. See also Exhibit 11 – Statement of Esplin, Attachment 28 (WIT.005.001.1949) 65 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [52]–-[54] 66 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [68] 67 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0086 68 For example, Exhibit 29 – Statement of Ferguson (WIT.022.001.0001_R) [7]–[8], [31]; Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [8(d)], [10]–[11], [14] 69 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [61] 70 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [7]–[11]; D Brown T1645:16–T1645:26; Exhibit 61 – Statement of Olorenshaw (WIT.034.001.0001_R) [51]; Olorenshaw T1884:25–T1891:27 71 Hull T1166:8–T1166:11 72 Gobbett T1500:10–T1500:12 73 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [47] 74 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [194] 75 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0086 76 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0091 77 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0091 78 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0092 79 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [7]–[8]; Gobbett T1498:12–T1498:29 80 Fraser T3054:15–T3056:27 81 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0197–0198 82 Exhibit 103 – Statement of Alice Barber (WIT.046.001.0001_R) [19]–[20]; Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [3] 83 Fraser T3054:17–T3056:24 84 The Commission acknowledges the evidence of Mrs Joan Davey in relation to the fire plan of her son, Robert Davey, and his wife Natasha. See Exhibit 23 – Statement of Davey (WIT.019.001.0001_R) 85 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0098, 0106 86 Exhibit 9 – (TEN.001.001.0077) at 0082 87 Exhibit 9 – (TEN.001.001.0004) 88 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [39]; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [68] 89 Exhibit 9 – (TEN.001.001.0004) at 0034, 0036 90 Esplin T564:19–T565:6 91 Esplin T575:6–T575:26; T584:12–T584:21 92 See for example Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) 93 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [166]–[167]; Rees T32:1–T32:14 94 Exhibit 9 – (TEN.001.001.0110) at 0119; Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0023, 0028 95 See for example Davey T787:23-T787:27; Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [11]; Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [8]; Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [42]–[43]; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [25]; Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [30] 96 Paton T2314:5–T2314:24 97 Exhibit 85 – Statement of Gledhill, Attachment 1 (WIT.025.002.0027) at 0034 98 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [13(3)]; Kane T1053:26–T1055:3; Exhibit 16 – Statement of Haynes, Attachment B (WIT.001.001.0001) at 0046 99 Exhibit 9 – (TEN.001.001.0004) at 0013 100 Exhibit 49 – Statement of P O’Halloran, Attachment 1 (WIT.3010.001.0007) 101 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R); Exhibit 23 – Statement of Davey (WIT.019.001.0001_R); Exhibit 116 – Statement of Matthews (WIT.057.001.0001_R); Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) 102 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [6]; Exhibit 70 – Statement of Casey (WIT.035.001.0001_R) [13] 103 See the discussion between Commissioner McLeod and Mr Esplin at T571:29–T576:27 104 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [75]; Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [36] 105 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [122]–[132]; Exhibit 69 – Statement of Paton (WIT.031.001.0001) [17]–[20]; Paton T2315:13–T2315:19 106 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [124]; Exhibit 84 – Statement of N Brown (WIT.023.002.0001) [38] 107 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [119]–[127]; Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0092 108 Exhibit 96 – Statement of Handmer (WIT.044.001.0002_R) [119], [125]–[126]; Exhibit 84 – Statement of N Brown (WIT.023.002.0001) [32]; Exhibit 90 – Statement of Edwards, Annexure 9 (WIT.039.001.0087) at 0095 109 Exhibit 9 – (TEN.001.001.0044) at 0045

333 2009 Victorian Bushfires Royal Commission—Interim Report

110 Exhibit 9 – (TEN.001.001.0004) at 0033 111 Exhibit 135 – Tolhurst Expert Report (Defendable Space) (EXP.003.005.0001); Tolhurst T4551:5–T4551:23 112 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [250] 113 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [61]–[64] 114 See for example, Exhibit 9 – (TEN.001.001.0053), which discusses the factors that go towards determining a house’s defendability. 115 Exhibit 9 – (TEN.001.001.0044) at 0046 116 Exhibit 9 – (TEN.001.001.0044) at 0047 117 Tolhurst T4551:5–T4551:23; T4572:11–T4572:26 118 Esplin T378:20–T378:22 119 Gledhill T2716:16–T2716:27 120 Tolhurst T4581:21–T4582:23; T4588:31–T4589:24 121 State of Victoria (SUBM.100.005.0001) [73(b)(ii)] 122 State of Victoria (SUBM.100.005.0001) [78] 123 Rees T1910:22–T1911:2 124 Exhibit 23 – Statement of Davey (WIT.019.001.0001_R) 125 Rhodes T3304:31–T3305:6 126 Paton T2312:12–T2312:29; Exhibit 9 – (TEN.001.001.0004) at 0013 127 Exhibit 9 – (TEN.001.001.0004) at 0013; Rhodes T3309:23–T3310:11 128 Exhibit 85 – Statement of Gledhill, Attachment 9 (WIT.025.002.0107) 129 Exhibit 9 – (TEN.001.001.0004) at 0032 130 Exhibit 9 – (TEN.001.001.0183) at 0194 131 Exhibit 85 – Statement of Gledhill, Attachment 9 (WIT.025.002.0107) at 0125 132 Rhodes T3314:1–T3314:6 133 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [254] 134 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0091 135 Exhibit 46 – Statement of Gobbett (WIT.026.001.0001_R) [2]–[3]; Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [38]–[41]; Exhibit 17 – Statement of Spooner (WIT.011.001.0001_R) [13]–[16]; Spooner T498:16–T498:24; Rogers T605:8–T605:12; Glassford T1345:13–T1345:21; O’Neill T3196:29–T3197:17; P Brown T3530:17–T3531:2;Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [9], [14]; Hainsworth T4533:11–T4533:22 136 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [203] THEMES IN THE EVIDENCE on Stay or Go

137 Australasian Fire and Emergency Service Authorities Council (SUBM.100.002.0001) [28] 138 Exhibit 9 – (TEN.001.001.0238) at 0244 139 Exhibit 9 – (TEN.001.001.0044) at 0046–0047 140 Exhibit 101 – Statement of Rhodes, Attachment (WIT.3004.004.0192) at 0211

8 risk and Refuge IDENTIFYING bushfire risk

1 State of Victoria (SUBM.100.005.0001) [85]–[87]; (RESP.3000.001.0001) [7]–[14] 2 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0246–0334 3 Exhibit 124 – Statement of Spence, Attachment 4 (WIT.4000.001.0088); Attachment 8 (WIT.4000.001.0340) 4 Exhibit 124 – Statement of Spence, Attachment 4 (WIT.4000.001.0088) at 0101, 0119–0121; Attachment 8 (WIT.4000.001.0340) at 0364, 0621–0627 5 Exhibit 133 – Statement of Nicholson, Attachment 10 (WIT.056.001.0280) at 0280 6 Exhibit 133 – Statement of Nicholson, Attachment 10 (WIT.056.001.0280) at 0281–0282; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [57] 7 Exhibit 27 CFA publication “Building in a Wildfire: Management Overlay. Applicant’s Kit 2007 (TEN.008.001.0007) 8 Building Code of Australia, 2009, Volume 1, Part G5; Volume 2, Part 3.7.4 9 Exhibit 133 – Statement of Nicholson, Attachment 9 (WIT.056.001.0167) 10 Building Regulations 2006, reg 804 (repealed 11 March 2009) 11 Building Regulations 2006, reg 114 12 Exhibit 92 – Statement of Free (WIT.049.001.0001) [26]–[48] 13 Esplin T319:5–T319:24; Exhibit 92 – Statement of Free (WIT.049.001.0001) [16]–[17] 14 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1196

