Incident Management in Australasia : Lessons Learnt from Emergency Responses [1 ed.] 9781486306183, 9781486306176

Citation preview

are inherently dangerous. Large incidents such as bushfires, floods and earthquakes often pose hazards that are not fully understood at the time of management, and the situation may be further

complicated by the involvement of multiple agencies. To promote the safety of personnel and of the broader community, incident management skills must be constantly developed. Incident Management in Australasia presents lessons learnt from managing major incidents at regional and state levels. It is not an academic work. Rather, it is a collection of stories from professionals on the ground and others who subsequently reviewed the events and gained significant knowledge and understanding through that process. Some stories are personal, capturing emotional impact and deep reflection, and others are analytical, synthesising the findings of experience and inquests. All the stories relate to managing operational events and capture knowledge that no one person could gain in a single career. This book builds on current industry strategies to improve emergency responses. It will assist incident managers and those working at all levels

Incident Management in Australasia

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mergency services personnel conduct their work in situations that

in incident management teams, from Station Officer to Commissioner. It is

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highly readable and will also be of interest to members of the public with an appreciation for the emergency services.

Editors: S. Ellis and K. MacCarter

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Incident Management Editors: Stuart Ellis and Kent MacCarter

3/4/16 11:30 AM

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INCIDENT MANAGEMENT IN AUSTRALASIA

Lessons Learnt from Emergency Responses

Editors: Stuart Ellis and Kent MacCarter

© Australasian Fire and Emergency Service Authorities Council 2016 All rights reserved. Except under the conditions described in the Australian Copyright Act 1968 and subsequent amendments, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, duplicating or otherwise, without the prior permission of the copyright owner. Contact CSIRO Publishing for all permission requests. National Library of Australia Cataloguing-inPublication entry Incident management in Australasia: lessons learnt from emergency responses / editors: Stuart Ellis and Kent MacCarter. 9781486306176 (paperback) 9781486306183 (epdf) 9781486306190 (epub) Includes bibliographical references and index. Assistance in emergencies – Australia – Management. Emergency management – Australia. Ellis, Stuart, editor. MacCarter, Kent, editor. 363.3480680994 Published by CSIRO Publishing Locked Bag 10 Clayton South VIC 3169 Australia Telephone: +61 3 9545 8400 Email: [email protected] Website: www.publish.csiro.au

Front cover: Top panel: (left top) USAR Category 1 training exercise © NSW State Emergency Service; (left bottom) Post-earthquake response in Christchurch © New Zealand Fire Service; (right) State-wide briefing at the State Control Centre, Victoria © CFA. Bottom panel: (left) Field operations centre © Victoria State Emergency Service; (right top) Prescriptive burning and fuel management © Department of Environment, Land, Water & Planning; (right bottom) USAR crew assessing a flooded neighbourhood © Queensland Fire and Emergency Services. Set in 11/13.5 Adobe Minion Pro and Helvetica Neue LT Std Edited by Joy Window (Living Language) Cover design by Alicia Freile, Tango Media Typeset by Desktop Concepts Pty Ltd, Melbourne Printed in China by 1010 Printing International Ltd CSIRO Publishing publishes and distributes scientific, technical and health science books, magazines and journals from Australia to a worldwide audience and conducts these activities autonomously from the research activities of the Commonwealth Scientific and Industrial Research Organisation (CSIRO). The views expressed in this publication are those of the author(s) and do not necessarily represent those of, and should not be attributed to, the publisher or CSIRO. The copyright owner shall not be liable for technical or other errors or omissions contained herein. The reader/user accepts all risks and responsibility for losses, damages, costs and other consequences resulting directly or indirectly from using this information. Original print edition: The paper this book is printed on is in accordance with the rules of the Forest Stewardship Council ®. The FSC® promotes environmentally responsible, socially beneficial and economically viable management of the world’s forests.

Foreword

I can thoroughly recommend this book. I greatly enjoyed reading it. My first reading left me with the satisfying feeling that I had just learned so much of potential future benefit to the community. More importantly, I was delighted that so many others would also have that opportunity. I am enthusiastic about this book being a powerful tool for the future. That is particularly so for any person potentially placed in the position of being a leader in an emergency. It may only be once in a lifetime, but the lives of others may depend upon the best possible decisions being made. This is a book for reading more than once. The first reading should be more for the satisfying comfort of seeing how well-trained incident managers have coped so well with various kinds of crises, and how the community has benefited. For potential leaders, the second reading should be a more pragmatic one, done with a pen in hand. Appropriate passages should be marked. An informal personal index, to enable later quick reference, should be made. The book should then be on hand for further focused reading. Such a reading would be a must on the night before an occasion when circumstances point to a possible emergency. Decisions made with the benefit of being informed by the experiences of others are so much more likely to be the best possible. When responding to bushfires, incident management is critical. It was a major focus of the Royal Commission into the Black Saturday bushfires, and not only in a general sense. Our questioning of witnesses and our deliberations focused greatly on how that management was effected in particular instances. To us, the benefits of co-location and interoperability were blindingly obvious. So too were the benefits of the right kinds of leadership skills. Our experience was not as leaders in a crisis, but as outsiders who had to analyse the decisions of leaders and how they were responded to by those who had to follow the lead. We had the benefit of hindsight. We could, and did, criticise: those who did not place the primacy of human life above all else; those who did not see the importance of Safety Advisors and of level 3 accreditation; those leaders who were not inclusive, or who opted not to give their all. v

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There are great advantages in having 10 accounts of different emergencies provided mostly by those who have had to face major dilemmas personally. There is a special attraction to the book in that it extends to different types of emergencies. The book helps to demonstrate the obvious point that the fullest possible program of preparation and training is an indispensable start. There are many other factors at play that a reading of the different accounts brings home strongly. Most of them revolve around the exercise of the best possible communication skills, especially that of listening. One that emerges from several accounts is the importance of being aware of the need to harness appropriately the resource, potentially available in any crisis, of untrained volunteers. This is a very special book. I have no doubt that these 10 accounts of crises requiring urgent decisions will contribute to many better decisions in similar crises in the future. Honourable Bernard Teague, AO Retired Supreme Court Judge of Victoria Chairperson, Victorian Bushfire Royal Commission

Contents

Foreword v Acknowledgements ix Introduction xi Stuart Ellis AM Chief Executive Officer, Australasian Fire and Emergency Service Authorities Council

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Fire catastrophe at Wangary on the Eyre Peninsula, South Australia

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Euan Ferguson AFSM Chief Officer, Country Fire Authority, Victoria (Formerly Chief Officer of the South Australian Country Fire Service 2001–10)

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Incident management in Bundaberg during the 2013 Queensland floods

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John Watson Assistant Commissioner, Queensland Fire and Rescue Service

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Responding to the Myer building fire in Hobart

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Gavin Freeman Acting Chief Officer, Tasmania Fire Service

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The aftermath of the Christchurch earthquakes, 2011

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Stuart Ellis AM Chief Executive Officer, Australasian Fire and Emergency Service Authorities Council

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A highway cyanide spill at Tennant Creek

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Leigh Swift Station Officer, Northern Territory Fire and Rescue Service, now retired

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Firefighter entrapment during routine hazard reduction burn at Mount Kuring-Gai 99 Bob Conroy Director Conservation Operations, Office of Environment & Heritage, NSW

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Large petrochemical fire in Adelaide’s industrial precinct

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Roy Thompson Incident Controller, South Australian Metropolitan Fire Service

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Thirty per cent of the entire state: Victorian floods, 2011

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Trevor White Chief Officer Operations, Victoria State Emergency Service

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Thinking differently, leading differently: lessons from the Canberra fires, 2003

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Mark Crosweller AFSM Director General, Emergency Management Australia

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Bushfire around Linton township, Victoria Greg Leach Incident Controller, Country Fire Authority (Now Deputy Chief Officer, Metropolitan Fire and Emergency Services Board)

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Acknowledgements

Australasian Fire and Emergency Service Authorities Council (AFAC), as the national council and peak body for the industry, wishes to thank Kent MacCarter for his professional guidance as coordinating editor during the project. Our gratitude also goes to Bob Conway, Mark Crosweller, Stuart Ellis, Euan Ferguson, Gavin Freeman, Greg Leach, Leigh Swift, Roy Thompson, John Watson and Trevor White – each a contributor to this book. Their experience and stories are our gain. AFAC would also like to extend a sincere thanks to Julia Stuthe, Lauren Webb, Tracey Millen and the CSIRO Publishing team for their work and guidance. And special thanks to Bernard Teague AO for his insightful foreword. Many of AFAC’s member and affiliate organisations contributed resources throughout the development of this publication, including Ambulance Victoria; Attorney-General’s Department, Emergency Management Australia; Country Fire Authority, Victoria; Northern Territory Fire and Rescue Service; NSW National Parks and Wildlife Service; Queensland Fire and Emergency Services; South Australia Metropolitan Fire Service; Tasmania Fire Service; and Victoria State Emergency Service. In addition to chapter authors, we would like to acknowledge Bruce Byatt, Jillian Edwards, Trevor Essex, Zoe Kenyon, David Letheby, Kathryn Levi, Paul McGill, Mick O’Flynn, Steve Rothwell, Naomi Stephens and Lynette White for their assistance. AFAC Publishing Team

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Introduction Stuart Ellis AM Chief Executive Officer, Australasian Fire and Emergency Service Authorities Council

Firefighting, flood rescue, earthquake rescue and other responses required of fire and emergency services are inherently dangerous and even more so if the hazards are not understood. The dangers to personnel have been well mitigated over the years with excellent training, equipment, personal protective clothing and operational procedures that minimise the risk. That said, managing the major incidents that inevitably occur, and developing the capability of our personnel to be best prepared, has not always received a high level of priority and resourcing. While the safety of our people and the broader community remains our highest priority, the incident management skills required to maximise this require constant development and practice to remain current. I have maintained the view for many years that our industry has placed too little attention on incident management. Although we have developed some very capable individuals, there has been an expectation that they will simply develop almost ‘automatically’ through ‘the system’ with experience. Individuals have been exceedingly committed, but the commitment of the industry to developing incident management capabilities has not always been optimal. In the last 15 years we as an industry have been repeatedly advised we need to place greater resources on developing incident management; now our Australasian Fire and Emergency Service Authorities Council (AFAC) agencies and our jurisdictions recognise this is required and indeed are resourcing this requirement. Some agencies have been better listeners and have taken up the challenge with formal courses and even some professional screening and development pathways. This has certainly been of benefit. Until recently, however, even the need has not been well recognised by some of our agencies, let alone transformed into an implemented strategy, training and development. We have heavily relied on Australasian Inter-service Incident Management System™ (AIIMS) as our incident management doctrine and it has supported incident management well. The system reflected in the manuals, courses and xi

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training materials continues to be the foundation for our incident managers. It is one of the core elements binding AFAC agencies. Agencies have also contributed numerous courses in AIIMS roles and conduct exercises. The analysis contained in numerous post incident reports, independent inquiries, coronial reports and royal commissions have added significant depth to our incident management knowledge. These formal reports have provided greater understanding and, at times, specific criticism regarding how we have managed operational incidents. The publishing of this book was seen as part of that greater commitment by the industry to inform and educate incident managers. It is a further element to progressing our understanding of incident management and managing major events and multiple incidents at state and regional level. It is not intended as an academic work. Rather, it is a collection of stories – some very personal and specific, some more generic – from people who were there, who felt the strain and the pain, or from people who reviewed the incidents subsequently and gained significant knowledge and understanding through that process. All relate to managing operational events and all contribute to what we already know. I have been reliably informed that there is far too little academic literature on incident management. While we have used AIIMS since the 1980s, little has been written in academic literature. I am aware some progress is being made and I welcome this; however, this book is not part of that academic library. It is the words of practitioners recalling what they had to manage and the impact that had. The stories in this book traverse the roles of an incident manager, a regional manager and indeed State Controller, Chief Officer and Commissioner. There are clear operational lessons and impacts, which this book captures across a range of incidents no one person is likely to ever face in a career – certainly not at the intensity and impact of the incidents discussed in this book. There is also significant discussion about the strictly non-operational considerations, the reflections and approaches adopted. They reflect several initiatives that are changing and indeed improving our incident management. The stories in this book, linked with more formal inquiry and research, will assist incident managers and all those working in incident management teams. Together with research conducted previously by the Bushfire Cooperative Research Centre and now by the Bushfire and Natural Hazards Cooperative Research Centre, it will increase the body of knowledge available to those completing this challenging task. Like many, I truly value the power of our leaders telling their story. They do so in this book – not just relating what happened, but in many instances how they felt and reacted, the impact and the pain and the lessons they identified. In one volume this book provides a range of experiences across a diverse series of hazards. This includes some of the most significant fires that have shaped our incident management and operational procedures, as well as our equipment and personal

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protective clothing, through to floods, earthquakes and broader reflections on emergency management. The recently introduced Emergency Management Professionalisation Scheme will further recognise, support and assist incident managers. The introduction of this scheme emphasises messages from the stories in this book: that incident management is demanding and challenging; it requires the application of professional skills; and knowledge and currency can only be maintained by ongoing engagement and professional study. I recommend the book to you all.

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1 Fire catastrophe at Wangary on the Eyre Peninsula, South Australia Euan Ferguson AFSM Chief Officer, Country Fire Authority, Victoria (Formerly Chief Officer of the South Australian Country Fire Service 2001–10)

Introduction From December 2001 to November 2010, I was the Chief Officer of the South Australian Country Fire Service. On Tuesday, 11 January 2005 a major bushfire burned across much of the southern Eyre Peninsula in South Australia, causing significant damage and loss of life. The country was in long-term drought. The grassland and roadside scrub was tinder dry, as was the stubble from the recent harvest. The whole of South Australia was under a total fire ban. Flames were initially fanned by scorching hot and dry winds from the north. Spread rates were consistently over 30 km/h – the fastest ever recorded grassfire rate of spread. In the late morning, a strong and intense dry wind change from the south-west swept the eastern flank of the fire and roared towards the east coast of the Eyre Peninsula. Through luck and circumstance, the fire skirted around the north of Port Lincoln. Other communities, farm houses, stock and infrastructure were not so lucky. Over

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70 000 ha were burnt; most of that was burnt in about a four-hour period. Nine people died. Over 100 dwellings and buildings were destroyed. Communications infrastructure, power lines, water pipelines, fences and even road surfaces were scorched, melted and twisted by heat. The fire had a catastrophic impact and a long-lasting effect on the southern Eyre Peninsula. It would take many weeks and months to restore essential infrastructure. For the people, their homes and farming livelihoods, it would be many years to get to a new normality. For some, the memory, loss and hurt from the Wangary fire will never be gone. This chapter is a personalised account of how we prepared for the fire, how we responded to and managed it, as well the consequences of the fire and the subsequent coronial inquest. In particular, I refer to how I as Chief Officer, along with the Country Fire Service (CFS) team, took the initiative after the fire to develop and implement a change strategy within CFS. The changes we made in the years after the fire were lauded by the Coroner at the time. This chapter deals with the effect that the fire had on me, both professionally and personally. As I write this on the eve of the tenth anniversary of the fire, I have had 10 years to ponder and reflect on the enduring lessons this fire taught me. I am using this chapter as an opportunity to influence women and men who might be in, or aspire to, senior operational roles in fire, emergency management and crisis management roles. I offer 10 tips for successfully managing an emergency which have worked for me over the years. I have gone on to be Chief Officer of the Victorian CFA and, to a large degree, I still use the 10 tips outlined here to good effect. They have stood the test of time and served me well.

