Lessons from the Island
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LESSONS FROM THE ISLAND An independent review of the fires that burnt across Kangaroo Island during December 2019 - February 2020 November 2020 TABLE OF CONTENTS 02 OBSERVATIONS, INSIGHTS, LESSONS IDENTIFIED AND RECOMMENDATIONS 04 INTRODUCTION 04 ABOUT C3 RESILIENCE 04 DEBRIEF APPROACH 05 CONSIDERATION OF OTHER REPORTS 05 ANALYSIS METHOD 06 DATA MAPPING 07 BACKGROUND 08 THE FIRE CHRONOLOGY 13 FOCUS 1: ESTABLISHING COMMAND AND CONTROL 15 FOCUS 2: STATE (STRATEGIC) COMMAND 25 FOCUS 3: REGIONAL (OPERATIONAL) COMMAND 31 FOCUS 4: INCIDENT (TACTICAL) COMMAND 66 FOCUS 5: INTEROPERABILITY AND COOPERATION 72 FOCUS 6: PUBLIC INFORMATION AND WARNINGS 74 FOCUS 7: MENTAL HEALTH AND WELLBEING 76 FOCUS 8: PLANNING ALIGNMENT AND INTELLIGENCE 79 FOCUS 9: LOGISTICS GOVERNANCE 81 CONCLUSION 82 ANNEXE 1 - COMPARISON BETWEEN 2007 AND 2020 KI FIRE LESSONS 91 ANNEXE 2 - ANALYSIS AGAINST THE INDEPENDENT REVIEW 94 ANNEXE 3 - ACRONYMS 95 ANNEXE 4 - REFERENCES Lessons from the Island The Independent Lessons Review of the 2019/2020 Bushfires - Kangaroo Island INSIGHTS LESSONS IDENTIFIED PAGE 0 2 Posture of SEC-LO in The current process of L3 IMTs reporting through RCCs added additional 2 Operational Structure reporting layers which had negative impacts on the strategic overview of the incident. There was a lack of strategic focus and assurance of the activities in Coordination Role relation to the IMTs performance, and we saw this repeated with the SCC 3 needed in SCC overseeing the RCC. 1 Lack of Strategic 637 Obs 4 We heard the SACFS is resource deficient, with which we agree. Based on this Focus of the SCC review, however we found duplicated roles, and a general tactical focus on many MAP occasions from all three levels of the command of the organisation. Furthermore, L3 IMTs reporting the position of Regional Liaison Officer confused these reporting lines. 6 to RCC Due to the operational load within the organisation, the process of only sending Lack of endorsed IMTs ceased, replaced with an ad-hoc manner of the selection of staff for 9 Standardisation and Trained IMT IMTs including field command positions. This lack of competence resulted in 2 communication deficiencies between the ground, lack of integration of local Lack of Internal and knowledge. The break down at times with communications across the IMT in the 10 Field Based IMT 1497 Obs Comms planning and operations cells, for example on the Ravine fire provided a basis for the failure of operational planning occuring at critical times. 1 RCC Overwhelmed The design of doctrine, combined with a lack of capability and competency programs for regional staff along with fatigue led to the RCC being overwhelmed. 3 This led to a lack of strategic resource planning, including using what capability Significant Under- 643 Obs LESSONS 7 existed within their own region to support operations on KI. resourcing of Fire Much of the good work completed was discounted by a culture of some not Fireground Discipline following, or actively working against, the chain of command. Secondly, there was a 14 and Accountability lack of accountability by some crews for the mopping up and blacking out 4 procedures led to further fire spread. The lack of technology gave the IMT little 22 Use of Technology 643 Obs intelligence picture to work to in collecting the achievement of tactics where successful, and detecting issues of lack of accountability where they occurred. Safety Officer There was a general lack of integration of the Safety Officer role within the IMT. They 12 posture in IMTs largely self tasked based on where they saw risk. While on the ground, physical and mental health management (through SAFECOM) is delivered connectively, it is not Mental Health and done so together in doctrine, nor are near misses or incidents treated the same 21 Wellbeing 5 (physical and psychological). Safety was addressed in the IAPs in the form of 455 Obs reminders yet, the placement of crews in the Rocky River precinct on the 3rd of Dynamic Risk- January 2020, was against the instructions in the IAP, the State Controllers Intent 11 assessed Safety Decision Making and lacked any type of dynamic risk assessment application. BUSHFIRES Staging, Base Camps Fires on KI are not new, nor are the challenges they bring. The lessons from 2007, 15 and Changeovers were repeated. The SACFS has a lessons management system, however it failed implementation for the KI fires, as the lessons have not translated into planning Interoperability and across coordinated fire fighting agencies. 