334 Endnotes

15 Esplin T319:27–T319:31 16 Exhibit 92 – Statement of Free (WIT.049.001.0001) [92]; Annexure 4 (WIT.049.001.0045) 17 Exhibit 92 – Free Tender (TEN.029.001.0001); Free T2987:18–T2987:25 18 Exhibit 92 – Statement of Free (WIT.049.001.0001) [18]–[25], [52]–[56], [63]–[92] 19 Esplin T319:16–T319:21; T320:13–T320:17; Free T3001:20–T3002:13 20 Exhibit 92 – Statement of Free (WIT.049.001.0001) [99]; Annexure 4 (WIT.049.001.0045) at 0053 21 Free T3012:15–T3015:8; T3016:14–T3016:20 22 Exhibit 146 – Victorian Fire Risk Register - Supports and Informs Your Plan - Handout - Version 2 (CFA.001.019.0051) at 0052 23 Exhibit 146 – Victorian Fire Risk Register - Supports and Informs Your Plan - Handout - Version 2 (CFA.001.019.0249) at 0249–0252 24 Free T3012:15–T3013:22; T3016:14–T3017:16 25 State of Victoria (SUBM.100.005.0001) [85]–[87]; (RESP.3000.001.0001) [7]–[14] 26 State of Victoria (RESP.3000.001.0001) [11]. 27 State of Victoria (SUBM.100.005.0001) [83]–[88]; (RESP.3000.001.0001) [7]–[20]. See also Exhibit 156 – Business Case for Safety Preparedness (CFA.001.020.0044) at 0083–0085 Fire refuges AND SAFER PLACES

28 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) 29 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0583 30 Spence T4115:2–T4115:5 31 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0574; Spence T4113:6–T4113:10 32 See generally Rhodes T3370:25–T3375:19 33 Exhibit 141 – Tender (TEN.048.001.0001) 34 Exhibit 141 – Tender (TEN.048.001.0001) at 0088 35 Exhibit 141 – Tender (TEN.048.001.0001) at 0089 36 Exhibit 141 – Tender (TEN.048.001.0001) at 0143–0144 37 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0576 38 Exhibit 133 – Statement of Nicholson, Attachment 6 (WIT.056.001.0047) 39 Exhibit 133 – Statement of Nicholson, Attachment 6 (WIT.056.001.0047) at 0048 40 Exhibit 133 – Statement of Nicholson, Attachment 6 (WIT.056.001.0047) at 0050–0051 41 Exhibit 124 – Statement of Spence, Attachment 1 (WIT.4000.001.0008) 42 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0576 43 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0074 44 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0074 45 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) 46 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0060–0061 47 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0061 48 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0081 49 Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0060–0062 50 Esplin T386:9–T386:20; T387:13–T387:27; Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [15] 51 Exhibit 104 – Rhodes tender (EXH.104.0001) 52 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [300]; Rhodes Attachment (WIT.3004.004.0686); Rhodes T3373:8–T3373:13 53 Free T2999:19–T2999:22 54 Relevant extracts of this report are at Exhibit 9 (TEN.001.001.0180), (TEN.001.001.0181), (TEN.001.001.0183) 55 Exhibit 9 – Tender (TEN.001.001.0183) at 0198 56 Exhibit 9 – Tender (TEN.001.001.0183) at 0198 57 Exhibit 9 – Tender (TEN.001.001.0183) at 0199 58 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) 59 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0583 60 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0587–0588 61 Exhibit 9 – Tender (TEN.001.001.0269) at 0270; Spence T4153:24–T4154:13 62 Exhibit 124 – Statement of Spence, Attachment 5 (WIT.4000.001.0272) 63 Exhibit 124 – Statement of Spence, Attachment 9 (WIT.4000.001.0629) 64 Exhibit 124 – Statement of Spence, Attachment 9 (WIT.4000.001.0629) at 0645

335 2009 Victorian Bushfires Royal Commission—Interim Report

65 Exhibit 124 – Spence Tender (EXH.124.0007) at 0007–0008 66 Spence T4156:2–T4156:20 67 Spence T4156:20–T4156:24 68 Exhibit 124 – Statement of Spence, Attachment 7 (WIT.4000.001.0325); Spence T4150:17–T4150:20 69 Exhibit 124 – Spence Tender (TEN.047.001.0009); (TEN.047.001.0010); (TEN.047.001.0011); Spence T4155:4–T4158:13, T4175:29–T4177:24 70 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R); Exhibit 88 – Statement of Seear (WIT.042.001.0001) 71 Spence T4120:9–T4120:19 72 For example, Exhibit 39 – Statement of Hull (WIT.030.001.0001_R); Exhibit 17 – Statement of Spooner, Attachment 1 (WIT.011.001.0005) 73 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) 74 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0109 75 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0110 76 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [14]–[20]; Attachment 2 (WIT.037.001.0018); Dwight T2060:9–T2061:23 77 Spence T4164:3–T4167:19 78 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [19] 79 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [14] 80 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [17]–[18] 81 Exhibit 64 – Statement of Dwight, Attachment 3 (WIT.037.001.0023) at 0051–0054 82 Exhibit 64 – Statement of Dwight, Attachment 2 (WIT.037.001.0018) 83 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [20] 84 Seear T2790:23–T2790:31 85 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [18]–[19], [24] 86 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [25], [28]–[30] 87 Exhibit 88 – Statement of Seear (WIT.042.001.0001); Seear T2788:18–T2789:3 88 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [20]–[25]; Attachment 3 (WIT.042.001.0024) 89 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [33]–[46] 90 Exhibit 88 – Statement of Seear (WIT.042.001.0001) [46], [61] 91 Exhibit 13 – Statement of Newman (WIT.009.001.0001_R) [7]; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [9]; Ananiev T2775:27–T2776:11; Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [21]; Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [27]; Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [29]; Hainsworth T4539:23–T4539:24 92 Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [21], [32]; Fraser T3053:21–T3053:26 93 Exhibit 103 – Statement of Barber (WIT.046.001.0001_R) [12]; Exhibit 39 – Statement of Hull (WIT.030.001.0001_R) [10]; Hull T1167:1–T1167:7 94 Exhibit 95 – Statement of Fraser (WIT.048.001.0001_R) [32] 95 Exhibit 39 – Statement of Hull (WIT.030.001.0001_R) [10]; Hull T1166:26–T1166:31 96 Exhibit 64 – Statement of Dwight (WIT.037.001.0001_R) [40]–[42] 97 Exhibit 73 – Statement of McCulloch (WIT.043.001.0001_R) [9], [26] 98 Hendrie T864:7–T865:2 99 Exhibit 17 – Statement of Spooner, Attachment 1 (WIT.011.001.0005) at 0012; Spooner T483:25–T484:14 100 Exhibit 114 – Statement of D O’Halloran (WIT.058.001.0001_R) [23]; D O’Halloran T3719:14–T3719:25 101 D O’Halloran T3720:28–T3720:29 102 D O’Halloran T3720:14–T3720:27 103 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [15] 104 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [19] 105 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [20] 106 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [21(a) and (b)] 107 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [22] 108 Spence T4150:28–T4152:31; T4180:13–T4180:17 109 Exhibit 124 – Spence Tender (TEN.047.001.0001) 110 Exhibit 124 – Spence Tender (EXH.124.0001), (EXH.124.0002), (EXH.124.0005); Spence T4127:6–T4127:13; T4181:30–T4183:1; T4200:25–T4201:24 111 Spence T4201:25–T4202:17 112 Spence T4202:28–T4203:2 113 Spence T4114:11–T4114:18 114 Spence T4131:14–T4131:27