The day before the fire Some parts of the Wangary fire stand out very clearly in my mind. Other parts are lost in a fog. I do recall the briefing teleconference we had at the CFS (the South Australian Country Fire Service) headquarters on Monday, 10 January 2005 in the late afternoon. The Bureau of Meteorology forecaster read out a grim set of weather statistics – in today’s terms, extreme and ‘catastrophic’ fire dangers across the state. The experienced forecaster said that these were about the worst set of weather conditions he had ever seen. I still recall the unease that comment triggered in my gut: a nervous discomfort that would persist for the next few days. There was a chill of nervous anticipation amongst those around the briefing table. Following the briefing our discussions centred around preparations for the next day. A grass fire had occurred near Wangary late in the afternoon. (Later, the Coroner would determine that the cause was a modified exhaust on a prospector’s four-wheel drive that was driven across long grass.) We discussed our concerns

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about the fire. Details seemed sketchy. We teleconferenced with the local CFS region. There were offers of help, met by reassurances that the fire was in hand. But the sense of unease persisted. As was our practice, on Monday afternoon and evening we were busy preparing. Specialist personnel had to be contacted and rosters activated. Other agencies had to be warned and briefed. Total fire bans were declared for the whole state. Media messages and community warnings were issued. CFS people were briefed and tasked, and discussions were held with senior police, the Department of Environment and Heritage (DEH) and the Minister’s staff. Briefings were arranged for a range of government agencies and emergency management bodies early the following day.

11 January 2005 Dawn on Tuesday, 11 January heralded the dry heat of an untrustworthy wind, mild at first but building in strength. It had been a sweaty, uncomfortable night. I awoke to the alarming news that the size of the fire at Wangary the previous day was far larger than we had first believed. Crews on the fireground had worked hard overnight to secure the edge of the fire. They reported that the fire had been contained, but it was tenuous. As local controllers described the task confronting them, I was filled with a sickening dread. At CFS headquarters, our team assembled to deal with new fires across the state. At this time, the Wangary fire was contained. Everyone was anxious. We knew that crews would have their work cut out for them with the winds that were building quickly on the southern Eyre Peninsula. The time and distance involved in sending support to the CFS teams on the Eyre Peninsula were problematic. This day was a day of extreme fire danger across all of South Australia. Even if we had taken a decision to move scarce resources from other parts of the state to the Eyre Peninsula, it would take many hours for them to arrive; and we were potentially robbing our initial attack capability for new fire starts elsewhere. Updates to briefings and warnings were made, as we monitored the worsening conditions. Under these conditions I had regular contact with the Chief of the Metropolitan Fire Service (MFS), the Police Commissioner and his Deputy, and the Minister’s Office. My key people, senior CFS and DEH fire managers, helped me analyse where the greatest risk lay. Sometime after 10 a.m. I was advised that the Wangary fire had broken through its containment lines. The fire was running again – totally out of control on the southern section – in harvest stubble, roadside scrub and through the Wanilla Forest. My worst fears were being realised. I recall standing with a small group in the CFS planning cell, looking at a map of the southern Eyre Peninsula. With a highlighter pen I drew a broad swathe to the south then, knowing that a south-westerly wind change was imminent, I continued

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the swathe to the east and north-east. Some weeks later I compared that actual fire area to the roughly drawn map of that morning; it was tragically accurate. Warnings were prepared and issued for settlements in the path of the fire. Additional resources from across the Eyre Peninsula, including from the South Australian MFS, were activated. Incident management personnel, already weary from their efforts the previous night, were recalled to the Incident Control Centre at Port Lincoln.

Coordinating a major fire It was clear that this was going to be a major emergency, so Police Commissioner Mal Hyde, his Deputy John White, and MFS Chief Grant Lupton and I gathered in the State Coordination Centre (SCC). Between us, we were able to gather and share information on the progression of the fire at Wangary. In the mid-afternoon, under strong winds, a new fire started on the edge of the Adelaide-Crafers Highway, burning up towards Crafers. From a corner of our room at the SCC we could peer out the window and see billowing grey-black smoke in the direction of Mount Osmond and the freeway. We could only wonder what it was like for residents, crews and emergency workers out there in these hostile conditions. Fortunately that fire was controlled late in the day with little loss, thanks to the tireless efforts of firefighters from all the South Australian fire services. At the SCC we received new information. We were noting changes to weather, locations of the fire head, road closures, warnings, resource movements and supporting requests from incident management teams. By mid-afternoon, police advised of the first fatalities: two bodies were found near a burnt out farm fire unit. Then more bodies were discovered in a burnt out car. This sobering news put a new scale of gravity on the situation. The afternoon wore on. The details are now a blur in my memory. My CFS official log book is my enduring record of the day. There were regular calls to and from my location at the State Emergency Centre and the CFS headquarters. Support, in the form of fixed wing firebombing aircraft from the Adelaide Hills, ‘strike teams’ of additional firefighting trucks, and incident management personnel was sent from Adelaide and from surrounding districts. We arranged additional CFS staff officers to fly to Port Lincoln. There were regular situation and damage updates – each passed on to the Police Commissioner and the Chief of the MFS, as well as to the Minister or to his advisor. Major highways and roads were blocked, the main water pipeline burst and the count of houses, farms, stock and fences destroyed grew. That evening we held a press conference: lines of cameras, voice recorders and dazzling spotlights. While the tally of losses would take days to confirm, we knew that nine people had lost their lives in the Wangary fire. We were all shocked at this loss of life. I recall my own numbness at the extent of the fire and the reports

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of widespread damage to properties and infrastructure. It is hard to fully describe the surreal feeling of exhausted detachment – a combination of shock, grief, weariness and anxiety probably overcame me. That evening there was a briefing of the State Emergency Committee, Premier, Ministers and senior government officials. Mal Hyde and I were the key speakers. The Premier Mike Rann and the Emergency Services Minister Patrick Conlon were keenly interested. They asked questions and sought details. By the time the briefing finished it was dark and, thankfully, cooler. I still recall the pent-up emotion. Outside the building, MFS Chief Grant Lupton and I shared a moment to check and reassure each other. Later that evening, I returned to the CFS headquarters. I was physically and emotionally drained. The mood at the headquarters was sombre – something that would take many months to turn around.

The days after the fire Amongst the death toll from the fire were two CFS volunteers, Neil Richardson and Trent Murnane. Brave men, they were on a farm fire unit and died trying to fight the fire shortly after the wind change. Each was loved by a family – a family that would never again be able to share special days, never be able to see their loved ones grow old and wise. The saddest day of my life was, with CFS Board members Ray Dundon and Russell Branson, visiting these two families shortly after the fire. There was no anger or bitterness, just sadness, hugs and many tears. If I were to dedicate changes to CFS since the Wangary fire to anyone, it would be to the memory of Neil and Trent. I recall driving around the fire area the day after, with Emergency Services Minister Pat Conlon. We visited the Incident Control Centre and the CFS Regional Office. The government moved quickly to establish Minister Patrick Conlon as a ‘Duty Minister’, located at Port Lincoln. He was effectively delegated the authority of the Premier and Cabinet to get relief and recovery efforts underway quickly and without fuss. Pat was a larger than life personality who gave clear and unambiguous direction. He was a no-nonsense, pragmatic Minister who was tough but fair, and he was ideal for this role in the first week after the fire. The media’s attention was constant. Initially they were seeking facts and accounts by various players. Much of the media was positive. But as journalists do, over time there were theories and differing views on the fire cause and the CFS effort at managing the fire. Questions were asked as to the timing of warnings: why were there not more aircraft – specifically why didn’t South Australia have more aircraft and why no Aircrane (heavy firebombing helicopter)? Some of the social media was brutal. An email (from a disaffected person) that accused us of being murderers reduced our small, talented media team to

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tears. The calls would start before dawn and often go late into the evening. The media people had to synthesise messages with government and other agencies. Wherever possible I tried to take the media load (especially where it was critical of CFS). I tried to ensure that the media team were well supported and rested. In spite of this, each of the media team, in their own way, needed time out to recover after the fire. At the end of the first week after the fire, Pat rang me and asked that I meet with some angry farmers from the fire-affected area who had been in contact with him. When I met with these farmers at the Wangary hall, I was told of the disappointment that they felt about how CFS fought the fire. I listened for several hours, then toured the fireground with them. I took on board their concerns, most of which seemed to be reasonable and to have validity. Before leaving, I made sure that I could work through one of their leaders in the future. This was the start of an ongoing and very productive relationship. I think it was on the flight back to Adelaide that evening that I first realised that, as Chief Officer, I had a responsibility to fix the issues that they had identified.

Project Phoenix I set about forming a team to carry out our own analysis and report of what had happened in the lead-up to and during the Wangary fire. We had a group of people from other government organisations and from local government and the then South Australian Farmers Federation, who helped steer our analysis. We engaged a small group of ex-military consultants to guide us through the process and to help the process to be objective and (as much as it could be) inclusive and transparent. These consultants injected new thinking and (because they weren’t involved in the firefight) they were able to be optimistic when we lost our focus and our energy ran low. This improvement process developed into what we called ‘Project Phoenix’ – a report that made over 130 recommendations for change. Two of the principles for Project Phoenix were ‘no blame’, and that change has not occurred until it has been implemented and validated. Another principle was that everyone works in a system. If a mistake or error occurs, it is because the system has broken down. Don’t look to blame the people in the system – look to the design of the system. Change needs to focus on improving the systems of work. Project Phoenix was completed around three months after the fire. It quickly became our template for future CFS activities and for controlling the agenda – including the media. I kept coming back to the Project Phoenix Steering Committee, local farmer leaders and CFS leaders and testing whether we were on the right track or not. I was determined that I was going to be responsible for seeing the CFS systems of work improve to make CFS a better, stronger fire service and to set up systems to better warn and protect the community.

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Support for CFS The government of the day was very supportive. Premier Mike Rann and Emergency Services Minister Patrick Conlon both were significantly involved and I felt that they were both with us at every step along the way. In the first week after the fire I had a telephone call from the head of the Department of Premier and Cabinet, Warren McCann. Warren wanted to specifically tell me that Cabinet supported CFS and me in my role as Chief Officer. It was a reassuring phone call. Others too were there to offer advice and constructive views: Police Commissioner Mal Hyde and Mal’s Deputy, John White, were constant supporters along the journey; Grant Lupton, Chief of MFS, was a collaborator as was the Environment Department chief Allan Holmes and former CFS CEO Vince Monterola. Vince was tireless in his role leading the recovery effort after the fire. He played a crucial role in joining up local Eyre Peninsula property owners with local government agencies and getting the task of recovery done with a minimum of fuss. He was always watching to ensure any concerns about CFS were channelled back to me. Each of these people, in their own way, took time out to provide personal support to me and organisational support to CFS. This is something I have never forgotten. The lesson here is that the seeds of trust, sown while developing relationships, can bear a rich harvest.

The coronial inquest There was the long period of the coronial inquest under the control of Deputy State Coroner Anthony Schapel. At the time, this became the longest running coronial inquest in Australia’s history. There were few stones left unturned. One of the experts, CSIRO’s Dr Jim Gould, gave evidence that for much of its run the Wangary fire burnt at a rate of spread in excess of 30 km/h. This is an exceptional speed – easily the fastest ever documented. It is proof that the fire on 11 January was one of the most severe and ferocious in Australia’s history. By the time my turn came to give evidence to the Coroner, CFS was well down the track of making significant changes and improvements through Project Phoenix. I spent a long time, many days, in the witness box. This is accountability at work. It was a stressful period. I was subjected to death threats and for a time during my evidence had a police detail for my protection. There was a rare light-hearted moment. As a forester I have fought many fires using a rake-hoe, a basic hand tool that enables the user, alone or in a team, to scratch a mineral earth trail, or control line, around a fire. At a particular stage in my evidence the Coroner was keen to explore my views on how the fire could have been fought differently. In my view, a vulnerable edge of the fire in a creek bed on the southern part of the fire could have been strengthened by using a rake-hoe trail supported by hose lines on the Monday evening before the fire broke away. I am

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somewhat an aficionado of the rake-hoe and I enjoy teaching people about their use. My evidence started with the words: ‘The rake-hoe is a much maligned and most underrated, but versatile and effective firefighting tool …’ Lunch followed soon after my explanation finished. A few days later I was told that my account about rake-hoes was the longest response to a single question of the whole inquest. Months later I used my explanation about rake-hoes in a short handout that I gave to CFS people (along with a small metal rake-hoe lapel pin). The rake-hoe remains an effective and relevant firefighting tool today. I continue to extoll the effectiveness of its use. The day the Coroner brought down his findings was another strong memory. It had been over two years from the time of the fire. The Minister of the day Carmel Zollo had asked me not to go to Port Lincoln where the Coroner was delivering the findings. I think this was partly because there was some concern for my welfare, but also because of the high media interest and an uncertainty about what the findings would contain. The Coroner, in making his findings and recommendations, applauded the fact that CFS had recognised the need for change and had effected many of our own changes. In delivering his findings the Coroner specifically said that I continued to be the right person for the job. I can still recall the surge of relief and the emotion that washed over me when the Coroner uttered these words. Later that afternoon there was a media conference with the Acting Premier Kevin Foley and Minister Carmel Zollo. Both the Minister and the Acting Premier spoke. I answered questions. One journalist, who knew me well, asked if I had ever considered resigning. My throat, already dry and tense, seized up. My emotions welled. Kevin Foley jumped to be by my side, took the stand and said that if I had offered my resignation that it would not have been accepted by the government. The strength of his response quashed any further discussion on that subject.

Managing myself I have several books, newspapers and videos of the fire and the period of the recovery. The statistics and many stories of the fire are well told in those publications. Many of the books are on my bookshelf, unread to this day. For weeks after the fire I could not read newspaper reports and I avoided the nightly news. The pain of memories evoked was too real, too deep and for a long time the emotion was too difficult to deal with. The fire had a deep impact on me. I had to purposefully analyse my own role and actions on the days around the fire. I had to lift the morale of tragically affected CFS personnel. I felt that many – in CFS, in government and in the community – were looking to me for direction and to provide hope for the future. I engineered time (I tried to get half a day a fortnight) to think things through and plan the recovery and transformation of CFS. I deliberated on a set of behaviours

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that I needed to display to give confidence to those around me and to the community. I found myself constantly reviewing my own performance and seeking feedback. I was lucky to have some very close and dear friends and a wonderfully supportive family. Each of these, in their own way, would understand when I came home sad or grumpy, or if I called but didn’t have the composure to utter the words that I wanted to spill out of my mind. I recall one evening, after some particularly gruelling media, coming home late. The family had eaten. I was tired, upset and sensitive, but trying hard to hide all this from those who were closest to me. I walked into the kitchen and my eldest son Ben, then about 17, just came up to me and gave me a big long hug. He didn’t say anything and I had no words to offer him, but we both understood. My wife Kristin was constant and unwavering in her love, support and understanding.