17 Resource Sharing Discussions which ensued about machinery and aviation use on DEW estate, 6 pre-planning base camps and staging area should be documented within the Planning 1214 Obs 23 Connectivity GOMP and ROMP framework, but given the complexity of KI, the state had a role to play as well. The planning and execution of shift change overs often took 3-5 hours to achieve which lost critical fire ground time during benign hours where Sub-standard ICC 8 Facilities aggressive tactics could have taken place. ISLAND The level of responsibility and accountability outlined in doctrine for L3 IC's is not reflective of the CO, or delegate appointment to the role. L3 ICs had to report Posture of L3 ICs in through three levels of management below the CO to escalate issues. The multi- 16 SACFS and ZEST layered reporting lines was not conducive to assurance at the state level on 7 resourcing, exampled when the SDC discovered only one IMT member was rostered Public Information at night less than three days out from an extreme fire danger day. Compounded 318 Obs 20 and Warnings with this, having the ZEST directly reporting to the L3 IC, was a distraction, which was only resolved when delegated to a DIC. The L3 IC/ IMT were questioned too many times about the issuing of public warnings, relating to on ground fire conditions. Integration with the The fires on KI needed every capability they could get. The insertion of the ADF was 18 ADF a welcome one, however the tasking process took some time to adjust to and work 8 through. The integration of the forestry industry was mixed between fully Integration with 213 Obs integrated and not at all. Understanding capabilities outside the general 19 Industry coordinated fire fighting agencies was generally not applied. KANGAROO There is significant opportunity to achieve good community outcomes by further FFU Integration to integrating FFUs into operations of fires across KI. By all parties agreeing on a 13 IMT and Field Ops 9 coordination model, and common standards of PPE, safety standards and how to 227 Obs communicate, it will only increase positive outcomes for the community. Aviation responded well to support ground crew efforts. The establishment of a TRZ Aviation and IMT could have assisted with a more rapid deployment to the Ravine Complex. An even CFS 5 Integrated Knowledge 10 closer relationship between IMT and aviation specialists will increase the outcome 148 Obs for fires on KI to integrate air and ground tactics. Good outcomes were achieved in Logistics, with the general lack of resources SA 24 Logistics Governance 11 applied to the cells at all levels of command, however there was a need to integrate 250 Obs a finance officer into the IMT at the point of escalation to L2. PAGE 0 3 RECOMMENDATIONS Review the doctrinal environment that governs L3 incidents immediately to: Simplify the flow and reduce the repetition to make it less voluminous. Consider making it a formal joint operational policy between SACFS and DEW. Establishing L3 Incident Controllers as a direct report to either the DSC, DCO or CO. Establishing minimum training and competency standards for L3 IC that are achievable, in line with approaches such as the NSW RFS and VIC CFA. Establishing the RCC as a resource management centre for L3 Incidents. 1 Establishing the SCC as an operational coordination centre for L3 incidents. Prescribing the requirement to undertake annual L3, RCC and SCC exercising to maintain competence and currency. Delegating financial responsibility and delegation to ICs and L2/3 Logistics Officers Reviewing the current audit process undertaken by the SDC, and replace with regular assurance discussions between the L3 IC and an executive member suitably qualified to undertake such an assurance level. Prescribing an LO as the link between ZEST and the IC. Influence Government Policy to formally recognise the SACFS as the lead agency for AIIMS, and, working alongside the increased focus at present by the MFS in AIIMS, increase capability and competence in AIIMS training and experience for all agencies involved in coordinated firefighting operations including: Increasing the number of L2 and L3 functional area leads (including agencies such as MFS) with a competency based standard assessment. Increase the number of L3 ICs from 4 to 8. 6359 2 Perform annual exercising of L2/3 IMTs, RCCs and the SCC based on the hazard context forecasted for the next season. Increase the number of sector and divisional commanders, including observations maximising the opportunity for newly trained officers to be mentored. Increase the available aviation personnel, and determine the scope to deliver key aviation courses within SACFS. Increase human factor training including emotional intelligence for crews to better integrate to communities when deploying to L3 incidents. A general awareness campaign is conducted across SACFS about the importance 522 of blacking out and mopping up, and an increased expectation is provided to 3 those deploying to scrub areas, that this will be key tasks they will be asked to surveys (15.1% completed) complete. A project is sponsored by the CO to further explore the cultural issues which exist within the KI Group and its broader connection into the organisation, and 4 develops a change management plan which promotes a more cohesive relationship into the future.