336 Endnotes

115 Spence T4132:13–T4132:22 116 Exhibit 92 – Statement of Free (WIT.049.001.0001) [103]–[107] 117 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) 118 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [297] 119 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [297] 120 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [303] 121 Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [306] 122 Rhodes T3317:22–T3318:11 123 Rhodes T3382:5–T3382:9 124 Exhibit 120 – Packham Tender (TEN.038.001.0003); Packham T3968:30–T3974:4 125 Exhibit 120 – Packham Tender (TEN.038.001.0001) 126 Packham T4001:4–T4002:29; T3994:10–T3994:24; T4024:11–T4024:23; T3995:16–T3995:22 127 Packham T3993:22–T3994:24 128 Packham T4001:4–T4001:8 129 Packham T4001:19–T4001:22 130 Packham T4010:27–T4011:20 131 Packham T3994:10–T3994:28 132 Packham T3997:27–T3997:30 133 Packham T4017:1–T4017:23 134 Packham T4000:30–T4001:3 135 Packham T3993:21–T3993:25 136 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) 137 Nicholson T4475:29–T4482:2 138 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [20] 139 Nicholson T4505:4–T4505:13 140 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [17]–[19] 141 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [41]–[42]; Nicholson T4505:28–T4505:31 142 Exhibit 133 – Statement of Nicholson; Attachment 10 (WIT.056.001.0280); Nicholson T4501:23–T4502:5; T4503:7–T4503:10 143 Nicholson T4504:29–T4504:31 144 Nicholson T4501:15–T4501:22; T4510:21–T4511:1 145 Rees T1930:1–T1930:3; Esplin T376:7 146 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [73]–[74] 147 Exhibit 85 – Statement of Gledhill (WIT.025.002.0001) [74] 148 Lawson T2832:8–T2832:13 149 s. 20 Emergency Management Act 1986; s. 55A Country Fire Authority Act 1958; Spence T4114:6–T4114:24 150 State of Victoria (SUBM.100.005.0001) [162]; Stay or Go Tender – (TEN.001.001.0055) 151 Rhodes T3370:25–T3375:19 152 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [15(a)]; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [295]–[296] 153 Exhibit 11 – Statement of Esplin, Attachment 3 (WIT.005.001.0568) at 0580; Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [15(a)] 154 Exhibit 124 – Statement of Spence (WIT.4000.001.0001) [15]; Exhibit 101 – Statement of Rhodes (WIT.3004.002.0001) [296], [300] 155 Exhibit 101 – Statement of Rhodes (WIT.4000.001.0001) [304]–[306]; Exhibit 124 – Statement of Spence, Attachment 3 (WIT.4000.001.0055) at 0060–0061 156 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [27]–[28]; Nicholson T4502:9–T4502:27 157 Packham T3999:19–T3999:22 158 State of Victoria (SUBM.100.005.0001) [92] 159 State of Victoria (SUBM.100.005.0001) [82] 160 Myers T5038:28–T5038:30 161 State of Victoria (SUBM.100.005.0001) [89] 162 State of Victoria (SUBM.100.005.0001) [80] 163 State of Victoria (SUBM.100.005.0001) [81] 164 Myers T5038:18–T5038:28 165 State of Victoria (SUBM.100.005.0001) [89]–[90] 166 State of Victoria (SUBM.100.005.0001) [83]

337 2009 Victorian Bushfires Royal Commission—Interim Report

167 State of Victoria (SUBM.100.005.0001) [88] 168 State of Victoria (RESP.3000.001.0001); Exhibit 156 (CFA.001.020.0044) 169 Exhibit 156 – Business Case for Community Safety Preparedness Programs 2009–10 (CFA.001.020.0044) at 0052–0054 170 State of Victoria (RESP.3000.001.0001) [14], [19] 171 State of Victoria (RESP.3000.001.0001) [16] 172 Exhibit 156 – (CFA.001.020.0044) at 0084 173 State of Victoria (RESP.3000.001.0001) [6] 174 State of Victoria (RESP.3000.001.0001) [15] 175 State of Victoria (RESP.3000.001.0001) [19]; Exhibit 156 – (CFA.001.020.0044) at 0085 176 State of Victoria (SUBM.100.005.0001) [90(a)] 177 State of Victoria (SUBM.100.005.0001) [84] 178 State of Victoria (RESP.3000.001.0001) [18]–[19] 179 State of Victoria (SUBM.100.005.0001) [92] Schools and THE SAFETY OF CHILDREN

180 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [7]–[11]; Cook T4749:19–T4750:11 181 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [21]–[27] 182 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [91], [93]; Cook T4727:1–T4727:9; Cook T4749:19–T4750:11 183 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [13]–[14], [64]; Rees T1931–T1933 184 Exhibit 133 – Statement of Nicholson (WIT.056.001.0001) [13]–[14]; Attachment 5 (WIT.056.001.0042) at 0044; Rees T1932:26–T1933:11 185 Rees T1933:1–T1933:11 186 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0363 187 Exhibit 148 – Statement of Cook (WIT.3029.001.0001); Cook T4751:5–T4751:14 188 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [33]–[37]; Attachment 3 (WIT.3029.001.0030) at 0033 189 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [38]–[39]; Attachment 4 (WIT.3029.001.0043) 190 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [42]–[46]; Attachment 6 (WIT.3029.001.0111); Attachment 7 (WIT.3029.001.0118) 191 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [41]; Attachment 5 (WIT.3029.001.0108) 192 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [45]–[46] 193 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [47] 194 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [32], [52]–[58]; Cook T4727:17–T4727:23; T4743:11–T4743:26; T4744:25–T4744:26 195 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [64] 196 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [65]–[66], [69]–[74], [76]; Cook T4751:15–T4751:24; T4752:16–T4752:28 197 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [73], [76] 198 Cook T4753:23–T4753:30 199 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [77] 200 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [81]; Attachment 20 (WIT.3029.001.0217); Attachment 21 (WIT.3029.001.0234) 201 Exhibit 148 – Statement of Cook, Attachment 21 (WIT.3029.001.0234) 202 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [82] 203 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [83] 204 Cook T4757:15–T4758:12 205 Cook T4749:12–T4749:16 206 Cook T4739:9–T4739:29 207 State of Victoria (SUBM.100.005.0001) [98] 208 Exhibit 148 – Statement of Cook (WIT.3029.001.0001) [84]–[86]; Cook T4762:3–T4763:2

9 INCIDENT MANAGEMENT: A CASE STUDY Australian inter-service incident management system

1 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [65] 2 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [65] 3 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [71] 4 Pearce T1401:3–T1403:9; Walshe T704:3–T704:25 5 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [67] 6 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [69]