Lessons learnt We made many changes as a result of the Wangary fire and Project Phoenix. Of these, the wonderful team in CFS and our collaborating partners must take the credit. Since 2005 there have been numerous other major fires on the Eyre Peninsula. While each has caused damage, none was to the extent of the Wangary fire. Of changes, there have been many. Better systems for issuing community warnings; improved community fire safety engagement; training of CFS and DEH fire leaders in incident management; better integration with MFS; more and larger firefighting aircraft and improved fire truck capability. For those who are in positions of responsibility in fire, emergency or crisis management organisations, I offer these 10 tips: 1 Write things down. Much of my evidence at the Wangary Coronial was based on detailed notes I took in the period leading up to and during the fire. Because of these notes, there was a story to tell. It was a story that was evidenced in my own hand and one that I was able to repeatedly and consistently return to. During any emergency there is a huge amount of information (and mis-information) to note, process and communicate. In the period after the emergency you will lose track of times, places, people, your actions and decisions. Even the most disciplined and ordered mind can become frazzled. I urge young emergency managers to practise the art of writing down key events – preferably in a bound book with numbered pages. Alternatively, in this digital world, record things. In my career I have given evidence to two royal commissions and two long-running coronial inquiries. On more than one occasion, my detailed notes have told a story. They have never let me down. If you make key decisions, particularly decisions that may change the course of

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an incident or the fate of people, write down who was involved and what the decision was, and note any factors that you may have considered and the rationale you used for arriving at that decision. 2 Prepare and practise decision-making. During the Wangary coronial inquest the Coroner and barristers asked questions of many people about their decision-making and the rationale for adopting one particular course of action over another. In my view, decision-making is something that the emergency services and emergency management agencies do not do well. Compared to the military and some industries, there is a lack of a coherent decision-making process theory in fire and emergency management. It is done in an incomplete and fragmented way in our doctrine and teachings at a national level. There is some very good research and theory on decision-making – some that is focused on fire and emergency services. I include here some of the recent Bushfire Cooperative Research Centre research on decision-making and some excellent texts on the psychology of decision-making. However, sadly, we as an industry have failed to consolidate this into a national doctrine. There is hope that the next revision of Australasian Inter-service Incident Management System™ (AIIMS) will give decision-making due priority. Following the Wangary fire, a small team of very talented incident managers developed a decision-making process to address this issue for the South Australian Country Fire Service. They developed a decision process with the acronym MIDAS. The key steps are: Mission (analyse the intent, purpose, objectives and end state); Information (identify factors, current and forecast); Develop options (consider most likely and worst case options); Analyse options (assess risks, exposures and vulnerabilities); and Select preferred option (this becomes your plan). In the absence of anything else, this is a good decision process to use and to train to. Once a decision process is adopted, it should be tested through scenario exercises. Even a table-top discussion can identify deficiencies in readiness and draw out the weaknesses in decision-making and systems of work. 3 Use aide-mémoires. During the Wangary fire, I referred to some aidemémoires to help me prepare and act during the event. An aide-mémoire (or checklist) is a set of notes or dot points that are written well before an event – perhaps after a training course or in reflection after a previous incident. The aide-mémoire is written in calm clarity, but enables you to recall actions or prompts that you should consider but might otherwise forget in the heat of the moment. In an emergency things are very dynamic and fast paced. You will be expected to make decisions with incomplete and often conflicting information. I find that even basic processes can be hard to remember in the heat of action. There may be procedural and technical processes that you might need to refer

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to. I find that a set of clear and simple aide-mémoires that can be carried around in a briefcase, handbag, glove box or ‘Go-Bag’ can be extremely useful. Often, during the progress of an incident, or perhaps when planning for a high fire risk day, I will pull out my aide-mémoires just to check I have everything covered. There is a second reason for establishing a set of aide-mémoires. Through our own life experience and through the experiences of others, we are continually learning. Every time I attend a course or a lecture I am taking things in and asking myself: ‘How can I apply this to my situation?’ Aide-mémoires then become a ‘continuous improvement’ record. What you take from instructional courses and lessons learnt in exercises and creative thinking can be drilled into practice through the aide-mémoire. I review my aide-mémoires about every six months to keep them current. I keep a set in my bag, which is always with me. 4 Encourage creativity and foresight. In hindsight, if, on the Monday night before the Wangary fire broke its control lines, we had been able to envisage what might have happened on the Tuesday, then our warnings, preparedness and actions may have been very different. Foresight is the ability to imagine what a fire or emergency might look like at a point of time in the future. It is an essential characteristic for emergency managers. Foresight is essential for estimating the community consequences of an emergency. I have found that the emergency management industry sometimes tends to create people of a fixed and structured mindset. Many emergency services are para-military in structure. The plethora of orders and procedures runs the risk of suppressing, indeed stifling, individual creativity. Our culture often discourages a divergence of thought and the use of initiative. I encourage readers to embrace the concept of ‘Intent Based Operations’ (also known as ‘Mission Command’). Intent Based Operations is a philosophical approach that encourages delegation of decision-making to the lowest appropriate level in a structure. Intent Based Operations is centred on a ‘leader’s intent’, an expression of task, purpose and end state. Properly applied, Intent Based Operations encourages good decisions quickly and promotes the use of subordinate creativity, spontaneity and initiative. The concept is predicated on good training, good communication and trust between seniors and subordinates. There is insufficient space to treat this philosophy properly here, but it is encouraging to see more discussion about Mission Command and an increasing use of leader’s intent in emergency operations. 5 There is no room for complacency. I sometimes think back to the conversations we had between CFS headquarters and the regional headquarters on the Monday afternoon before the fire broke control lines. Perhaps, if we had had a ‘devil’s advocate’ in the room that afternoon, our acceptance and

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confidence in the reports we were getting may have been tempered. Perhaps we might have acted more strongly to demand an incident action plan sooner. The nature of emergencies means that there is urgency in our response. There is often an inherent risk. Emergency managers are encouraged to plan and prepare well. However, what we know is that often we have an ‘optimism bias’ that results in us focusing on the probability of success. We become so focused on what we think we would like to happen that we do not see, or we ignore, disconfirming evidence. In focusing on the probability of success, we fail to see the consequences of failure. In what we do, we should assume nothing. We should test information and, from time to time, challenge strategies. When operating in teams, it can be instructive to include a ‘devil’s advocate’ on the team. Their role is to ask tough questions about the strategy and to look for weaknesses and flaws in the decision process. Good teams will sometimes rotate this role amongst team members. 6 The main thing: creating hope in the community. A big lesson for me after the Wangary fire was the effect that we were able to have on how people were feeling – simply by being there, listening and acting, sometimes in small and seemingly insignificant ways. It is easy to be distracted. Never lose sight of the main purpose for our existence: to serve the community and to create hope in their time of need. We build resilience in many ways, but most importantly by creating hope amongst the people we serve. Hope is the essence of what drives and motivates individuals, families, communities and generations. Without hope, there can be no confidence, no vision and no purpose. Whether it be through the execution of a deliberate strategy, or just doing our job, or going out of your way to do an unexpected act of kindness, or a simple act of service, or just being there with a friendly smile or a hug or a pat on the back, we create hope in people. Never underestimate the power of hope in humanity. 7 Know thyself. The Wangary fire took me on a challenging journey. I learned a lot about myself that I hadn’t really known before the fire. I encourage young emergency managers to spend time investing in themselves. Your people, your team, your organisation and the community expect us to be fit for the job we do. Every one of us has capacities – physical, intellectual, emotional and spiritual. We should critically analyse how well we are doing in each of those capacities. I encourage you to work on your own individual plan to strengthen yourself through building on these four capacities. We all aspire to do the best we can. This can be an admirable story if called to account. But it is no excuse for failure. In striving to be the best we can be, we must recognise that (in what we do) there are others out there who are smarter and better than us. We should see ourselves in a journey where, even if we think we are out in front, there are others who are ready to do what we do – only better. There are people

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about to overtake us at every point because they are better than us. Everyone should think about what they need to do to better themselves. 8 Stay positive. During the days after the Wangary fire I had many days of uncertainty and some dark days. As a leader, managing your mindset is crucial. Negative thoughts can overcome you quickly and a spiral into depression is a risk. I developed a set of personal behaviours that I tried to demonstrate whenever I was with our people. I deliberately analysed these behaviours so that they were deeply understood and ingrained in me. Being seen is important. But being seen to be positive is what makes the difference to other people on the team. Many readers will be leaders in their organisation. Others may not necessarily regard themselves as a leader, but will have leadership thrust upon them through fate and circumstance. An essential part of creating hope in your own people is to remain positive. No matter how bad the situation, or how uncertain the future may be, it is vital to infuse optimism into yourself, your thoughts and your deeds. Your presence, your attitude and the acts you perform will inspire others. Never forget the multiplier effect of a warm greeting, a pat on the back or an encouraging word. Never underestimate the power of your people seeing you at a time of challenge. Keep thinking positive thoughts, talking positive words and doing positive actions. 9 Take care of your people. My approach to dealing with the people affected by the Wangary fire was underpinned by compassion. I cared for my people and for the communities for which I was responsible. Our foremost legal and moral responsibility is to ensure the safety and welfare of our people. Words are unable to describe the tragedy that is felt from a serious accident or injury to one of your own people. Confronting friends, family and workmates after a critical loss is one of the hardest things you will ever have to do. The loss of one of your team, and the feelings associated with the grief that goes with it, will never leave you. If we look after our people well, and with compassion, your people will respect you. 10 Think and act with humility. The events of the Wangary fire, the public media exposure and subsequent examination through the coronial inquest would have been unforgiving if egos dominated. Like compassion, humility is one of those traits that we should know, we should practice, and we should aspire to. Humility is about respecting the other person’s view and respecting others for who they are. Humility is not underestimating the capability of others. It is embracing and promoting a spirit of service. Humility is seeking out and listening to different views and new ideas, even weird ideas. Humility involves being passionately curious and having a mindfulness to learn from the lessons of the past. The greatest threat to humility is when ego starts to grow. Often we fail to see this happen in ourselves. I was lucky in that I had some very honest and down-to-earth friends who (sometimes none too subtly) told me how they

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thought I was travelling and how others were perceiving me. Think and practise humility.

Some concluding remarks Fire will continue to be a threat to lives throughout the Eyre Peninsula and South Australia. As communities grow into forests and grasslands, so too will they become vulnerable. The task of protecting our community from fire cannot be one for the fire services alone. This is truly a responsibility that is shared, between fire agencies and governments but also by industry, landholders, communities and individuals. The risk of major fire continues to be real. Climate change, resulting in more severe fire weather and the likelihood of drier conditions in the future, means we can never drop our guard. No one can be complacent about the bushfire risk, for to do so would be to invite another disaster such as the Wangary fire of 2005. Through disaster and tragedy we must learn so that we become a stronger and more resilient community. A further aspect has emerged from significant fires in the last 15 years – the increasing scrutiny that the fire and emergency services leaders are experiencing in the days, weeks and months after a major emergency. The 1998 Linton fire in Victoria, the Canberra and New South Wales bushfires of 2002 and the major alpine fires in Victoria in 2003 and again in 2007 have heralded an era of formal inquiry. In the last 15 years we have seen fires cause and, more importantly, firefighters and fire managers endure (I can’t think of a better word) long-running coronial inquiries, royal commissions, parliamentary inquiries (at state and federal level) and ‘expert’ led reviews. Many of these inquiries then led to complex, high stakes and long-running civil litigation. I have been a Chief Officer of two fire services spanning a period of over 14 years. I reflect on my lessons learnt – both personally and from others. I sometimes worry about future generations of fire and emergency leaders. How will they learn the lessons I have? How will they cope with the increasing community, media and government expectations? These senior leadership jobs are getting increasingly hard. How do we best prepare them for their role? Accountability is a good thing, but it can be brutal. It can claim reputations and careers. In the time it takes for one fire to rip through a community – one bad afternoon – good people can be discarded. They can lose their careers, their reputations and their physical and mental health. The Wangary fire triggered many reactions in me. Through this tragedy and its aftermath, I have learned a lot about myself. I have grown to analyse the lessons that have been presented to me. I hope that, through this process, I am a better person and a better leader.

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I was recently asked: ‘What legacy do you want to leave?’ After dwelling on that for a while, my answer is: a new generation of confident fire and emergency service leaders. I hope, in some way, the lessons that I learned from the Wangary fire can help others to be better emergency managers. And so, as I finish this account, I again recognise that, through adversity and disaster, we can grow and become stronger – as individuals, as families and as communities. We all will be called upon in different ways and I hope that in the future you can make a difference in some positive way. Keep on learning. It is the key to unlocking the challenges of tomorrow.

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2 Incident management in Bundaberg during the 2013 Queensland floods John Watson Assistant Commissioner, Queensland Fire and Rescue Service

Introduction I grew up in Bundaberg from the age of five and I have spent much of my working life in the region. I commenced my fire service career with the Bundaberg Fire Brigade Board as a firefighter moving away to gain promotions in other locations. I returned to Bundaberg as the Area Director during the mid-1990s and managed five fire stations. It was during this period that I built many professional relationships with the other emergency services. Importantly I developed strong and enduring linkages with the regional council and in particular the Chief Executive Officer Peter Byrne and the councillors, in particular Deputy Mayor David Batt, who is also a former police officer. It was through these networks that I was able to build trust and an understanding of Queensland Fire and Rescue Service (QFRS) that would prove most valuable. In 2009 I again moved away for promotion, but the Bundaberg area was still within my sphere of management and the bonds and networks operated on a new level.

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At the time of the floods in Bundaberg and the North Burnett region in 2013 I was the QFRS Assistant Commissioner for the North Coast region. I have been in the QFRS (as the service was known at the time of the floods in 2013) for over 30 years and I have been involved in numerous major fire and disaster events both within Queensland and interstate. Some of those major events include Childers Palace Backpackers Hostel fire, Shoalhaven bushfires, Canberra bushfires, Cyclone Larry, Gaeta bushfires and the 2010 Queensland floods. During these events I performed various roles including Regional Fire Commander, Incident Controller, Fire Commander, Operations Officer and Planning Officer. When putting this story together I have reflected on my memories of Bundaberg, as I moved to Bundaberg with my family in 1965 and I had lived there or nearby for almost 50 years. During that time I had experienced flooding in the 1970s, 2010 and again in 2013, and there were many occasions when we expected flooding as a result of wet seasons and heavy rainfall. Residents of Bundaberg had developed many landmarks by which the ‘locals’ would judge a flood. The ‘old timers’ would often refer to patrons drinking on the second floor of the Melbourne Hotel because in the 1942 flood (the highest on record) the water was up to the floorboards of the pub. Another mark was officially recorded on the gatepost of the old gasworks next to Kennedy Bridge at the bottom end of Bourbong Street. In North Bundaberg familiar locations such as the Foundry and Hinkler Avenue indicated a fairly big flood, but as a rule ‘North School Hill never goes under’. The 2013 floods were to create new reference points. As ex-tropical Cyclone Oswald tracked slowly from central Queensland over Gladstone in January 2013, it delivered intense rainfall into the catchment areas of the North Burnett region around the Monto and Eidsvold communities. The communities experienced torrential rain over a 12-hour period that measured between 300 and 450 mm. The areas of the North Burnett region, including Monto, Eidsvold, Mundubbera and Gayndah received the deluge simultaneously, causing numerous creeks and streams to break their banks and the community to be stranded. At this time, further downstream the communities of Biggenden, Wallaville and the city of Bundaberg also experienced the severe weather effects of ex-tropical Cyclone Oswald. This chapter has been written from the point in time that the events occurred. It describes how the events unfolded and were responded to. In addition, it reflects on the many organisational changes that have taken place since January 2013, including major changes that saw QFRS become Queensland Fire and Emergency Services (QFES) and the retirement of the then Commissioner Lee Johnson.

The Queensland Fire and Rescue Service Queensland is divided into seven QFRS operational regions for administration and day-to-day management. The boundaries of the seven regions generally align with

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groupings of Local Government Areas and each is led by a regional Assistant Commissioner. Each region is broken into zones administered by a Zone Commander who is responsible for the business administration of the zone and subsequently each zone into areas. Each area is led by an Area Commander, who has an operational focus on ensuring service delivery and operational performance within their patch. The QFRS is in an almost unique situation of having control of both urban and rural fire services operating under the one commissioner. The unified command and single mission focus has enormous capacity to support the community, particularly when it is controlled through a well-structured command and control layer delivering logistical support in the field. QFRS has developed a concept of the ‘operations centres’ at Regional Operations Centre (ROC) and at State Operations Centre (SOC) levels; these used to complement the Australasian Inter-service Incident Management System™ (AIIMS) process and this has been developed on two fronts. The Regional Operations Centres and State Operations Centres are an additional ‘logistical’ source of resources that the Incident Controller can go to when their ability to source locally has been outstripped or exhausted. Second, the senior levels require a constant and accurate flow of information in order to develop a common operating picture and situational awareness.