338 Endnotes

7 Individual CFA brigades led by Captains are grouped for administrative purposes into CFA ‘groups’, usually centred on a local area and led by a senior volunteer Group Officer. Captains and Group Officers are elected to their positions by other volunteers. A number of CFA Groups are managed by a CFA Region. 8 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [72] 9 ICS refers to Incident Control System. It is an additional reference to AIIMS that is not used by the Commission and is not used in the AFAC reference text — AFAC, The Australasian Inter-service Incident Management System, Third Edition, East Melbourne, 2005. 10 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [73] 11 Adapted from Exhibit 131 – Mapping Information Flow During Critical Incidents (TEN.033.001.0001) at 0024 12 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [183]; Rees T2427:28–T2427:29 13 Rees T25:13–T25:16 14 Statement of Rees (WIT.004.001.0001) at [127]–[129]; Rees T25:23–T26:17 15 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0082 16 Rees T2415:1–T2415:13 17 Exhibit 81 (TEN.028.001.0001) at 0029 18 Exhibit 141 (TEN.038.001.0001) [141], [154] 19 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [167] 20 Exhibit 9 (TEN.001.001.0183) at 0194 21 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1270 22 Exhibit 76 – Rees Tender (SUMM.036.002.0257) at 0257 23 Exhibit 85 – Statement of Gledhill, Attachment 1 – (WIT.025.002.0027) at 0035 24 Exhibit 137 (SUMM.022.002.0297) at 0298 25 Exhibit 137 (SUMM.022.002.0297) at 0303 26 Exhibit 74 (SUMM.022.069.0086) 27 Exhibit 74 (SUMM.022.069.0086) at 0089 28 Exhibit (SUMM.022.069.0086) at 0115 29 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [167]; Rees T31:23–T32:14 30 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [166] 31 Statement of Rees (WIT.004.001.0001) [183] 32 Exhibit 131 — Mapping Information Flow During Critical Incidents (TEN.033.001.0001) at 0024 33 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0263 34 Exhibit 3 – Statement of Rees (WIT.004.001.0246) at 0263 35 Caughey T1687:5–T1687:25 36 Rees T2420:18–T2420:21 37 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0263 38 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0270 39 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0255 40 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0272–0273 41 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281 42 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281 43 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0272–0273 44 Exhibit 38 – Tolhurst article (SUMM.035.002.0006) at 0007 45 Exhibit 38 – Tolhurst article (SUMM.035.002.0006) at 0008–0009 46 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) 47 Barca T3469:11–T3469:21 48 Exhibit 115 – Statement of Cowan (WIT.3004.009.0001) [2], [4]; Cowan T3726:25–T3726:31 49 Cowan T3727:31–T3728:9 CASE STUDY: KILMORE EAST FIRE

50 Exhibit 4 – Supplementary statement of Rees (WIT.004.002.0001) [14]; Exhibit 2, Rees Tender (WIT.004.002.1459) at 1466 51 Murphy T1262:24; Murphy T1262:20–T1262:23 52 Murphy T1262:26 53 Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [5] 54 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0082 55 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [112]; Rees T2415:5–T2415:27 56 Rees T2415:18–T2415:27

339 2009 Victorian Bushfires Royal Commission—Interim Report

57 Paterson T4261:10–T4261:27 58 Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [28]–[29] 59 Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [23], [25]; Murphy T1263:1–T1263:19 60 Murphy T1264:3–T1264:6 61 Murphy T1264:8–T1264:25 62 Murphy T1265:4–T1266:10 63 Murphy T1266:12–T1266:29 64 Murphy T1267:1–T1267:15 65 Rees T2416:15–T2416:31 66 Paterson T4262:4–T4262:8 67 Rees T2416:22–T2417:3 68 Murphy T1268:8–T1268:16 69 During a discussion with Commissioner McLeod, Mr Rees agreed that these were inadequacies that contributed to the difficulties on the day. See T2430–T2432:9 70 Barca T3466:17–T3467:4 71 Barca T3465:29–T3466:16 72 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [3]–[4]; Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [14] 73 Lawrence T1571:1–T1571:8 74 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [26], [36] 75 Barca T3478:28–T3479:2 76 Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281; see also Exhibit 127 – Statement of Paterson, Attachment 3 (WIT.3004.010.0281) at 0445 77 Lawrence T1570:30–T1571:17 78 Lawrence T1571:13–T1571:15 79 Barca T3463:7–T3463:11; T3464:6–T3464:25 80 Barca T3463:20–T3464:5 81 Barca T3465:4–T3465:25 82 Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1466 83 Paterson T4267:27–T4267:28 84 Paterson T4268:24–T4268:31 85 Paterson T4268:31–T4269:2 86 Keating T3224:3–T3224:15 87 Exhibit 21 (TEN.003.001.0001) at entries 20–21 88 T1280:11–T1280:15 89 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [157]; Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [30] 90 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) 91 Williamson T4435:30–T4437:1 92 McGahy T2247:26–T2248:4 93 Murphy T1269:23–T1269:31 94 Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [22]; Murphy T1261:10–T1261:17 95 Exhibit 2 – Statement of Rees, Attachment (WIT.004.002.1459) at 1466 96 Exhibit 21 – Walshe Tender (TEN.003.001.0001) at 0002 97 Williamson T4438:10–T4438:16; T4440:1–T4440:6 98 Williamson T4440:7–T4440:31 99 Williamson T4441:9–T4441:13 100 Williamson T4441:4–T4441:19 101 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [40] 102 Keating T3226:30–T3227:1 103 Exhibit 98 – Statement of Keating, Attachment (VPO.001.002.0237_002_R) at 0003_R 104 Sholl T4347:14–T4348:24 105 Exhibit 98 – Statement of Keating, Attachment (VPO.001.002.0237_002_R) at 0003_R 106 Exhibit 7 – ABC Radio transcript (SUMM.001.002.0001) at 0245; Keating T3230:14–T3240:19; Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [53]

340 Endnotes

107 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [44]–[48] 108 Exhibit 30 – Google Star Tool as at 13 May 2009 (WIT.010.002.0001) 109 Exhibit 122 – Statement of Sutton (WIT.3024.001.0008) [66] 110 McGahy T2248:27–T2249:5 111 McGahy T2249:10–T2249:27 112 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [56] 113 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [58]–[59] 114 Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [59]; Williamson T4450:6–T4450:19 115 Exhibit 98 – Statement of Keating (VPO.001.002.0237_R) at 0243 116 Cooper T3255:17–T3255:29 117 Cooper T3257:7–T3257:10 118 Cowan T373:1–T3731:2 119 Exhibit 115 – Statement of Cowan (WIT.3004.009.0001) [1], [4] 120 Cowan T3730:18–T3731:18 121 Cowan T3731:22–T3731:28 122 Cowan T3736:19–T3736:28 123 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [33] 124 Barca T3470:18–T3470:25 125 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [35] 126 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [37] 127 Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1466 128 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) at 0212; Lawrence T1588:9–T1588:12 129 Lawrence T1588:18–T1588:19 130 Exhibit 7 – Statement of Barca (WIT.3026.001.0001) [50] 131 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [25] 132 Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1467 133 Exhibit 4 – Statement of Rees, Attachment (WIT.004.002.0343) at 0390. Map was produced using the Emergency Information Management System 134 Rees T2673:6–T2673:8 135 Rees T70:14–T70:28 136 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [342]; Tolhurst T1144:1–T1144:16 137 Exhibit 157 – (EXP.003.006.0002) 138 Exhibit 157 – (EXP.003.006.0003) 139 Tolhurst T1736:24–T1737:23 140 Tolhurst T1738:6–T1738:16 141 Tolhurst T1739:7–T1739:11 142 Tolhurst T1058:16–T1058:18 143 Exhibit 38 – Statement of Tolhurst, Attachment (SUMM.035.002.0131); Tolhurst T1121:12–T1121:18 144 Exhibit 72 (WIT.004.003.0001) at 0002–0003 145 Rees T2400:9–T2401:2 146 Waller T4358:12–T4358:16 147 Waller T4359:7–T4359:19 148 Henshaw T4778:26–T4779:13 149 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [57] 150 Henshaw T4803:7–T4803:9 151 Henshaw T4803:12–T4803:25 152 Henshaw T4803:31–T4804:26 153 Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) at 0577 154 Exhibit 122 – Statement of Sutton, Attachment 9 (DSE.CD03.0001.0035); Sutton T4068:26–T4069:28 155 Sutton T4065:6–T4066:19 156 Exhibit 122 – Statement of Sutton, Attachment 9 (DSE.CD03.0001.0035) 157 Exhibit 122 – Statement of Sutton (WIT.3024.001.0008) [68]