North Coast region The North Coast region of the QFRS covers a geographical area of 55 000 km2 from Caloundra on the Sunshine Coast to Gin Gin (50 km north of Bundaberg) and west to Kingaroy. The region covers the six Local Government Areas of Bundaberg, Fraser Coast, Gympie, Sunshine Coast, North Burnett and South Burnett.

A history of natural disaster Queensland is prone to natural disasters and the disasters are not limited to any one specific region within the state. The types of calamity that we have come to expect range from tropical cyclones, severe weather events, storm cells and floods to droughts and bushfires, and they occur as frequently or infrequently as Mother Nature desires. The Burnett River rises close to Mount Gaeta, east of Monto, flowing in a general southerly direction past Eidsvold and Mundubbera. Downstream of Mundubbera, the river swings east, going through the townships of Gayndah, Biggenden and Wallaville before entering the major regional city of Bundaberg. The river flows into the ocean at Burnett Heads, some 435 km from its source. In the 120 years before 2013 the Burnett River had experienced major flooding several times, causing life loss and inundation of significant infrastructure and

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properties. Prior to the 2013 event, major flooding had been recorded in 1893, 1942, 1972 and 2010. Anecdotally, up until recent times the 1893 flood was thought to have been the worst, but the official benchmark was that of the 1942 flood or, as the locals know it, the ‘42 flood’. The 1942 level had been set (before the 2013 event) by the Bundaberg Regional Council as the one in 100 year height for buildings at a habitable height. The 1942 flood has been accepted as the benchmark as the worst flood recorded by the Bureau of Meteorology accurately recorded for the Burnett River at the Bundaberg City gauge, even though some historians claim otherwise. A simple Google search will uncover some amazing stories from early settlers to the area, if believed, making 1890, 1893 and 1942 flood events minor by comparison with stories of flooding on a biblical level. In recent history (2010–11), the central Burnett towns of Gayndah and Mundubbera saw major flooding on 28–29 December 2010. The Burnett River peaked at 18.25 m (59.9 feet) at Mundubbera – the highest river height since 1942 – inundating more than 20 houses. Downstream at Gayndah, the river peaked at 16.1 m (53 feet) with floodwaters reaching two houses. Both towns were isolated for several days and there was major disruption to the potable water supply and local agricultural production. In the same year Bundaberg experienced severe flooding, the worst in 40 years, after the Burnett River flooded the city, although the Paradise Dam reservoir contributed to some flood mitigation. This resulted in the evacuation of 300 homes. The Bundaberg Port, a major sugar exporting facility, was closed late in December 2010 as flooding deposited silt in the port, forcing its closure. The port re-opened in early March 2011 after successful dredging operations allowed ships to berth. The 2013 flood height eclipsed these peaks by almost 2 m. The severe weather that followed ex-tropical Cyclone Oswald affected Queensland and caused flooding in many regions of the state from Cairns to Brisbane. Its impacts affected several major river systems and catchments in Queensland and the Burnett River was chosen for this chapter as it captured a significant response to communities heavily affected. The way that the 2013 flood developed differently to those of the past was not only because of the new peak that was set but the speed with which the river rose. This could help to explain why so many of the residents were caught by surprise in light of the fact that there had been recent and long-term historical events that should have caused lessons to be learnt. Like many communities that settled in regional Queensland our forebears looked for major rivers as means of transport and sustenance, and relied on the timber that grew close to the rivers as well as the benefits of rich alluvial soils from silt of the floodplains. Bundaberg and many of the smaller communities developed along these same paths. Sometimes it’s very easy to stand back with modern eyes and the wisdom of hindsight and pass a comment such as ‘who in their right mind would build a town here?’ The simple answer is that, in those days, ‘just about everyone’.

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Disaster management in Queensland has been based around the resilience of each community and the ability of local town councils to support themselves during periods of crisis and disaster. Where the calamity is of a scale that the local community cannot respond and recover, its neighbouring communities would come to assist. As the structure of disaster management developed, additional levels of support have come from state and federal governments. On a local level councils have developed State Emergency Service (SES) volunteers who have become the frontline in times of disaster. The SES is founded on volunteers from the community and resourced by local government to come to the assistance of local people. In modern times during major disasters SES volunteers have travelled to other communities to assist their neighbours when their local resources can no longer cope with the level of disaster. SES units provide an excellent support force and are more often than not a great source of local pride for the community. The Queensland Government also has a legislated responsibility to ensure that they support the local governments in the delivery on their counter-disaster capability. At the time of the 2013 floods Emergency Management Queensland had the role of audit and support for the various Local Disaster Management Groups to develop, document, exercise and disseminate their plans. Emergency Management Queensland also takes an active role in the supply and delivery of equipment and training across the 72 Local Government Areas in Queensland. The capability of individual councils to build the necessary capacity varies from shire to shire and the level of interest and resourcing also vary. Often that is commensurate with the history of the area and as an example communities in the far north of the state have well-developed plans for cyclones yet there may be far less planning for failure in their water supplies due to demographic and climatic differences. The relative size, population density and wealth of an area will influence its ability to fund disaster management operations and their plan may be to call for assistance far earlier than a council that has the necessary capability.

Evolution of disaster management The District Disaster Management Group is led by a Queensland Police Service District Officer, who provides support to one or more Local Disaster Management Groups. The District Disaster Management Group will activate when the event or disaster is of a magnitude that the local resources and capability of the Local Disaster Management Group cannot cope or they require additional support. The State Disaster Management Group has membership of Ministerial/ Departmental level staff. Beyond this point the federal government support is provided through Emergency Management Australia, who has the national resources of the military and the federal government. However, at the ‘sharp end’

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of the disaster it is still the local government that has to deal with the disaster that is occurring in its backyard. QFRS had been providing support to Local Disaster Management Groups through various functions and roles for several years. Although not specifically supported through legislation, Commissioner Lee Johnson had taken a lead role in introducing AIIMS. It was introduced into the fire service and he championed it across all of the emergency services as well as to assist the local government in times of disaster. Emergency Management Queensland, Queensland Ambulance Service and many local government associations had come on board AIIMS with only the Queensland Police Service holding fast to its Queensland Police Incident Management System, which was developed locally and evolved from the American National Incident Management System (NIMS). The NIMS and Queensland Police Service systems are remarkably similar to AIIMS with a few exceptions. Over several years and various disasters QFRS has raised its profile in the disaster management field from a combatant agency for fire, to a rescue agency for vehicle, aircraft and transport events to having an Urban Search and Rescue (USAR) capability along with some disaster management capability in command and control of resources. The USAR capability was developed as a natural progression for QFRS in the rescue field. Road crash rescue had been taken on by QFRS as an organisation in the early 1990s and provided a genuine life-saving role for firefighters. In the era of privatisation and selling off services across the country, a new direction was in the wind and other states had taken on ‘technical rescue’ to varying degrees as components of their work. In its entirety technical rescue encompassed USAR, high angle rescue, confined space and trench rescue as well as swift water rescue. Most of these skills were common amongst fire services; they rescue people from heights, holes in the ground and so on. Not new but far more structured and accredited, QFRS got on board with the system. This evolution came to the fore in the lead-up to Cyclone Larry in 2006 when, through a close relationship between the Commissioner and the then Chief Officer of Emergency Management Queensland, there was the epiphany that they had a cyclone imminently bearing down on the major regional city of Cairns and they needed to act in a pre-emptive way to support the community of Cairns. Subsequently, on each occasion as a disaster loomed or a major event occurred, QFRS became more embedded in the response and then the recovery – the recovery because of the ‘surge capacity’ that resides within QFRS. That surge capacity is made up of 35 000 volunteers who are organised and willing to assist, along with a command and control structure that commands, leads and manages those resources. Natural disasters regularly occur on a seasonal basis, so the surge capacity can be continuously available; for example; fires and floods usually follow each other in a sequence on a seasonal basis.

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The flash flooding in Toowoomba and the Lockyer Valley in 2011 brought QFRS into the spotlight when 34 people lost their lives (another three are still unaccounted for) and a commission of inquiry reviewed the performance of all agencies that had a stake in the event. As with all inquiries several recommendations were made, and these included the need for QFRS to address several shortfalls in its capacity to respond to similar events by increasing the numbers of trained personnel, and upgrades in equipment and procedures. After the commission of inquiry, QFRS enhanced much of its policy, operational planning and preparedness to improve the swift water response capability as part of the technical rescue function. One of the key enhancements was the inclusion of the Severe Weather Alert Level (SWAL) process, which was based on the very successful Wildfire Alert Level (WAL) that had been introduced to trigger levels of readiness for the bushfire season. The SWAL also had predetermined trigger points that caused various actions to occur, based on weather and hydrological conditions within the catchments.

The 2013 Queensland floods In 2012 the region had experienced an extended dry period leading into December and we were waiting for significant rain to end the fire season. The preparations for the severe weather season had commenced as part of ‘Operation Baker’. During the first three weeks of January 2013 significant fires had been burning in the North Burnett region around Gayndah and Mundubbera. Commissioner Lee Johnson was travelling to the far north of the state and by that time (the third week in January 2013) the far north was beginning to receive its annual monsoon rains and indications that tropical Cyclone Oswald would cross land somewhere in the Gulf of Carpentaria. During the weekly video conference I passed the comment to the Commissioner that ‘it would be nice if he could bring a couple of inches of rain back with him to help with our fires’. Reminders of this comment would be handed back to me frequently as being more than a little prophetic in hindsight. An Incident Control Centre had been established at the Mundubbera fire station and several Incident Management Teams had been rotated during the operation. On 20 January 2013 demobilisation had occurred from Mundubbera and Gayndah as the fires were well within the control of the local rural brigades. On 24 January 2013 the North Coast region hosted the annual Australia Day medal ceremony for the emergency services; this was conducted in Gympie. The ceremony is held separately to those conducted by local governments to reduce the volume of awards handed out at the community events and to recognise the efforts of the emergency services staff and volunteers. During the informal discussions amongst those attending, the topic turned to the current level of bushfire activity around the region and the dire need for rain. It

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was at this time one of the local rural area directors mentioned that we were in for a real deluge, with over 300 mm of rain predicted in the next few days. I probed a little and it was explained that this was a result of the effects of ex-tropical Cyclone Oswald having turned into a rain depression and heading south. I have developed a sensitivity to this type of information as in the past little snippets such as this may have been overlooked; it’s uncanny how many times small leads play out. Commissioner Johnson constantly raises the need to be aware of ‘what’s going on in your patch’ and there is nothing like the acute embarrassment of having a gap in my knowledge pointed out by the Commissioner to enhance my situational awareness. Later that afternoon a state-wide video conference was coordinated as part of Operation Baker to check the state’s readiness for the predicted heavy rainfall. The effects had already commenced in Cairns in the far north parts of Queensland and as far west as Mt Isa. The tropical coastal areas were quite accustomed to heavy rain in the wet season where recordings were in the hundreds of millimetres with up to a metre of rain falling. Their river catchments received this type of event on an annual basis and the community viewed this as almost part of the season. Over the next 24 hours ex-tropical Cyclone Oswald moved slowly south into the QFRS Central region that includes the Mackay to Rockhampton area. As the weather system moved south the capability of the river networks to cope with the torrential rain reduced. On 25 January an Operation Baker video conference was again convened to track the progress of the rain depression caused by ex-tropical Cyclone Oswald down through the state and to review the planning and preparedness of each region. The Assistant Commissioner for Central Region Ewan Cayzer described the deluge as unrelenting from Mackay to Rockhampton and said he had never experienced rainfall at this intensity. He commented that the Bureau of Meteorology forecasts of 300 to 400 mm of rainfall in the previous 24-hour period were severely underestimated and probably twice as much had actually fallen. The intelligence provided by Assistant Commissioner Cayzer gave regions such as the North Coast a good ‘heads up’ that we could expect similar conditions. The other comment was that the duration of the deluge was staggering, with the low pressure system seeming to stall over Central region far longer than predicted. I felt a sense of foreboding, and the intensity in Ewan Cayzer’s recounting of his experiences had my undivided attention. Ex-tropical Cyclone Oswald had taken a path from the Gulf of Carpentaria south into the Carpentaria area where it tracked inside the Great Dividing Range south towards the New South Wales border; however, it was large enough and close enough to the warm waters of the Coral Sea to continue to draw moisture and maintain its intensity as it moved south.

Pre-deployment In 2010–11 Bundaberg had experienced major flooding and, based on those experiences, we planned for likely locations where roads might be cut and where

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we could need to pre-deploy our resources. The region has several major river systems flowing through it and in 2011 we deployed resources to Kingaroy in the South Burnett, Maryborough and Gympie on the Mary River, and Gin Gin, which is affected by the Kolan and Burnett rivers when they flood. Resources included swift water rescue crews, equipment and Incident Management Teams. In some cases additional fire crews were deployed to communities that had been separated by bridge closures and where communities were isolated. QFRS had deployed swift water rescue teams into Bundaberg for Christmas in 2010 and sustained those crews for almost two weeks. The creation of a significant flood event on the Burnett River usually requires the river to rise due to heavy rain over several days in the river catchment. Because of the length of the river and the knowledge of the floodplains, the communities that live along the river are very familiar with its behaviour and what levels can be expected during any given event. Localised rain along the river may cause local flooding, but by the time the extra flow reaches Bundaberg it often causes only a minor rise of the river level into parks and low-lying areas, rarely causing major damage or inundation of properties. In preparation for possible flooding in 2013, swift water operators and equipment were deployed to Bundaberg, Kingaroy and Childers in readiness for possible road closures along the Bruce Highway. In severe weather events over the previous five years the Bruce Highway (the national highway running through North Coast region) had been cut on several occasions, restricting our ability to deliver services. Sections of the Bruce Highway were frequently cut by floodwaters from the Mary River, Cherwell, Burnett and Kolan rivers. The highway between the Sunshine Coast and Gin Gin was regularly cut at the Cherwell River, and between Childers and Bundaberg numerous creeks and the Gregory River also became impassable. Fundamentally the region was divided into several sub-regions that had to be self-sufficient until the stormwater receded. To the west of the region through the North and South Burnett numerous creeks and rivers caused similar disruption so pre-deploying resourcing into Kingaroy gave some support to the communities of the North and South Burnett.

Command and control structure On the morning of 26 January (Australia Day) I woke to the sound of very heavy rain at my residence in Hervey Bay and not long afterwards I received a phone call from the Acting Deputy Commissioner of QFRS Mark Roche. The Acting Deputy Commissioner had received reports of widespread heavy rain and was enquiring as to the region’s level of preparedness for a severe weather event. Based on the available resources and historical events I felt that the region had adequately prepared for the events that were unfolding. I thought that we had planned and pre-deployed to a reasonable level; however, hindsight would again prove me

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wrong. In a region as large as the North Coast, covering all of the possible scenarios would be maddening and sometimes it feels like the board game ‘Battleship’ where you place resources using all the information available. This is not an exact science, and you win some and you lose some. Later that day the Commissioner convened a video conference to establish a common operating picture and assess the level of readiness as well as receive a situation report from each of the regions. This provided each of the Assistant Commissioners with an appraisal of the situation across the state and the potential for support as required. The Commissioner has a passion for command and control systems, and he often takes lessons and systems from the military for use within QFRS. Systems include Command, Leadership and Management, Commander’s Intent and, of particular relevance in operations of this nature, Unified Command. In the normal business day within the QFRS the operational streams of urban and rural operations each have individual management and reporting lines. Each stream operates and reports up through their respective managers and Assistant Commissioners to the Commissioner. When a major event occurs the Commissioner has developed a process to unify command under a ‘Regional Fire Commander’. The Regional Fire Commander formalises the unification and delegation of authority to a single commander within the regions affected. This with a mission objective delivers the Commissioner’s Intent throughout the organisation. This makes available to the Commander all of the resources of QFRS without having to go through any other line management processes. It clarifies who is in charge and articulates who is responsible for operations for the event. The Regional Fire Commander Standing Order has been enacted for major fires and other major campaign incidents, and has produced the desired results. On the morning of 26 January the Commissioner invoked the Regional Fire Commander Standing Order for the region and I was appointed as the Regional Fire Commander. By mid-morning, the Incident Control Centre in Bundaberg had been established in preparation for potential flooding in Bundaberg. By lunchtime a major flood was predicted and the establishment of a temporary fire station to be located in North Bundaberg was taking shape, with plans for the Bargara appliance and crew to be deployed to the North Bundaberg Primary School on North School Hill. In Hervey Bay the rain was falling and the roads out had been cut in all directions. From this point I was flood-bound and unable to travel to my ROC in Maryborough. In the ROC I had my two Directors, Chief Superintendent John Bolger (Director Regional Operations) and Superintendent Brad Schealler (Director Regional Development), along with their support staff. Both are very seasoned senior fire officers who have had extensive experience in fire and emergency management including flood events.

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Tornados in Bundaberg During the video conference convened at around 1.30 p.m. on 26 January, reports started coming in that several tornados had hit the coast near Bundaberg crossing at Bargara, Burnett and Elliott Heads, causing damage to the multistorey apartments on the esplanade. The Bargara station had responded to a vehicle crushed under a fallen tree with occupants trapped. Numerous reports were received of roofs blown off and damage caused by the tornados. I listened to the report almost with disbelief as tornados in Bundaberg had been outside the scope of our discussions and totally unexpected. This was not a weather event regularly experienced in the region, but on rare occasions they had occurred. Damage to structures and property was not common as they usually occurred in uninhabited rural areas. Their paths would be obvious as trees were completely stripped of foliage, making clearly visible tracks. Five tornados were reported during the event in Bundaberg; one also crossed the coast at Burrum Heads some 50 km south of Bundaberg and another touched down in the suburb of Avenell Heights in South Bundaberg. After the event the Bureau of Meteorology explained that, due to the track ex-tropical Cyclone Oswald had taken, it was just far enough inland from the coast that it created a ridge of unstable air just off the coast, and it was within this unstable area that conditions were conducive to the development of waterspouts or tornados. During my visit to Bargara on the Monday (28 January) I viewed the destructive path of one of these tornados. A path of destruction approximately 500 m wide had been carved through the properties from the ocean front at Bargara inland for about 1.5 km. As this tornado moved inland it had raised roofs and knocked over trees and fences along the way. Yet immediately adjacent to the path properties were untouched and it had caused no damage at all. It was quite amazing to see the destructive power that had been unleashed in such a localised area. As I drove along the esplanade at Bargara Beach many of the medium-rise apartment buildings had their curtains blowing in the breeze, as the glass doors and windows had been blown in by the tornados. The windows and doors had been installed to withstand cyclonic winds. Large Norfolk Island pines that lined the foreshore had survived storms and cyclones over many decades but were no match for the weather on that day. The damage to these and other properties along the coast and in Bundaberg was almost overlooked in the shadow of the great disaster that was unfolding on the Burnett River.

Flooding in the North Burnett region In the North Burnett region on 26 January (Australia Day) the communities were experiencing severe flooding. Where previously the usually placid Burnett River had meandered through the townships of Mundubbera and Gayndah, on the afternoon of the 26th and through that night into Sunday, the river had swollen

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beyond recognition and broken its banks in several locations flooding the towns and inundating hundreds of homes. Acting Superintendent Adam Gwin had been home in Gayndah for the weekend from his deployment to the Sunshine Coast and was preparing to return to Maroochydore where he was relieving as the Zone Commander. The Gayndah Mayor Don Waugh saw Adam driving out of town and flagged him down to let him know that the town needed him to stay; the Mayor expressed in the strongest terms that Adam wasn’t going anywhere. It is towns like Gayndah and Mundubbera where the Local Disaster Management Group has limited resources and people who can be called upon in disaster events. Here the local police officer and the Area Commander of Fire Service step up and provide support to the councils. Acting Superintendent Gwin, along with several of his firefighters, worked tirelessly to evacuate residents from their homes in response to the disaster and assisted the community during the recovery. The crew from the Bargara Fire Station had been deployed to North Bundaberg mid-afternoon on Australia Day, having dealt with the rescues on the Bargara Esplanade. The information coming through from the Local Disaster Management Group was that the Burnett River would flood due to the heavy rainfall and the flow of floodwater from the upper reaches of the North Burnett River. Intelligence also made it clear that it was likely that flood levels would exceed those experienced in 2010–11. The firefighters under instruction from the Queensland Police Service began doorknocking the residences in the low-lying areas of North Bundaberg to encourage the occupants to evacuate. To convey how the topography played such a big role in the flood, I will focus on the older section of North Bundaberg. This may help you understand the reasons for the level of damage sustained and the apathy exhibited by local people in the lead-up to the flood. In cross-section the elevation of the land on the north bank of the Burnett River resembles a very gentle ‘saw tooth’ configuration with the river bank and parks at the first level of approximately half a kilometre, then a ridge at Perry Street, which gently falls gradually for approximately 2 km, and another ridge to North School Hill, which again falls gradually to North High School in Marks Street. These ridges with gradual falls in elevation have the effect that when a ridge is breached by floodwater the depth increases the further from the river that you go until you reach the next ridge. Even at three levels from the river the lowest point of the third plain above the river is still only approximately 7 or 8 m above the normal river height. The misconception of the people living on the second level, which included the area from Perry Street to the base of North School Hill, was that they would be high and dry. However, once the river broke through the first ridge west of the Tallon Bridge and created a new channel further downstream opposite Millaquin Sugar Mill, people found themselves in the main current of a

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flooded river. This area had been well established with a residential area of about 800 homes, ranging from near new to up to 70 or 80 years old; the homes had never been inundated before so their disbelief was understandable. The area has a large commercial and industrial precinct adjacent to the river. As the firefighters doorknocked the homes on that Saturday afternoon in the lower lying areas of North Bundaberg, they met responses from the residents ranging from apathy to hostility at being asked to leave. The responses included comments that floodwater had never reached here before so, ‘Don’t worry, mate. I’ll get out if I need to’.

Realising the need for additional resources Yet another role that QFRS had taken on through circumstance was that of rapid damage assessment of infrastructure and properties. As previously mentioned, QFRS plays a role on the national and international stage by maintaining a USAR capability. As part of its capability teams will enter a disaster area and complete a rapid damage assessment to triage buildings and establish a priority to best target the search, rescue and recovery efforts. Originally a paper-based process, QFRS developed an electronic system for a hand-held electronic device known as a ‘Trimble’. Using Trimbles, technicians quickly gather relevant information, store it and up-load it into databases and onto maps to provide numerous interested parties with a snapshot of the area and the level of damage in a disaster zone. To gain early intelligence as to the level of damage, QFRS has an agreed assessment period of 72 hours from the time of the disaster to having the data presented. The initial impact of the tornados hitting Bargara had started the clock ticking and there was an organisational imperative to gain as much intelligence as possible. Direction was sent through the Incident Control Centre in Bundaberg to have the swift water rescue teams respond to Bargara to begin the rapid damage assessment work and start developing a picture of the level of devastation that they were experiencing. After two hours the ROC was not receiving any advice that the rapid damage assessments had commenced, and every enquiry was being batted back with comments that they were busy or the weather conditions were too difficult. Frustration at the lack of information throughout the chain of command began to build and questions over the ability of the Incident Control Team to cope with the scale of the event started circulating. The Incident Control Team was reporting to the Regional Operations Centre that they were coping with the workload and they would deal with each task in order of priority with the resources available. In reality the Incident Control Team was beginning to struggle with the magnitude of the event and it was becoming obvious even at this early stage. When pressed as to why they had not deployed any of the three swift water rescue teams staged in Bundaberg to undertake the rapid damage assessment, the response filtered back that they were too busy rescuing stranded people from the rapidly rising

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floodwaters. This for me was a moment of realisation that we didn’t have enough resources in the right place and my pre-deployment strategy (‘Battleship’) was listing and in trouble. The Incident Control Team had a staff of four people and was receiving requests for assistance and information from the Local Disaster Management Group, ROC and crews at work. To compound the situation additional staff could not be called back to support the team due to road closures and isolation. From lunchtime on the Saturday until late Sunday evening, the Incident Management Team in Bundaberg was isolated with no additional staff or support able to get into the city by land, sea or air. This was also the case for the single fire crew from Bargara and other services such as Queensland Police Service and Queensland Ambulance Service based in North Bundaberg. This was an experience in isolation and helplessness that many of our people had never had and would later cause a great deal of psychological trauma. By late afternoon on Australia Day there were strong indications that Bundaberg was going to experience its worst flood, with predictions that it would exceed the 2010 flood level and approach that of 1942. Very few people had accurate recollections of the 1942 event other than the anecdotal stories of their forebears and the 80-year-old council mapping. Much had changed in development trends, drainage and the hydrology of the Burnett River in 80 years. By sunset the rail and the two traffic bridges had been closed, and the city was divided into separate north and south areas. During this period the regional and state managements were planning for support to go into both Bundaberg and the North Burnett region when access routes opened up. At the same time other regions, including areas from Rockhampton to Gladstone and south to the areas of Baffle Creek which borders onto North Coast region, were experiencing flooding and devastation. Major flooding of Baffle Creek and the Kolan River would force rescues and evacuations through treacherous, fast-flowing floodwaters.

Rescue operations Saturday night would be a long one for the swift water rescue teams, who were called to perform rescues in locations from Gin Gin to Moore Park. Some of these rescues were extremely dangerous and required great courage and tenacity by the teams. Rescue at Bailies Road The following is a précis of an extended swift water rescue that took place from 4 p.m. on 27 January 2013 at Bailies Road, Kolan River. The vignette is taken from a first-hand report by firefighter Trevor Farraway, written to me as the Assistant Commissioner.

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At approximately sixteen hundred hours firefighters Trevor Farraway and Andrew Smith responded with Martin Cole, a Bundaberg Surf Lifesaving Club Inflatable Rescue Boat operator, to a report of persons trapped on the roof of their house near the old caravan park near the river at Moore Park beach. The directions were unclear so the crew responded to the Moore Park beach caravan park to investigate. On arrival there was no sign of flooding and Smith contacted the fire communications centre (Firecom) for any additional information. After a short period of time, Firecom rang us back and stated that the police had said that the only additional information that they had was the house was located somewhere in the vicinity of Bailies Road. Bailies Road is within close proximity to the Kolan River. The crew proceeded along Bailies Road until they could travel no further due to water back flooding up a small creek and into cane fields. There was a series of fishing shacks located on the banks of the Kolan River. Farraway and Cole put the Inflatable Rescue Boat into the flooded creek and attempt to locate any persons trapped at the shacks. Smith stayed with the vehicle and trailer and a mobile phone to contact Firecom. Both Smith and Farraway had portable radios for fire ground communication. The pair in the Inflatable Rescue Boat proceeded to travel slowly into the back flooded area, which became more extensive the closer they got to the river. They travelled through approximately three hundred metres of flooded bushland and came into an area of mangroves. The water flow in this area was increasing rapidly, which indicated that they were getting closer to the river. They entered what looked like a creek, and followed this for a short period of time taking them directly into the Kolan River. The water in the main flow of the river was running fast, and Farraway did not want to enter this fast flow unless absolutely necessary. The area of sugar cane to the rear of the line of shacks was underwater so they decided to proceed upstream against the flow from this point as the flow was not as intense. Farraway contacted Smith and informed him of the plan and advised him that we would probably have trouble retracing their steps back through the maze of mangroves and bushland. Farraway suggested that they would motor directly over the top of the flooded cane paddock and cut directly across to a boat ramp that was located on Bailies road about one kilometre behind their location. This was also an ideal location for an Ambulance to pick up any casualties that they may have located. Farraway had been up in this area fishing only a few weeks prior and knew the sugar cane was only about two feet high, and the water was at least ten feet over the top of the cane. Smith complied and relocated to the boat ramp.

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The pair in the boat proceeded out over the cane and after approximately one hundred metres came across the first fishing shack. It was almost fully submerged with only approximately sixty centimetres of the peak of the roof out of the water. They continued to proceed another one hundred metres upstream to the second shack and it too was almost completely underwater. The flow of the water had increased at this location along with the amount of debris in the water. The next shack up the river was larger than all of the others and was located where the high voltage transmission power lines ran across the river. As they approached the larger shack a head popped up on the upstream side of the house and they could see a middle-aged man on the roof. They asked him if he was ok and how many other people were with him. He stated that there were three people and one was in a bad way. Once Cole was able to get the boat close to the house they could see a middle-aged man was injured with what appeared to be lacerations, a younger male who appeared uninjured and an elderly woman. The elderly woman was lying on the upstream side of the roof and had extensive injuries to her legs and arms. Farraway radioed Smith and informed him that we had located the casualties and that they would need an ambulance. With only minimal first aid supplies Farraway quickly dressed the worst of the lady’s wounds and loaded everyone into the boat. The elderly lady could not walk and had to be carried into the boat and they also picked up a small black and white dog to complete the family unit. The water level continued to rise quickly and by this time about a metre of the roof remained above water. They proceeded to head across the rear of the shacks again and make their way to the boat ramp meeting point. Under normal operating conditions the boat could carry six persons. The force of the current and by now they were dodging debris in the water made their going very slow. After about ten minutes they had only travelled about one hundred metres and at that rate it would take us about an hour to reach their destination. Concerned about their fuel consumption Cole tried various manoeuvres to try and make some distance to no avail. Farraway had to make a decision as he had four people’s lives and a dog to consider and he didn’t want to risk running out of fuel. Without power it would put them in a situation where they would have no control of the boat. They decided to turn the boat around and head downstream to the Miara Holiday Park which was on the opposite side of the river approximately one kilometre downstream. Farraway contacted Smith and informed him of what they were doing. They discussed a few options and decided that Smith would relocate back to Moore Park where he would have better phone and radio reception. One issue that Farraway had with going to

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Miara was that it was cut off due to flooding on the access road from the North side of Bundaberg and the only way out would be in a helicopter. They made it to the caravan park in quick time only to discover that it was flooded. Miara is at the mouth of the Kolan River and it opens up really wide. As it is at the mouth of the river Farraway did not think that it was possible for the caravan park to flood. As the caravan park was no longer an option, the only other alternative was to access Moore Park beach on the opposite side of the river. On the beach they could be accessed by 4WD vehicles from Moore Park. At the mouth, the river is at its widest at this point and the flow was not nearly as fast and they were able to cross to the southern side of the river. Cole found a suitable location to gain access to the beach. Then Cole and Farraway removed the casualties from the boat and placed them on the beach in a safe location. They then carried the boat to their location and used it for a makeshift shelter. The elderly female casualty was then placed back into the IRB and made as warm and as comfortable as possible. Farraway then made contact with Smith who was now at the Moore Park Surf Lifesaving Club. He informed Smith of their location asked Smith if he had organised vehicles to retrieve them. Little did the group sheltering on the beach know but a section of Moore Park beach was impassable during the incoming tide due to fallen timber and tree stumps on the beach. It was decided that the rescue could not be attempted until low tide around midnight. It was now eighteen thirty hours and it was starting to get dark. The only lights they had were the light on Farraway’s Swift Water helmet and a dolphin torch that was in the boat. The rescue crew made the casualties as comfortable as possible and managed their injuries. Farraway radioed Smith to see if there was any way of getting more first aid supplies and some water to our location. After a period of time Smith advised that two members of the Moore Park Surf Life Saving Club were going to access their location on a Jet Ski via Oyster Creek which was behind our current location. They arrived with a fully stocked first aid kit and some water. The two lifesavers were able to access Moore Park beach safely in the same spot where we landed. Finally the rescue team with their patients were retrieved and handed over to Queensland Ambulance Service Paramedics at approximately 0900 hours on 28 January. The rescuers would then travel back to North Bundaberg and continue to assist with the rescues and evacuation of residents. They would continue their efforts until they were helicoptered out at around 1100 hours on 29 January. When I read the story above I was moved by the sheer determination, courage and ingenuity displayed by the intrepid team involved. I am sure that without their

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selfless efforts lives would have been lost. After the event I heard stories from many locations along the Burnett River as far up as Eidsvold of rescues being performed by farmers on tractors saving friends from trees when the floodwaters rose so quickly they could not get out. Many of these rescuers would be recognised with awards for courage and bravery after the event. A significant issue that arose during the rescue operations was that two of the three rescue teams based out of Bundaberg became trapped by the rising floodwaters from which they had rescued members of the public. They had travelled into an area with four-wheel-drive vehicles towing trailers with rescue equipment and performed the rescue, and their path of retreat had been cut by the rising waters. The two crews remained marooned there for two days. They were safe, sheltering in farm residences or on one occasion bunkered down in a fire station, but lost to our rescue capacity for the duration of the event.