341 2009 Victorian Bushfires Royal Commission—Interim Report

158 Exhibit 4 – Statement of Rees, Attachment (WIT.004.002.0343) at 0399 159 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [65] 160 Henshaw T4784:31–T4785:4 161 Henshaw T4785:5–T4785:17 162 Exhibit 149 (EXH.149.0001); Henshaw T4799:24–T4800:16 163 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [17]; Caughey T1689:6–T1689:9 164 Caughey T1687:5–T1687:17 165 Caughey T1689:26–T1690:11 166 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [33]; Caughey T1687:18–T1687:25 167 Caughey T1688:12–T1688:22 168 Caughey T1688:30–T1689:3 169 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [69]; Annexure 9 (WIT.3004.009.0193) 170 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [19]; Annexure 5 (WIT.3004.001.0154) at 0179 171 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [20], [22]; Annexure 6 (DSE.HDD.0017.0470); Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509); Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [72] 172 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [23]; Annexure 7 (WIT.3004.001.0154) at 0183 173 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [23]; Exhibit 3 – Statement of Rees, Attachment 3 (WIT.004.001.0509) at 0533 174 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [25]; Annexure 8 (WIT.3004.001.0154) at 0185 175 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) 176 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [71]; Annexure 10 (WIT.3004.009.0195); Henshaw T4805:28–T4806:4 177 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [72]; Annexure 11 (WIT.3004.009.0199) 178 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0530 179 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [73] 180 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [27]; Attachment 9 (WIT.3004.001.0154) at 0188 181 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0537 182 Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) 183 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [31]; Annexure 10 (WIT.3004.001.0154) at 0190 184 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [78] 185 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [80]; Annexure 17 (WIT.3004.009.0218) 186 Henshaw T4807:18–T4807:29 187 The benefits of this type of co-location are promoted in the AIIMS Information Unit Guidelines. See Exhibit 3 – Statement of Rees, Annexure 7 (WIT.004.001.0246) at 0272 188 Caughey T1688:5–T1688:7 189 Caughey T1687:22–T1687:30 190 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [33] 191 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [35] 192 Exhibit 52 – Statement of Caughey, Annexure 6 (WIT.3004.001.0154) at 0192 193 Hunter T1720:16–T1720:27 194 Hunter T1721:8–T1721:22 195 Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [22], [36]; Caughey T1694:10–T1694:11; T1698:17–T1698:20; T1701:13–T1702:3 196 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [81] 197 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [81]; Henshaw T4808:7–T4808:9 198 Exhibit 7 – ABC transcript (SUMM.001.002.0001) at 0319 199 Exhibit 7 – ABC transcript (SUMM.001.002.0001); Henshaw T4808:27–T4809:11 200 Exhibit 7 – ABC transcript (SUMM.001.002.0001) at 0337 201 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [82]; Annexure 19 (WIT.3004.009.0224) 202 Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [83]; Annexure 20 (WIT.3004.009.0227) 203 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [2], [18] 204 Munns T1354:28–T1355:10 205 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [22] 206 Exhibit 44 – Statement of Munns, Annexure 1 (WIT.3004.001.0065) at 0081–0100; Munns T1355:7–T1355:28 207 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [26]; Annexure 1.4 (WIT.3004.001.0065) at 0099

342 Endnotes

208 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [26]; Munns T1357:14–T1357:26 209 Lawrence T1624:17–T1624:31 210 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [27] 211 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [36]–[37]; Barca T3467:28–T3468:25 212 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [33]–[35]; Barca T3468:26–T3471:16 213 Barca T3473:29–T3473:6 214 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [39] 215 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [32]; Munns T1361:8–T1361:27 216 Exhibit 44 – Statement of Munns, Annexure 4.4 (WIT.3004.001.0065) at 0112 217 Munns T1361:28–T1362:6 218 Lawrence T1588:27–T1589:26 219 Lawrence T1589:21–T1589:26 220 Lawrence T1589:12–T1590:10 221 Lawrence T1589:31–T1590:10 222 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [41]–[42] 223 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [38]; Barca T3473:6–T3473:21 224 Barca T3477:26–T3478:3 225 Exhibit 107 – Statement of Barca, Annexure 1 (DSE.0088.0879.0041) at 0046; Barca T3477:21–T3477:23 226 Barca T3477:24–T3477:31 227 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [24]; Annexure 1.1 (WIT.3004.001.0197) at 0212; Lawrence T1590:11–T1590:22 228 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [25]; Annexure 1.1 (WIT.3004.001.0197) at 0213 229 Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [40]; Annexure 4.6 (WIT.3004.001.0065) at 0116; Lawrence T1577:29–T1577:30 230 Lawrence T1577:29–T1578:11 231 Barca T3482:10–T3482:13 232 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [23], [27] 233 Munns T1366:13–T1366:24 234 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [56] 235 Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0771–0776; Lawrence T1616:9–T1616:13 236 Rees T1845:3–T1845:11 237 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [67] 238 Rees T1924:24–T1924:30 239 Rees T1926:1–T1926:4 240 Rees T2500:24–T2501:26 241 Quoted remarks are to be found in Exhibit 3 – Statement of Rees (WIT.004.001.0001) [166] –[167] 242 Rees T41:21–T41:24 243 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [80]–[82] 244 Rees T1924:18–T1924:22; T2420:8–T2420:28 245 Rees T2420:18–T2460:21 246 Tolhurst T1004:13–T1004:25 247 Lawrence T1597:24–T1597:28; T1613:17–T1613:24 248 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [38] 249 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [47] 250 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [48] 251 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [51] 252 Barca T3478:28–T3479:2 253 Lawrence T1625:8–T1625:11 254 Lawrence T1613:26–T1613:31 255 Barca T3480:27–T3480:31 256 Barca T3481:1–T3481:6 257 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [36] 258 Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0437–0440

343 2009 Victorian Bushfires Royal Commission—Interim Report

259 Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0438 260 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [20]; Barca T3477:26–T3477:28 261 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [22] 262 Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [52] 263 Kreltszheim T1288:23-T1289:3 264 Kreltszheim T1289:1–T1289:30 265 Kreltszheim T1289:23–T1289:26 266 Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [23], [26]–[28] 267 Hunter T1728:3–T1729:7 268 Murphy T1257:5–T1257:20 269 Hunter T1719:16 270 Hunter T1718:1–T1718:16 271 Hunter T1721:6–T1721:18 272 Williamson T4474:24–T4475:7 273 McGahy T2246:14–T2246:24 274 Hendrie T863:16–T863:19 275 Cooper T3270:1–T3270:8 THE iECC