Evacuation and the citizen’s navy On Sunday, 27 January 2013 the rain had stopped and the sun was out, but the water was still rising and Bundaberg’s worst flood in recorded history was still on track. Concerns in Bundaberg were being compounded by the knowledge that the water from the North Burnett River had not yet arrived and this would push the flood peak to new heights. During this period I was facing my own personal challenges as I was still flood-bound in Hervey Bay while the ROC had ramped up to a fully active status. Although I was able to participate in video and telephone conferences and I could receive emails for communication, I felt that I was not in a position to command the region or add value. It was at this time that I advised the Acting Deputy Commissioner that he should appoint Chief Superintendent John Bolger as the Regional Fire Commander. I would again be appointed as the Regional Fire Commander once I was free from the constraints of the local flooding. In Bundaberg the rising floodwaters were now threatening the residents of North Bundaberg and the evacuation was well underway. Initially the community was there in the form of an armada of small private boats going door to door and rescuing people from their front stairs and porches, and later from their rooftops as the water rose. This ad hoc citizen’s navy continued their effort for hours and were supported by the emergency services workers in the North School Hill. The North School Hill was by now the north bank of the Burnett River. Everything south of that ridge was going underwater. By Sunday afternoon well over 1000 people had been rescued or evacuated to higher ground. The clear skies allowed reinforcements in the form of several army Black Hawk, Emergency Management Queensland Rescue and Surf Life Saving helicopters to join the evacuation. Ironically, those being rescued on that day were the same residents that refused so vigorously less than 24 hours earlier to heed the call to evacuate. Twenty-four hours earlier they could have walked or driven out

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and taken a few of those precious possessions with them; now they would lose them to the floodwaters. Once the evacuations were complete the residents moved to makeshift evacuation centres at the North High School and when the flood level began to rise above the North School Hill they retreated to the Oakwood Caravan Park some 4 km north-west of the school. The centres had few amenities or the capability to cope with the 2000 people who sought shelter, so the decision was made to commence the secondary evacuation to the south side of Bundaberg where there was the necessary support. The helicopters then began the non-stop shuttle from the caravan park to the Hinkler Airport. The shuttle commenced with the injured, sick, aged or urgent cases, then moved through to the fit and healthy.

Floodwaters reach new heights Saturday had brought the realisation that floodwaters would reach new heights and that included the inundation of critical infrastructure including the Bundaberg Fire Station, which up to that point housed the Incident Control Centre. I directed the Incident Controller to look for an alternative temporary Incident Control Centre site and be out of the fire station by Sunday afternoon. This entailed relocating appliances and equipment to a suitable site. That site was the Hinkler Airport, and the temporary fire station and Incident Control Centre would be operational out of a hangar and the office of a flight training school. The predictions of record flood levels raised concerns about several key pieces of infrastructure and three key elements were highlighted as the floodwaters rose. The Talon Bridge had been built 20 years earlier and, as mentioned above, the deck of the bridge was higher than the Burnett Traffic Bridge; however, the north side departure ramp discharged traffic below a level that would be affected by a moderate flood. Another interesting design feature of the bridge was that, as the water rose and reached the underside of the bridge, the western face of the bridge began to catch the flood debris and cause a dam effect. The floodwater was forced off each end of the bridge with devastating consequences. On the northern end of the bridge the flow of water around the approach ramp caused turbulence that eroded the base material and left a gaping hole in the ramp. At the southern end of the bridge the dam effect off the face of the bridge caused water to be redirected towards the Bundaberg Base Hospital. The redirected water entered the hospital’s electrical sub-station, eventually causing the power to be shut off and ultimately causing the evacuation of the entire hospital for the first time in over 100 years. The Talon Bridge was closed for three days after the flood subsided for major repairs to the approach ramp while the 100-year-old Burnett Traffic Bridge was opened as soon as the floodwater dropped. The events over that 48-hour period highlighted a need for a survival strategy for the fire service when we are placed in an extraordinary situation and the need to continue to press our people to provide an accurate picture as to the situation on

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the ground. It also highlighted the need for more extensive planning and predeployment of resources during severe weather seasons. Developing a ‘big picture’ appreciation and responding in kind with adequate resources were essential. The situation had stabilised by Sunday night and the rate at which the water was rising had slowed to steadily rising towards a new peak. During this period people had settled into evacuation centres and temporary housing. Preparations had commenced for the recovery that would begin as soon as the water began to recede.

Recovery efforts The water levels between Hervey Bay and Maryborough were dropping quickly and it was clear that I would be able to get to either the ROC or Bundaberg on Monday morning. The region had been working with the state level to plan for the recovery effort, commencing with the rapid damage assessment process that would be larger than any undertaken since the Brisbane floods of 2010 and that would be required along the length of the Burnett. Other plans were being developed to provide relief staff for those who had been exhausted in Bundaberg including operational crews and the Incident Management Team. The need for information was increasing as the media interest grew. I decided that to gain an appreciation of what was happening on the ground I needed to go to Bundaberg and get a firsthand insight into our needs. On Monday, 28 January 2013 the recovery effort commenced even though the Burnett River had yet to peak. Resources had begun streaming into Bundaberg first by air via commercial flights and military transport and by mid-morning, by road from the south. I travelled by road from Hervey Bay as the rivers (other than the Burnett) and streams began to fall and bridges and roads opened. On arrival in Bundaberg I visited the makeshift Incident Control Centre and fire station that had been established in a hangar in the Bundaberg Airport. Conditions were not good as the facilities were very basic with little in the way of accommodation or infrastructure to work with. The first deployed staff had arrived about an hour before my arrival and had barely had time to meet the team that had endured the worst of the response phase. The members of the Incident Management Team that had been in place were obviously fatigued and in desperate need of rest and relief. Inspector Ron Higgins was the outgoing Fire Commander and he was handing over to Superintendent Michael O’Neill who had flown in with a specialist Incident Management Team to take on the rapid damage assessment and establish the resourcing requirement for the coming days. The resourcing for rapid damage assessment and swift water rescue was also receiving a boost as crews began arriving by air and road. The Sierra vehicle (Specialised Command/Communications Vehicle) was deployed to bolster communication with its satellite (V-SAT) and advanced radio communications systems.

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One of the major roles by this time was to complete the rapid damage assessment work that had commenced and technical rescue operators were beginning the mammoth task of breaking up the affected areas and tasking crews. The rationale behind using swift water rescue operators for this type of work is that they can deploy into a hostile environment by watercraft before the road network is open and gather early intelligence. The scale of the disaster was beyond that previously experienced and required a degree of ‘new thinking’ in order to achieve the 72-hour deadline. The only similar scale of event was during the Rockhampton floods in 2010 and this formed the base for calculating the amount of resources that would be required. To cover the affected area some 32 rapid damage assessment technicians would be deployed to gather and upload the assessments. QFRS conducted and recorded 5456 rapid damage assessments and provided the information to the Local Disaster Management Group for planning and response purposes. The rapid damage assessments gathered information and mapped the communities along the Burnett River from Burnett Heads to Monto. The technicians utilised all methods of transport to access the disaster areas including watercraft, road and helicopters where access was too difficult. During the rapid damage assessment of the North Burnett region a new hazard was identified in the Gayndah area where the major industry is citrus orchards. The floods destroyed farming sheds and released numerous drums of chemicals. The drums had floated down creeks and streams, presenting an environmental issue. QFRS responded by deploying Hazardous Materials Response (Hazmat) teams to identify and recover the material where possible and, where it was not, to map and report the locations of the drums and containers.

Establishing control in a hostile environment The scene that I was presented with on my arrival on Monday, 28 January made it very clear that the accommodation that we were currently in would not satisfy our needs for long. The issue we faced was that any suitable alternate accommodation had been taken up by other departments and we could not add to the difficulties that the community was facing. As discussed previously, QFRS supports a heavy USAR team capability that enables us to move into disaster areas and be selfsufficient. The accommodation shortage issues for our USAR teams are resolved by the use of a rigid-framed tent system known as the ‘Flexible Habitat’. The Flexible Habitat has several modules that can be configured to provide a command centre, sleeping accommodation and ablutions wings, in order to form a base of operations. The Flexible Habitat was requested and would be set up at Salter Oval, which is the local cricket ground. This would be home for the QFRS for the next 28 days. The decision was taken to deploy the entire ‘heavy’ USAR cache, which would require the services of the Australia Defence Force (ADF). The ADF would transport the 14 tonnes of equipment by C-17 into the Hinkler Airport and the base at Salter Oval would be operational by 7 a.m. Wednesday, 29 January. The

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base would have a staff of technicians that were deployed specifically to service and maintain its operation. It was self-sufficient, including meals, and it accommodated up to 120 staff (sleeping) per day over the duration of the operation. The value to the community was reinforced by not taking up valuable bed space and supplies that would be needed by the community and other agencies. A similar deployment was made to Gayndah using part of a second cache to accommodate 50 staff sent to support the North Burnett region. The Flexible Habitat would provide 1865 beds over the next month in Bundaberg and 396 beds in Gayndah. The QFRS would provide 18 165 meals. The community benefited through the supply chain as it became more able to provide food and accommodation to the emergency workers without stripping it of its ability to sustain itself.

Unleash the volunteers In past flood and cyclone disaster recoveries QFRS supported the effort by releasing the standing army of rural fire brigade volunteers who number in the thousands. The effectiveness of the well-structured, disciplined and professionally coordinated group is that they can be set a task and get on with achieving it. The fire appliances can provide the necessary equipment to assist in washing out silt-filled homes and the more-than-willing workforce is ready to help. The other community benefit of a large, recognisable group like the Rural Fire Service volunteers is that they lift community morale by being a visible presence there to help. The washing out of 1400 residences in Bundaberg and the North Burnett communities was undertaken mostly by volunteers, who came from all regions of Queensland. A number volunteered more than once. The number of firefighters on the ground helping the community varied throughout the month-long engagement, but during peak periods of work numbers averaged 200 with approximately 80 support and control staff. The type of work that volunteers undertook included removing flood-damaged furniture and possessions from homes and businesses and cleaning out the silt, mud and rotten food stuffs that had been underwater for days. This was not glamorous work but they set about it as something that was helping the community to get back on its feet. I often heard comments that it was a terribly sad thing to see someone’s life piled up on the footpath after the clean-up and that they hoped they never experienced it again.

Commissioner visit adds to the reality The reality of the disaster that was unfolding in Bundaberg became evident as the media reports began to flow. The scale of the disaster would not be understood by many outside the area for some days and it was one of my challenges to ensure that a common understanding or picture was being portrayed up through to the

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Commissioner. This would be aided by a visit to Bundaberg by Commissioner Lee Johnson on Wednesday, 30 January. A tour of the damaged areas of Bundaberg and meetings with the Minister for Police and Community Safety Jack Dempsey (Minister Dempsey is also the Member of Parliament for Bundaberg), Mayor Mal Forman, Chief Executive Officer of the Bundaberg Regional Council Peter Byrne and the District Disaster Coordinator Police Superintendent Rowan Bond gave the Commissioner a good appreciation of the scale of the recovery effort that would be required. Visiting North Bundaberg for the first time was shocking as the damage to the roads and other infrastructure was unexpected. As we drove around there were large volumes of sand beside the roads and spread across properties. In places the sand was up to 500 mm deep and at first glance it appeared that the Council had dumped the sand as part of recovery. In fact it was river sand that had been either gouged from the banks of the Burnett River upstream or from North Bundaberg itself. Large craters in the roadways, caused by the fast-flowing river, had undermined the pavement. As the water reached the subsoil it liquefied the silt from past floods and large sections of the ground subsided. Houses literally sank into the ground and were swallowed up by the sand and silt, and the picture was more akin to the aftermath of an earthquake. Anywhere the floodwater could penetrate the surface crust it gouged out massive tracts of the ground. The sand that was released and deposited did not resemble the usual smelly river silt or mud as it was more like clean fine brown sand that had been commercially quarried.

Coordinating the effort Coordination of the volunteer workforce that peaked at approximately 230 per shift required significant command and control to be established in Bundaberg as well as development of supply lines at regional and state level. On the ground in Bundaberg the Flexible Habitat at Salter Oval became the Incident Coordination Centre and Staging Area. There were 20 strike teams of between 80 and 100 vehicles to be maintained and serviced, and an equipment cache of personal protective clothing and equipment to be cleaned and maintained. Standing behind the strike teams was a support team of 80, who ensured that they were fed and accommodated and provided with meaningful tasks to allay inactivity and boredom. The Incident Control Centre was fully staffed with the four functions of AIIMS, including the Incident Controller, Operations, Planning and Logistics. Crews came from across Queensland and were rotated in and out on a seven-day cycle for paid staff and a five-day cycle for volunteers. Resourcing an operation of this scale for four weeks required the full engagement of the Regional Operations Centres in all regions to provide people to support the effort. Coordinating the effort from the ‘supply regions’ into Bundaberg, the State Operation Centre took on

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the task of coordinating the logistics of the supply and transportation of staff as well as meeting the request for equipment and supplies. To achieve the maximum impact of the crews on the ground the event was divided into sectors and the strike team reported into the sector command to be given tasks each day. A systematic process was developed to move street by street, emptying out homes and washing them out until the job was done. At the same time crews were working in the townships of Eidsvold, Mundubbera and Gayndah using a similar system to help the communities recover. There were 80 firefighters working to clean up over 300 homes in these centres and they were based out of the Incident Control Centre that had been set up at the Gayndah Fire Station. To put these numbers into perspective, in Mundubbera more than half of the 300 residences were directly affected by the floodwater and required assistance.

Lessons learnt Looking back on the events that unfolded throughout the course of the response to the Queensland floods of 2013, several important lessons stand out.

Control of aircraft A decision was made at the State Disaster Coordination Group level to place control of all aircraft at the disposal of the various agencies under the Queensland Coordination Centre. This decision was based on the sound logic of unification of resources for the greater good and was supported by the Commissioner. In reality the ability of the Queensland Coordination Centre to physically coordinate all aircraft was found severely wanting due to a lack of resources and a realistic appreciation of the events unfolding on the ground. There was also a lack of control on scene for airbase operations as the Queensland Police Service had neither the expertise nor the numbers to deal with the role. Throughout the events, the loss of control of our aircraft proved that the need to secure them was critical to operations. The loss of control also became a safety issue. It became almost farcical to see teenage Surf Life Savers loading and unloading aircraft in a very hazardous environment. That is not a criticism of the Life Savers as they were doing their best for the community. The situation arose more due to a controlling authority grabbing resources and, some would say, power, without an adequate appreciation, knowledge or understanding of the situation. QFRS, through its extensive use of aircraft during fire operations, has developed a very good capability in air operations, including control, coordination and tasking. In Bundaberg the District Disaster Coordinator made the decision not to allocate any of these roles to QFRS and after the event several pilots and operators raised safety concerns regarding the air operations.