276 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1240 277 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1240 278 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [96] 279 Statement of Rees (WIT.004.001.0001) [98] 280 Rees T2369:31–T370:14 281 Rees T2370:21–T2370:30 282 Rees T2370:30–T2371:2 283 Rees T2371:5–T2371:7 284 Rees T2386:26–T2387:6 285 Rees T2372:17–T2372:24 286 Rees T2373:29–T2374:10 287 Rees T1848:10–T1848:14, T2388:9–T2388:17 288 Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [48]; Paterson T4241:6–T4241:25 289 Paterson T4246:28–T4247:13 290 Rees T2369:11–T2369:31 291 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [65]; Annexure 7 (WIT.003.002.0061) 292 Exhibit 19 – Statement of Walshe, Annexure 7 (WIT.003.002.0061) 293 Rees T2555:2–T2555:15 294 Rees T2555:25–T2555:31 295 Country Fire Authority Act 1958 s30(1) 296 Country Fire Authority Act 1958 s28(1) 297 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [33] 298 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [105] 299 Rees T21:22–T22:18; T2382:20–T2383:12 300 Rees T21:4–T22:19 301 Rees T2514:18 302 Rees T21:24–T22:8 303 Rees T2533:4–T2535:8 304 Rees T2535:25–T2535:30 305 Rees T2536:20–T2537:5 306 Rees T2537:13–T2537:21 307 Rees T2538:9–T2538:11

344 Endnotes

308 Rees T2403:23–T2403:27; Sutton T4056:30–T4057:6 309 Rees T2405:30–T2405:31 310 Rees T2406:4–T2406:10 311 Waller T4354:4–T4354:26 312 Waller T4354:10–T4355:8 313 Waller T4355:9–T4355:15 314 Waller T4355:26–T4356:2 315 Waller T4358:22–T4358:30 316 Waller T4359:7–T4360:31 317 Waller T4360:31–T4361:9 318 Waller T4361:20–T4361:28 319 Exhibit 71 – Rees Tender (CFA.001.001.0001) 320 Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0001 321 Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0002–0003 322 Paterson T4247:23–T4247:29 323 Paterson T4248:6–T4248:7 324 Paterson T4268:6–T4268:23 325 Paterson T4282:8–T4282:27 326 Paterson T4267:26–T4267:31 327 Paterson T4275:11–T4275:16 328 Rees T2405:30; Paterson T4268:6–T4268:23 329 For further information about where this responsibility derives from, see Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0003 330 Tolhurst T1077:29–T1078:8 331 Tolhurst T1078:9–T1078:25; Waller T123:16–T123:20 332 Tolhurst T1084:15–T1085:1 333 Waller T123:24–T123:27 334 Tolhurst T1085:26–T1086:4 335 Tolhurst T1111:31–T1112:5 336 Sutton T4072:12–T4073:19 337 Sutton T4062:31–T4063:6 338 Volunteer Fire Brigades Victoria Inc (SUBM.100.004.0001) at [129], [137] AIIMS and INFORMATION — how it might change

339 Rees T2564:7–T2564:15

10 EMERGENCY MANAGEMENT VICTORIA’S EMERGENCY MANAGEMENT ARRANGEMENTS

1 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [10] 2 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [15] 3 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [23] 4 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [13] 5 Emergency Management Act 1986, s. 4 6 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [14] 7 Emergency Management Act 1986, s. 4A 8 Emergency Management Act 1986, s. 5(1) 9 Emergency Management Act 1986, s. 6 10 Emergency Management Act 1986, s. 5(2) 11 Emergency Management Act 1986, s. 7 12 Emergency Management Act 1986, s. 8(1); Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [25] 13 Emergency Management Act 1986, s. 8(2)

345 2009 Victorian Bushfires Royal Commission—Interim Report

14 Exhibit 11 – Statement of Esplin, Attachment 57 (WIT.005.001.2350); Esplin T203:24–T203:31 15 Emergency Management Act 1986, s. 8(3); Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [25]; Esplin T203:21–T203:23 16 Emergency Management Act 1986, s. 9 17 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [26]; Esplin T204:13–T204:23 18 Esplin T204:13–T204:23. See also Exhibit 11 – Statement of Esplin, Attachment 57 (WIT.005.001.2350) 19 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) 20 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [32]; Esplin T201:8–T201:14 21 Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [31] 22 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0127–0128 23 Emergency Management Act 1986, s. 10 24 Walshe T599:8–T599:15 25 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [19]; Walshe T599:16–T599:17 26 Emergency Management Act 1986, s. 23(1) 27 Emergency Management Act 1986, s. 24(1); Esplin T213:9–T213:19; Walshe T1247:2–T1247:13 28 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [125]–[127]; Emergency Management Act 1986, s. 24(2)(c), (d) and (e). The power to compel evacuation in s. 24(2)(e) is subject to the pecuniary interest exception in s. 24(7). 29 Esplin T212:14–T213:25; Walshe T1210:11–T1210:24; T1245:19–T1245:23; Rees T2407:22–T2407:24; T2408:14–T2408:17; Collins T2182:13–T2183:15 30 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [128] State Emergency Response Plan

31 Emergency Management Act 1986, s. 10 32 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [20] 33 Emergency Management Act 1986, s. 11(1); Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [33] 34 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [12], [13], [33]; Walshe T597:3–T597:10 35 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0173 36 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0174 37 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [26]; Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0174 38 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0174–0175 39 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0175 40 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [27]; Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0361, 0374, 0392 41 Section 16 also provides that in the absence of agreement the relevant emergency response coordinator may direct a chief officer to appoint an incident controller. This was not necessary on 7 February 2009. Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [29]–[30] 42 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [29] 43 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [28], [30] 44 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [15] 45 Walshe T600:4–T600:24 46 Walshe T600:9–T600:17 47 Emergency Management Act 1986, s. 13(2) 48 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0176 49 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0176–0178 50 Walshe T624:20–T624:27 51 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0179 52 Exhibit 19 – Statement of Walshe, Annexure 3 (WIT.003.002.0044) 53 Walshe T625:11–T625:17 54 Walshe T623:1–T623:5; T624:30–T625:9 55 Walshe T625:20–T626:4 56 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0180 57 Emergency Management Act 1986, s. 13(2); Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0181–0182; Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [35]; Walshe T623:19–T624:2 58 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0181 59 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0443

346 Endnotes

60 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [24]–[25]; Statement of Walshe, Attachment 1 (WIT.3010.001.0025) at 0038; Walshe T631:4–T632:21; Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [42] 61 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0184 62 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0442–0443 63 Walshe T696:4–T696:13; Exhibit 40 (INF.005.001.0001) 64 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [98]; Walshe T657:7–T657:11 65 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [98]; Walshe T656:29–T657:3 66 Walshe T632:16–T632:21. See also Exhibit 11 – Statement of Esplin, Attachment 23 (WIT.005.001.1856) 67 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [124]; [129]–[142]; Walshe T657:4–T660:31 68 Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [48] 69 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [98], [129]–[142]; Walshe T657:12–T660:31; Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [42]–[47]; Collins T2166:23–T2169:19 70 Collins T2108:3–T2108:24 71 Exhibit 66 – Statement of Collins, Attachment 1 (WIT.3010.001.0025); Collins T2125:5–T2125:10 72 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) 73 Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1240 74 Collins T2126:7–T2126:17 75 Exhibit 66 – Collins Tender (TEN.020.001.0001) 76 Collins T2126:18–T2126:30 77 Exhibit 3 – Statement of Rees (WIT.004.001.0001) [93]–[96]; Exhibit 6 – Statement of Waller (WIT.002.002.0001) [158]–[160]; Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [12] 78 Collins T2125:17–T2126:6 79 Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [28] 80 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0180 81 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [65]; Annexure 7 (WIT.003.002.0061); Exhibit 66 – Statement of Collins, Attachment 3 (WIT.3010.001.0041); Collins T2132:10–T2134:17; T2186:24–T2188:14 82 Collins T2133:5–T2134:8 83 Walshe T651:23–T651:27; Collins T2129:17–T2129:26 84 Exhibit 66 – Statement of Collins (WIT.3010.001.0013) [30]–[33] 85 Walshe T650:28–T651:22; Collins T2131:27–T2132:9 86 Walsh T696:4–T696:12 87 Exhibit 66 – Statement of Collins (WIT.3010.001.0013) at 0015–0018 88 Exhibit 82 (OESC.001.001.0031) Roadblocks

89 Exhibit 3 – Statement of Rees, Annexure 5 (WIT.004.001.0231); Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [146]–[147]; Walshe T682:12–T685:17; Exhibit 66 – Statement of Collins, Attachment 1 (WIT.3010.001.0025) at 0029–0036 90 Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [144]–[146] 91 Exhibit 3 – Statement of Rees, Annexure 5 (WIT.004.001.0231); Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [147]–[151]; Annexure 10 (WIT.003.002.0064) at 0071; Walshe T682:12–T685:17; Exhibit 66 – Statement of Collins, Attachment 1 (WIT.3010.001.0025) at 0029–0036 92 Exhibit 13 – Statement of Newman (WIT.009.001.0001_R) [19]–[20]; Newman T345:29–T346:9; Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [74]–[79]; 93 Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [77] 94 Exhibit 97 – Statement of O’Neill (WIT.047.001.0001_R) [31]; O’Neill T3210:28–T3211:6 95 McGahy T2260:25–T2261:4 96 McGahy T2261:10–T2261:14 97 Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [34]–[36]; Harvey T2200:27–T2201:1; Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [27]; Ananiev T2781:30–T2782:3 98 Exhibit 126 – Bushfire CRC Interim Report (CRC.300.001.0001_R) at 0107–0108 99 Exhibit 13 – Statement of Newman (WIT.009.001.0001_R) [21]; Newman T346:30–T347:18; Sigmund T913:11–T913:22; Exhibit 125 – Statement of J Williams (WIT.055.001.0001_R) [70]–[72]; J Williams T4231:11–T4231:24; T4233:26–T4234:5 100 Sigmund T913:11–T913:22; Exhibit 28 – Statement of Sigmund, Attachment 3 (WIT.020.001.0015) at 0024–0026 101 Exhibit 125 – Statement of J Williams (WIT.055.001.0001_R) [70]–[72]; J Williams T4231:11–T4231:24 102 J Williams T4233:26–T4234:1 103 Walshe T685:18–T686:13; see also Rees T2495:2–T2498:14 and Exhibit 74 – Rees Tender (SUMM.022.069.0086) at 0149–0150

347 2009 Victorian Bushfires Royal Commission—Interim Report

104 Walshe T687:10–T687:21; T690:3–T690:31 105 Exhibit 10 – Statement of Odgers (WIT.008.001.0001_R) [24]; Exhibit 134 – Statement of Hainsworth (WIT.059.001.0001_R) [44]; Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [79] 106 Exhibit 140 (VPO.001.026.0153) at 0155 107 Police Association Victoria (SUBM.100.009.0002) [6(9)] 108 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [9], [13]; Kane T1057:2–T1057:8 109 Exhibit 87 – Statement of Ananiev (WIT.040.001.0001_R) [21] 110 Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [18], [19(f)–(g)]; D Brown T1649:16–T1649:26

11 COMMONWEALTH RESPONSE Division of responsibilities

1 Exhibit 45 – Pearce Tender (TEN.004.002.0009) 2 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [7] 3 Exhibit 45 – This is EMA (TEN.004.002.0010) at 0028–001 4 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [27]; Pearce T1404:14–T1404:28 5 Pearce T1405:25–T1406:10 6 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [7]; Exhibit 45 – Pearce Tender (TEN.004.003.0124) 7 Exhibit 45 – Pearce Tender (TEN.004.002.0500) at 0506 8 Exhibit 45 – Pearce Tender (TEN.004.002.0009); Pearce T1395:26–T1395:28; Pearce T1395:30–T1396:11; Pearce T1394:16–T1394:18 9 Pearce T1397:23–T1397:30 10 Pearce T1399:15–T1399:23 11 Pearce T1400:9–T1400:14 12 For a description of these groups see generally the flow chart at Exhibit 45 – Pearce Tender (TEN.004.003.0065) at 0079 THE ‘all hazards’ approach TO Natural disasters

13 Exhibit 45 – Pearce Tender (TEN.004.002.0437); Exhibit 45 – Pearce Tender (TEN.004.002.0431) 14 Exhibit 45 – Pearce Tender (TEN.004.002.0252) 15 Exhibit 45 – Statement of Pearce, Attachment 13 (WIT.032.001.0154) 16 Exhibit 152 – Pearce Tender (TEN.049.001.0001) 17 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0042, 0052, 0054, 0056–0058 18 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0056–0057 19 Exhibit 45 – Pearce Tender (TEN.004.002.0037) at 0074–0075 20 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [68] 21 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [67] 22 Exhibit 143 – Pearce Tender (TEN.045.001.0001) 23 Exhibit 45 – Pearce Tender (TEN.004.002.0285) COMDISPLAN and commonwealth aid

24 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [11] 25 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [23] 26 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [25]; Pearce Tender (AGD.510.0094) 27 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [27] 28 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [31] 29 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [32] 30 Pearce T1418:19–T1418:29; T1407:12–T1410:10; T1480:13–T1480:18 31 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [38]; Attachment 6 (WIT.032.001.0110) at 0111 32 Commonwealth (SUBM.100.007.0002) [84], referring to Pearce T1475:3–T1477:27

348 Endnotes

Commonwealth RESOURCES For detecting, tracking and suppreSsing fires

33 Pearce T1470:13–T1470:23 34 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [35], [174], [176]; Pearce T1470:13–T1472:5; T1474:1–T1474:5; T1475:3–T1479:18 35 Pearce T1475:12–T1475:24 36 Pearce T1434:29–T1438:4; Griffiths T810:24–T811:26; Edwards T2913:20–T2915:19 37 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [175] 38 Commonwealth (SUBM.100.007.0002) [87] 39 Commonwealth (SUBM.100.007.0002) [89] commonwealth involvement UP TO AND on 7 february

40 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [33] 41 Commonwealth (SUBM.100.007.0002) [70] 42 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [34]–[35]; Attachment 7 (WIT.032.001.0115); Attachment 8 (WIT.032.001.0121) 43 Pearce T1404:7–T1406:25 44 Exhibit 21 – Walshe Tender (TEN.003.001.0001) 45 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [46] 46 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [40] 47 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [41] 48 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [42] 49 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [40]; see also Exhibit 21 – Walshe Tender (TEN.003.001.0001) at 0008 50 Pearce T1490:4–T1490:16 51 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [45]; Pearce T1482:20–T1482:29 52 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [41]–[52]; Attachment 10 (WIT.032.001.0141); Attachment 11 (WIT.032.001.0146); Attachment 12 (WIT.032.001.0150); Pearce T1479:28–T1480:13; T1482:30–T1483:24; T1488:8–T1488:22 53 Exhibit 45 – Statement of Pearce (WIT.032.001.0001) [52]; Attachment 13 (WIT.032.001.0154)