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Queensland heat As the recovery efforts moved forward, the QFRS Flexible Habitat was deployed to accommodate the emergency workers and to serve as the control centre. A lesson learned from earlier use of the Flexible Habitat in summer weather was the need for climate control. The temperature during January in Bundaberg was over 30°C, with humidity consistently above 70%. The Flexible Habitat was designed to be fitted with industrial air-conditioners; however, due to cost and some indecision in previous campaigns, rarely was this capability exercised. On this occasion Commissioner Lee Johnson removed any doubt and directed that the Flexible Habitat would be mobilised with the air-conditioning. This decision supported the wellbeing and recovery of the workers, who were conducting hard labour in extreme conditions throughout the day.

Keep the volunteers busy A lesson that was learned early in the campaign was the harder that you work the volunteers, the happier they are. It was raised by some disgruntled volunteers early: that they had given up their jobs and time and were in Bundaberg to help the community and if they weren’t fully utilised they may as well be at home. I took that on board and made sure from that point on they were worked hard. My comment to the Incident Management Team was that the only time a volunteer is happier than when they are working 10 hours a day is when they are working 12 hours a day. The value that the volunteers contribute is rarely quantified and reported during events such as these, but on this occasion, this data was captured and supported through the Incident Control Centre. It is estimated that rural firefighters volunteered 49 068 hours of their time in support of the communities in Bundaberg and North Burnett, equating to around $1 472 000 in wages.

Scalable AIIMS Some of the great lessons that were clearly demonstrated to me during the Bundaberg floods were in the use of AIIMS for a structured approach to managing events of this magnitude and the tiered structure of the Operations Centres to secure supply. It became obvious to me that I was at the leading edge of a large machine that could bring the entire resources of the QFRS to bear on this event.

Collaboration The Australian Defence Force (ADF) had also come to the aid of Bundaberg during the floods. Initially the ADF provided assistance with the air support via the Black Hawks, through the transport of the heavy USAR cache and then as an engineering team to assess critical and civil infrastructure. After comparing accommodation and catering with our ADF counterparts, who were also set up at Salter Oval, I

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formed the opinion that QFRS had developed an excellent support and accommodation capability. The firefighters and soldiers established a great relationship, and both groups got a lot of satisfaction out of the deployment through delivering support to a community in need. Inevitably when you bring two groups together, a friendly rivalry develops and when they are housed at a cricket ground you can guess what occurred. Even though they were working 12-hour days the crews found the energy to put on a Twenty20 cricket match. The match attracted a great deal of media and a reasonable crowd of bemused onlookers and, despite the fact that the team in camouflaged green took out the honours on the day, it was a great morale booster for all involved.

Safety planning The region provided Incident Safety Plans and notices as part of the normal process of the Regional Functional Plan. The Regional Workplace Health & Safety Coordinator produced an additional flyer of advice pertaining specifically to hygiene. Given the very unhygienic working conditions in contaminated floodwater, the number of different work locations, the lack of readily available cleaning facilities, the close living arrangements and the many risks associated with providing food and water to operational crews in the field, it is a remarkable success that QFRS avoided adverse hygiene-related problems, cross-contaminations and spread of gastroenteritis. QFRS experienced three minor cases that presented to hospital for food-related contamination. This appeared to be related to local generosity when someone offered food in the way of sandwiches. Once the problem was identified, all personnel were reminded of the risks and directed to accept food and water only from the approved source. Hand sanitising was reinforced at every opportunity. To gain an understanding of how good this result was, consider that the QFRS provided 18 165 meals to operational and support teams during the operation. QFRS recorded a relatively small number of minor injuries: strains, sprains and minor cuts. A significant learning was the need for a pre-deployment assessment or questionnaire. A small number of QFRS personnel who were not physically capable of contributing to the effort were unnecessarily deployed. One had very recently undergone surgery and others arrived with medical conditions such as chronic emphysema and severe influenza. Some required immediate hospitalisation and subsequent medical evacuation.

The human impact of disasters The operational response often required personnel at all levels of the organisation to make efforts above and outside of their normal level of responsibility. The exposure of personnel to traumatic events typically has consequences. QFRS deployed the Manager of Firecare to coordinate critical incident stress management activities that

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involved the deployment of peer supporters and counsellors (psychologists). Of the cases of personnel requiring leave time for psychological injury, the majority have returned to suitable duty. The service of Firecare was significantly beneficial in mitigating and minimising the consequences to personnel working in severely dangerous, stressful and psychologically challenging environments.

Conclusion Operational achievements include the community value of QFRS leadership and effectiveness in a multidisciplinary, whole-of-government disaster response. In measuring the success of the campaign the community value was not limited to disaster response and recovery operations. QFRS contributed to local business operators through local purchasing whenever possible in order to boost commercial recovery within the communities. QFRS as an organisation is determined to be self-sufficient in the most severely affected areas and deployed in such a manner as to avoid depletion of local resources that are desperately needed by local communities. The communities of Bundaberg and North Burnett suffered great losses during the disaster that followed ex-tropical Cyclone Oswald on Australia Day 2013. The support provided through the Department of Community Safety and the Queensland Fire and Rescue Service assisted the community during the response and recovery stages of the disaster. A fond memory of mine was standing in Bourbong Street (the main street of Bundaberg) with Mayor Mal Forman, Minister for Emergency Services Jack Dempsey, a host of community leaders and hundreds of local people, farewelling the firefighters in a cavalcade of red and yellow fire trucks at the conclusion of the operation. It was the community’s way of saying ‘thank you for a job well done’ and that is a measure of success.

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3 Responding to the Myer building fire in Hobart Gavin Freeman Acting Chief Officer, Tasmania Fire Service

Introduction The fire in the Murray Street Myer Department Store, located in central Hobart, occurred on Saturday, 22 September 2007. This was the day immediately after Tasmanian Fire, Emergency and Land Management agencies had successfully hosted the Australasian Fire and Emergency Services Authorities Council (AFAC) Conference. At the time of the fire, I was a District Officer and, about an hour into the incident, I arrived at the scene and assumed the role of Incident Controller for the first operational period. The Myer building was built in 1908 and consisted of four levels, including one below ground. It contained a variety of merchandise, ranging from cosmetics and vinyl records through to clothing and homewares. The building was conjoined with a similar Myer building fronting onto Murray and Liverpool Streets as well as the Cat and Fiddle Arcade shopping complex,

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Fletcher Jones and Ellison Hawker Newsagency. The store was a shopping icon and pivotal to the main city block. What started out as a call on the Direct Brigade Alarm culminated in one of the largest fires of its type in Tasmania’s history with a damage estimate of $200 million. There were many valuable lessons learnt and some tremendous feats of human endeavour undertaken as the fire spread rapidly during the course of the firefighting operations and in the ensuing recovery over the following week. At the height of the fire, every available career firefighter in Hobart was on the scene, in addition to some volunteer crews, a total of more than 100 firefighters. Volunteer crews were also providing fire coverage for the Hobart area throughout the night. That Saturday was shaping up to be a very special day; that night we would be celebrating my daughter Olivia’s 18th birthday. During the afternoon, I attended the 60th anniversary of one of our volunteer fire brigades on Hobart’s eastern shore and then I headed home to get ready for the birthday celebrations that evening. On my way home, I was skirting around the Hobart city centre when the phone rang; it was the on-call District Officer for the Southern Region. ‘Where are you?’ asked Gerald Crawford in his usual straightforward fashion. I told him and he said, ‘We have a Direct Brigade Alarm at Myer in the city. There is some sort of fire there but I think the sprinkler is holding it. Do you mind calling around and having a look for me?’ Yes, it was going to be a big night … just not in the way that I had planned!

Background The Tasmania Fire Service is a fully integrated organisation consisting of 5500 people spread across three regions and comprises both career and volunteer personnel. The Hobart Fire Brigade is part of the Southern Fire Region and is one of 230 brigades in Tasmania. It protects the capital from fire and other emergencies, and consists of five career stations supported by 13 composite, retained or volunteer stations. At any one time, there are a minimum of 20 career firefighters and about 100 volunteer firefighters immediately available; up to a further 110 career firefighters were also available on recall with many more volunteers from across the Southern region. The Hobart brigade is equipped with Scania pumpers, heavy and light tankers, rescue, Hazmat and special equipment vehicles, and one aerial appliance. Once there are three crews committed at an incident, a senior commander is attached to the job. Outside of business hours, there are ‘on call’ arrangements, which provide for one District Officer to be on call to deal with any issues that can arise. The District Officer will also make a decision on whether the response and command structure

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for any particular job needs to be escalated and will coordinate that if it is required. Usually that means a couple of calls to the senior command staff that the on call District Officer knows are ‘on deck’. This is how I became the Incident Controller for the initial operational period of one of the larger and more complex fires in buildings we have encountered in Tasmania in modern history.

The response It was a normal day at the head station in Hobart; there were two crews, each consisting of an officer and three firefighters, on duty. They had spent the morning like any other, gear-checking the urban pumpers, the heavy rescue, the 26 m hydraulic platform, and an assortment of bushfire tankers and sundry vehicles that are housed at Hobart Head Station. The crews then got on with some training and familiarisation, and most were hoping that they could get enough work completed so they could watch a bit of the AFL preliminary final between the Adelaide Crows and the North Melbourne Kangaroos. The station itself has been on the same site since 1883; there have been a few makeovers but the knowing eye can still see reminders of days gone by, such as the outline of the original stables for the horses that pulled the hand pumps and steam engines. The original façade is heritage-listed and the modern day Scania pumpers are a very tight fit into doors that were originally designed for horsedrawn engines. It was soon realised that it would be cheaper to move the trucks than keep replacing the wing mirrors! Hence, the modern ‘turn out bays’ (where the trucks are parked) have been moved to an adjacent street frontage. The blood-curdling two-tone screech that is called the station bells jolted the B shift firefighters into action a little after 2.30 p.m. The pagers that each firefighter wears on their hip and the digital read-out on the wall in the room where their turnout gear hangs told them that they were on their way to a Direct Brigade Alarm at the Myer, Liverpool Street department store. As is habit for all of these men and women, they started running through their mental checklists. The time of day told them that normal trading was underway, access would be from the Murray Street entrance, and water would not be a problem if they needed it. Predetermined resources for a call of this type consisted of one pumper crewed by an officer and three firefighters. The powerful Scania pumper eased across the apron and the driver easily manoeuvred the vehicle through moderately light traffic for the three and a half blocks it took to get to the Murray Street entrance to Myer. The two firefighters in the back seat saw nothing untoward as the truck stopped in the ‘fend off’ position outside the front door. Radios, breathing apparatus and associated equipment were grabbed and placed as usual over shoulders, as they trudged towards the alarm panel that revealed to them the first piece of the puzzle; this is what firefighters call ‘size-up’.

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After checking the alarm panel the first arriving Station Officer noted that the zone activated was in the first floor switchboard area. As the Station Officer walked onto the first floor he noticed some light smoke and gave the Chief Warden an order to evacuate. Immediately, as is procedure, the Station Officer upgraded the call to ‘confirmed structure’, which automatically gets another pumper sent to the call location and triggers some other standby arrangements in other parts of Hobart. The Emergency Control Organisation or fire wardens, which a building such as this is required to have in place, swung into action like a well-oiled machine and evacuation was complete in 13 minutes (19 minutes from time of call) – an impressive effort! The first crew to arrive started hunting around for the source of the smoke. They thought they had seen a light wisp when they had first entered the area – someone definitely smelled something, but where and what was it? Maybe a burnt-out fluorescent light ballast? No, it was more than that, but it did smell electrical. The second crew arrived in Liverpool Street just around the corner from the first truck, and entered the floor below where their mates were still trying to locate what was causing the problem. They encountered water running out of the ceiling, always a worry for firefighters, on the ground floor. What was even more concerning was that a part of the false ceiling had dropped away, the electrical wiring dangled loosely in places and tell-tale blue flashes of light were evident. If firefighters are wary of anything, it is the deadly combination of electricity and water. The last firefighter killed in the line of duty in Hobart was electrocuted, a sad fact not lost on any of the crews present here. The current situation was all very strange and there was still no sign of fire, so the Officer in Charge ordered the sprinkler valve to be shut off. He just couldn’t take the risk of one of his firefighters being electrocuted. Once this was done the water running out of the ceiling space eased slightly, but it didn’t stop altogether. As is normal practice the Officer in Charge requested a ‘disconnect crew’ from the power provider and was given an expected time of arrival of 30 minutes from that point. Firefighters know that 30 minutes in these situations can seem like a lot longer. It was then time to work on contingencies. If we can’t remove the power hazard immediately, the next option is to stop the water. The first question that needed answering was: ‘Where was all this water coming from?’ The sprinkler gong was activating, a sure sign water was passing through the system, but there was no sign of any sprinkler heads activating. The water that was coming down was clean, whereas normally you would expect sprinkler run-off in a fire situation to be discoloured, if not black. There was a water tank that formed part of the system providing the warm air curtain at the store entrance in this area – maybe that had ruptured. Meanwhile, crews in breathing apparatus worked cautiously around the first floor. Visibility was good, but there was obviously something not quite right. One

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firefighter peered through the thermal imaging camera and saw a white strip in the floor measuring about 20 m by 2 m. This meant heat. Was there something alight in the floor or roof cavity? Two firefighters exited via the stairs for a hose line, while the other two firefighters remained and prepared the area for work, collecting dry chemical extinguishers from around the walls. One of the firefighters remaining on the first floor removed his glove and felt the carpet with his bare hand – it was hot. They were convinced that finally they had found the seat of the fire. There was still good visibility and little sign of heat other than the strip in the floor. What they couldn’t have known was that this 20 m by 2 m strip was also over a metre deep. As they worked to remove the clothes stands and clothing bins in the way, they thought through a plan: access the floor and use the dry chemical extinguishing powder they had gathered to fill this bit of a cavity, close it off and let the chemical do the work. They moved everything aside, peeled back the particle boards and encountered another layer of flooring. ‘Firies’ aren’t deterred easily. With the aid of a Hooligan tool they prised up these boards enough to force in the extinguisher nozzle and discharge the first dry chemical extinguisher. Without warning there was a dull thud and a hissing sound behind them; they spun around to be confronted by cylindrical flame that looked like a blowtorch coming up from the floor behind them. One firefighter reported later that it was the weirdest flame he had ever seen. Immediately things turned to hell. There was no visibility and the smoke was really thick. They tried to hit the fire again with the dry chemical extinguisher but then another nightmare occurred – they started to feel the floor going soft and saggy under their feet. It was deteriorating quickly. The smoke came right down to floor level; by now the two firefighters were on their knees. They tried to go back to the area where they had first lifted the carpet to reorientate themselves, but kept tripping over stands and bumping into walls. They not only lost track of where they were but also of how long they had been there for. The fire was still developing quickly and they had used up their available extinguishers to stop the flames from engulfing them. It was time to get out. After slowly moving around and crashing into a couple of walls they realised they couldn’t afford to use all their air trying to find their way out, and decided to bunker down and radio a distress call to their mates on the outside. ‘This is a priority call urgent message, emergency, two firefighters trapped on the first floor need assistance immediately.’ They repeated the message twice and listened … nothing. They lay motionless, listening, breathing slowly, as time stood still. As the two firefighters that left earlier to grab a hose line exited the building, the warning device on the breathing apparatus of the firefighter in front emitted its piercing whistle, which meant he was low on air. At the same time, the second firefighter heard the distress call over the breathing apparatus communications set;