12 EMERGENCY CALLS TRIPLE ZERO

1 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [29]–[30] 2 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14]; Foster T1963:10–T1963:15; Walshe T1215:10–T1215:13; Edwards T2863:30–T2864:2 3 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [115]; Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [144.e]; Kiernan T2025:17–T2025:26 4 The reference is to calls, rather than callers, as it appears likely many callers hung up and redialled Triple Zero a number of times when they were unable to get through. 5 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [57]–[58]; Kiernan T2021:28–T2022:10 6 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) 7 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [27]–[28]; Attachment 2 (WIT.5003.001.0105), Attachment 3 (WIT.5003.001.0109) 8 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [32] 9 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [34] 10 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [11] 11 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5], [24] 12 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [25] 13 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [61] 14 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5] 15 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [64]; Attachment 6 (WIT.5003.001.0180) 16 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [33] 17 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [57]–[58] 18 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [88] 19 Elkington T3821:9–T3821:29 20 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [88] 21 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [96] 22 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [51] 23 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [46]–[47]

349 2009 Victorian Bushfires Royal Commission—Interim Report

24 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [49] 25 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [55] 26 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [56] 27 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [100] THE ROLE OF eSTA

28 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [7]–[9] 29 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [33]–[34]; Attachment 5 (WIT.012.001.0032) 30 Foster T1956:3–T1956:6 31 Exhibit 62 – Foster (WIT.012.001.0001) [38], [40]; Exhibit 62 – Statement of Foster (WIT.012.001.0001) [35]–[38] 32 Foster T1960:12–T1960:18; Foster T1957:5–T1957:6 33 Foster T1957:29–T1958:4 34 Foster T1957:5–T1957:6 35 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14] 36 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14]–[15] 37 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [19] 38 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [26]–[27] 39 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [30] 40 Foster T1950:5–T1950:15 41 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [50] 42 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [55] 43 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [57] 44 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [14]–[15] 45 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [16] 46 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [21]–[22] 47 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [23] 48 Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [41], [43] and [44] 49 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [20], [65]–[66]; Exhibit 62 – Statement of Foster, Attachment 4 (WIT.012.001.0030) 50 Exhibit 63– Statement of Kiernan (WIT.3000.001.0001) [41]–[42] 51 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [43]–[48]; Attachment 4 (WIT.012.001.0030) 52 Foster T1955:1–T1955:10 PREPARATION FOR 7 FEBRUARY

53 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [72]–[86] 54 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [83]; Attachment 10 (WIT.3000.001.0118) 55 Exhibit 63 – Statement of Kiernan, Attachment 10 (WIT.3000.001.0118) at 0122 56 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [92]–[127], Exhibit 62 – Statement of Foster (WIT.012.001.0001) [65] 57 Elkington T3832:10–T3832:20 58 Elkington T3831:1–T3831:27 59 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [87] 60 Elkington T3831:17–T3832:3 61 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [87] 62 Kiernan T2021:28–T2022:10 63 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [107]–[115], [120]–[127], T2019:1–T2021:22; Foster T1966:4–T1966:8 64 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [101]–[102], [126]–[127] 65 Exhibit 63 – Statement of Kiernan, Attachment 16 (WIT.3000.001.0135) 66 Exhibit 63 – Statement of Kiernan, Attachment 18 (WIT.3000.001.0137) 67 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [107]–[115], [120]–[127]; Kiernan T2019:1–T2021:22 68 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [147]; T2023:3–T2023:7 69 Kiernan T2024:30–T2025:16 70 State of Victoria (SUBM.100.005.0001) [150] 71 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [94] 72 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [94] 73 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001); T3835:1–T3835:11

350 Endnotes

Events of 7 February

74 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [98] 75 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [100] 76 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [101]–[103] 77 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [107] 78 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [114] 79 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118], [121] 80 Exhibit 63 – Statement of Kiernan, Attachment 19 (WIT.3000.001.0138) 81 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [134] 82 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [135] 83 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [137] 84 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [146] 85 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [140] 86 Foster T1977:26–T1978:2 87 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118] 88 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123] 89 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [124]; T3844:17–T3844:30 90 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118] 91 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118] 92 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118] 93 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]–[119] 94 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123] 95 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123] 96 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123] 97 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]; Elkington tender (TEN.044.001.0001) 98 Graph based on data at Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [119] 99 Graph based on data at Exhibit 117 – Statement of Elkington, Attachment 22 (WIT.5003.001.0424); (WIT.5003.001.0431); (WIT.5003.001.0438) 100 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [122] 101 Elkington T3835:23–T3835:29 102 Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [41]–[42] 103 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5]–[6]; Attachment 1 (WIT.5003.001.0102); (WIT.5003.001.0103); Elkington T3819:3–T3820:3 104 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5]–[8], [25]–[26], [59]–[63]; Attachment 1 (WIT.5003.001.0104); Elkington T3819:3–T3820:12 105 Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [43]–[44] 106 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [116]; Exhibit 117 – Elkington tender (TEN.044.001.0001) 107 Elkington T3859:27–T3860:29; Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [43]–[44] 108 Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [139]–[144]; Attachment 20 (WIT.3000.001.0154) at 0159; Tender (EXH.063.0004) at 0005 109 Kiernan T2035:29–T2036:4 110 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [116] 111 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [126] 112 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [116], [126] 113 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [126] 114 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [127] 115 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [127] 116 Exhibit 117 – Elkington tender (TEN.044.001.0001) 117 Elkington T3837:9–T3837:26 118 Elkington T3838:1–T3838:5 119 Elkington T3841:11–T3841:27 120 Kiernan T2048:23–T2048:31 121 Exhibit 10 – Statement of Spooner (WIT.011.001.0001_R) [24]; Spooner T484:23–T484:24

351 2009 Victorian Bushfires Royal Commission—Interim Report

122 Kane T1050:27–T1051:6 123 Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [9]; D Brown T1642:13–T1642:31; see also Exhibit 119 – Supplementary Statement of Jennings (WIT.5004.002.0001) [7] 124 Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [27]; Scott T2925:26–T2925:30 125 Exhibit 116 – Statement of Matthews (WIT.057.001.0001_R) [30]-[31]; Matthews T3784:5-T3784:31 126 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [73] 127 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [74] 128 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [75]–[77] 129 Kiernan T2005:23–T2005:25 130 Kiernan T2006:15–T2006:18 IMPROVING THE coordination and capacity of emergency call services

131 Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) 132 Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1564 133 Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1565 134 Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1565, 1567, 1569, 1571 135 Exhibit 62 – Statement of Foster (WIT.012.001.0001) [66]–[71]; Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1561–1577, Esplin Tender (TEN.002.001.0366); Foster T1966:23–T1968:13 136 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [82] 137 Elkington T3862:10–T3862:26; Foster T1966:23–T1968:13; T1968:29–T1969:2; T1979:8–T1979:20 138 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [66]–[76] 139 Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [77]–[80], Attachment 13 (WIT.5003.001.0332); (WIT.5003.001.0335) 140 Elkington T3850:20–T3851:7 141 Elkington T3845:13–T3846:3 142 Telstra (SUBM.100.010.0001) [27] 143 Telstra (SUBM.100.010.0001) [27] 144 State of Victoria (SUBM.100.005.0001) [147]–[149] 145 State of Victoria (SUBM.100.005.0001) [150]; Myers T5046:23–T5046:26

13 NEXT STEPS 1 Practice Note No. 1 [12]

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