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he glanced towards the doorway and spotted his Station Officer. ‘Do you want me to go and get them?’ he shouted through the face mask. ‘Yep’ came the reply. This firefighter quickly retraced his steps to the top of the stairs where he encountered very heavy smoke. Something had changed. It wasn’t like this a few minutes ago. Now what? He thought, ‘I am on my own; I should go out and get someone else. What if my mates are out of air?’ In a split second, he made a conscious decision to go 3 m in from the top of the stairs, which was the last place he saw the other two. ‘If they aren’t there, that’s as far as I go,’ he promised himself. He groped around in the blackness and suddenly, a shoulder, then a masked face, and then another one – thank God! He guided them to safety. On the way out one of the rescued firefighters spied another dry chemical extinguisher and emptied it into the flames in an act of defiance. There was much discussion about this rescue in the ensuing weeks. I have always been cautious of second guessing decisions made by experienced people that are on the spot, when I am not. I am certain that if he hadn’t taken the decision to re-enter the building, two firefighters would have been killed. I’ll leave it to you to determine if that was right or wrong. The firefighter that risked himself to save his mates would later receive a Chief Officer’s commendation and a Royal Humane Society Medal for bravery. Once clear of the building the crews regrouped, refreshed their breathing apparatus sets and got back into their pairs. They attempted re-entry with a 38 mm hose line and a hose reel on hand, but the ceiling on the ground floor was now falling around them, there was still water running out of the ceiling, and smoke was all the way down to the floor. The decision was made that it was time to pull out and try another plan. By this time more resources were either on scene or on their way. Another Station Officer, after realising that no one was inside at that time, decided to turn the sprinkler valve back on. He went down to the sprinkler room, which by now was getting hot, checked the gauges and turned it back on. He heard a noise and the water flowed through. He then got out. This was about the time I arrived in Liverpool Street. The scene in front of me was not remarkable in itself. Three pumpers were strategically placed in the street (there were others around the corner) and the hydraulic platform was being set up in the middle of the building. A cursory glance told me that there was a fair bit of smoke on the first two levels and a very small hole in a window of the first floor was allowing grey white smoke to spill out. There was no indication that there was much pressure in the building. I looked around for the familiar tabard that would indicate to me who the Incident Controller was. I saw it further up the street on the back of a Station Officer who is well known to me and who is a very capable operational commander. As I walked up the Myer frontage side of Liverpool Street I noticed running down the footpath cool, clear water that almost went over the top of my

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Warrington Pro turnout boots. As I walked past the door of Myer where all the earlier action had taken place, I noticed a lot of false ceiling down on the floor and I also saw a red pipe hanging out of the ceiling at a 45° angle. I later wished I had stopped to look at this further and perhaps had even taken a picture on my phone. Hindsight is a wonderful thing. As I approached the Incident Controller, I gave him a wry grin and asked, ‘How is it going, mate?’ He responded with a bit of a chuckle and said, ‘We have a bit going on.’ I was given a very good briefing as to what had happened so far and what he knew about the situation to date. We had a quick discussion about the command structure we needed in place and then agreed I would pick up the Incident Controller role and he would run operations. I walked quickly back to my car, picked up the radio and advised Firecomm that I was assuming command of the incident. I confirmed there had been requests sent for further assistance and noted that additional crews were starting to arrive. We established sectors and my main focus at that point was to stop it extending beyond the Liverpool Street part of the building. By this time we had crews setting up to enter from the unaffected sides of the building, through the Cat and Fiddle Arcade at the rear and the Murray Street frontage of Myer. We were still restricted in our offensive attack efforts due to a shortage of crews, given the extended entry that had to be undertaken on multiple levels and the subsequent fatigue on firefighters. We knew we had to stop the fire spreading, particularly once we ventilated the building, which we planned to do. We stopped the fire extending beyond the part of Myer where it originated by positioning hose line crews at each fire door on each level; we also prevented the fire spreading to the conjoined newsagency at the northern end with an exposure line from the street. Satisfied that the operational component was in good hands, my focus turned to the supporting structure. The interagency cooperation was fantastic from the outset. A command post and breathing apparatus control point had been established, and the initial planning meeting was attended by our operations, planning and logistics section, Tasmania Police, Aurora Energy and Hobart City Council. This cooperative approach was pivotal to the outcome and the initial relationships that were established ensured a smooth transition from the response to the recovery phase. I initiated a request for more District Officers and the Deputy Regional Chief. It was obvious that smoke was spreading rapidly through all floors of the Liverpool Street store. We didn’t seem to be making a lot of progress on slowing the vertical fire spread, although we were holding it at the established boundaries of the Liverpool Street store. Even so, it was still a big area. I am not sure if I just thought it to myself or said it aloud to someone, but at that point I had a very bad feeling about this fire. When I started as a junior firefighter on shift, I had a wizened old superintendent who hailed originally from

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Czechoslovakia. On night shifts he used to take great delight in walking us through (and getting us completely lost in) the maze of old buildings in the city. He used to say in his thick accent and broken English, ‘If this catch fire we lose whole block.’ Those words were ringing loudly in my ears at that point. Ventilation was problematic. It was too dangerous to put people on the roof and breaking windows on the Liverpool Street side was considered an inappropriate risk, given we had crews still manoeuvring inside and it would have been on the upwind side of the building. We were still very conscious that opening this fire up, at the wrong point, could well have resulted in it going to the other side of the city block due to the conjoined nature of the buildings. Once the crews were in position on all unburnt sides of the building we were able to utilise the hydraulic platform to open the fire from the front. I watched intently. I wanted this thing out of the building; I wanted to see what we were dealing with. Crews on the platform broke the windows. ‘Here we go,’ I thought, ‘out you come.’ Then … nothing. ‘What?’ I thought, ‘that doesn’t make sense.’ At that point our crew realised that stud walls had been constructed behind the windows. This had obviously compounded our ventilation woes and possibly aided the upward progress of the fire. With a realisation of what we now needed to do, firefighters breached these walls, releasing the built-up gases and heat and providing respite to the fire crews inside, allowing them to sustain the attack to contain the fire within the established boundaries. I have no doubt that, during all the time taken in getting established at our identified cut-off points, bystanders were wondering what we were doing because all the action was taking place behind the façade! I might also point out that by this time a crowd had gathered; remember that this was the day after the 2007 AFAC conference in Hobart. Therefore that crowd included many firefighters and quite a few chiefs. No pressure really! We were now about three hours into the job. At around this time the Deputy Regional Chief arrived on the fireground. He came wandering down the street in his gardening clothes and said, ‘Is there anything I can do for you?’ I replied, ‘Go and get your turnout gear and shadow me because I intend to hand this job to you later. I have a birthday party to attend!’ We started to conduct a transfer of command over the next couple of hours, walking and talking around the fireground, using our combined experiences to check and double-check that we had everything covered. At one point I was at the fresh air base talking to crews as they conducted breathing apparatus changeovers, having their wellbeing monitored by ambulance crews and generally discussing what they were experiencing on each long entry at various floor levels where they were holding the fire at bay. At that point the Deputy Regional Chief came around the corner and asked if I had been in Liverpool Street lately. When I responded in the negative he said, ‘You might want to come and have a look.’

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When I trudged around the corner, it was a sight to behold – the fire had broken through the roof and flames were shooting 30 m into the evening sky. The Inspector of Police, who had shadowed me as my liaison for the past few hours, looked around at me and said, ‘This isn’t good, is it?’ It looked spectacular, but I reassured him it was OK and now at least the heat and fire would travel upwards into the atmosphere. Moreover, we could really see what we were dealing with. The strategy from that point on was relatively straightforward: hold the fire at the boundary walls on all levels, keep rotating crews and keep everyone safe. Generally it worked, with no injuries to the public and two minor injuries (a sprained knee and a cut hand) to firefighters. At around 8.30 p.m. I formally transferred command to the Deputy Regional Chief and left the scene in the hope I could still get to my daughter’s 18th birthday party. The building was over 100 years old and over that time had undergone many transformations and modifications. There were varying levels of fire separation and fire detection and suppression systems. There were a couple of anxious moments later in the evening where the fire tried to extend outside the established boundaries: once via heat transfer through beams to an adjoining newsagency, and later in the night when an air-conditioning unit toppled from the top of the Myer building and punched through the roof of the Cat and Fiddle Arcade behind it. On both occasions the plans the new Incident Controller and his team had in place ensured this fire spread was quickly cut off. At this point, I will make some observations about the building itself. Essentially the building on the right-hand side in Liverpool Street, while conjoined, was a separate building with walls independent of each other; this helped prevent lateral fire spread. The building on the left, containing the Ellison Hawker Newsagency, was structurally integrated into the Myer Liverpool Street building at the time of construction. The timber bearers for the first and second floors of both buildings passed through the wall separating the two buildings. This integration of structural components led to the fire in the Myer Liverpool Street building extending into the first and second floor of the Ellison Hawker building. The severity of the event was compounded once the first and second floors in the Myer Liverpool Street collapsed and the bearers were ‘pulled’ from the notches in the wall, creating an opening between the two buildings and allowing the fire to enter the wall cavity and then spread into the open floor areas. The closing of the fire-rated roller shutter in the opening between Myer and the Cat and Fiddle Arcade was controlled by smoke detectors on either side of the opening that were connected to the fire indicator panel. Staff did confirm that this door was closed at the time of evacuation. The sliding fire door on the first floor, the Cat and Fiddle Arcade side of the opening, was closed between 3.20 p.m. and 3.30 p.m. There were four openings between the Myer Liverpool and Myer Murray Street buildings: one each on the basement, ground, first and second floors.

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The openings on basement and ground floor levels were glass smoke doors only. The first and second floor openings had sliding doors controlled by links that release the doors when they are subject to heat. Firefighters were deployed to all of these doors to ensure that the building integrity in those areas was maintained without any fire spread. Numerous sprinkler heads had also operated on level two before crews reached that point, as fire had breached the sliding fire door, which had been wedged open by some debris. Essentially, where fire doors were installed they operated correctly and contributed to the prevention of lateral fire spread. The exception was the door that did not fully close; however, the sprinkler system did its job in that area until fire crews got into position. The lower level smoke doors would not have held without firefighter intervention and I am not convinced the fire doors would have either, given the intensity of the fire. The fire operation was to continue for several more days and throughout the night the command and supporting structures were built upon and enhanced by the incoming Incident Controller. This great work ensured the incident structure was robust enough to grow and ultimately transform into investigation and recovery. As with all incidents, this one was a bit like renovating an old house: the more we scratched around, the more complexities were uncovered. Remember, we were dealing with an old building, and what do we often find in old buildings? You guessed it – asbestos! The discovery of this stuff in the roof cladding meant that there was immediately a more formal Hazmat component to the incident. This slowed things considerably throughout the overhaul and investigation phase, as we took all precautions to ensure nobody was going to end up with any level of contamination. This involved the establishment of ‘warm’ and ‘hot’ zones and the need to establish a decontamination process for anyone who entered the site. A fixed decontamination facility was established and trigger points were set up to ensure that anyone who entered the site had the appropriate level of protection and that they were cleaned up before they left the site. It is tough enough ensuring our firefighters adhere to these protocols, particularly when the risk is not visible; it was even more difficult to engage the contractors helping with the demolition work in what I am sure they saw as overzealous protocols put in place by overly cautious firefighters! Many of the staff working at Myer on the day of the fire were students. They placed personal items in their allocated place in the staff locker room; these included laptops, wallets and purses, containing identification and credit cards and other important items. Given it was September, many of these students (staff) had significant and nearly completed assignments, and in some cases their entire theses on their laptops. This work represented a huge investment in time for them. As the particular part of the building that housed the staff locker room had partially collapsed, recovering those items presented a challenge. After some consideration

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we mounted an Urban Search and Rescue (USAR) operation. We saw this as the only way to retrieve these items that meant so much to staff, who were also now out of work. We also saw an excellent opportunity to test and practice our USAR capability in a ‘real’ environment. This component was a great success and we ended up with some fantastic learnings for our USAR operators, as well as some very happy students who had otherwise had a few bad days. There had been some very hot fire in the building and the main walls of the fire affected building were structurally unsafe; there was no choice – they had to be demolished. Now, fire investigators can get a bit testy if you wheel an excavator or two onto their fire scene before they have finished determining the cause. We managed any conflicting priorities by ensuring the demolition engineer and the fire investigation team were ‘joined up’ and that people forming integral parts of the incident management structure attended planning meetings and briefings on a regular basis. The recovery effort or, more precisely, the emergency stabilisation of the CBD started shortly after the response and was in full swing by the day after the fire. This fire had occurred in the heart of the city shopping precinct. It not only affected the Myer premises and business, which had the obvious effect of displacing employees, but it also had an impact on many other businesses in the city. It kept people out of the city and actually took an emotional toll on people who felt a genuine loss of something that had been there all their lives. There was enormous community and political pressure to restore normality as quickly as possible. To achieve this, an assessment team, consisting of experts in fire safety, asbestos and air quality monitoring, electricity and structural integrity, was established. This team was made up of a combination of people from various agencies who were able to assess and subsequently clear more than 100 premises, containing multiple tenancies in a matter of 2.5 days. Under Tasmanian legislation the Coroner has the power to order an investigation into large fires so, even though there had been no loss of life, we found ourselves preparing for a coronial inquest a few months later. Emergency management agencies accept that an inquiry, review, royal commission and anything else that places us under the eye of scrutineers with 20/20 hindsight is a common feature of our business. Some would say it is an occupational hazard! Those agencies also acknowledge that it is absolutely important that we do open ourselves up to scrutiny. We all know that the nature of our business means we inherit someone else’s problems. Our people move in when everyone else is moving out and no two situations are ever the same. Therefore it stands to reason that we can learn from them every time. The challenge with a coronial inquest is that it can create an almost adversarial environment, where lawyers for insurers and other parties with a vested interest argue against lawyers for the responders (Tasmania Fire Service in this instance).

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In this case, the insurers for the building owners and occupiers were attempting to find fault with the response to the fire and ultimately were trying to open up an avenue to recoup some costs. The coronial process was an interesting one, and one which didn’t pass without leaving an impact on our organisation. I can say without fear of contradiction that there is not one firefighter in Tasmania (and I suspect the rest of our country), whether they are fortunate enough to be paid or generous enough to volunteer, that does not have an underlying sense of community, professionalism and pride that drives them to do what they do. To see our organisation questioned and the motives and integrity of our people attacked for trying to do what they believed was the right thing to do, with the information that was available to them at a given point in time, is saddening and hurtful. Essentially, the lawyers for insurers focused on the decision to shut the sprinkler off and the degree to which that contributed to the spread of the fire and ultimately to the damage caused. It stands to reason that this action would come under scrutiny, as shutting off a sprinkler system is not common operating practice; however, there is not a lot that is common, if anything at all, when it comes to firefighting. At the end of the day, the Coroner did find that our people’s actions may have contributed to the spread of the fire. This opened the door for civil action to be taken against our fire service; however, the Supreme Court subsequently ruled that the indemnity clause of the Fire Service Act 1979 (Tas) mitigated any chance of a successful civil action, regardless of whether the Supreme Court would have agreed with the findings of the Coroner. While this was a relief in many ways, I would have relished the opportunity for our people to get a hearing in a higher court. I hold a view that the findings would have been different, and the observations and opinions I am about to share with you will help you understand why I have formed that opinion. There were some obvious questions that ran through my mind in the weeks following the fire. I have listed these below and included my conclusions after each question. Why did our firefighters open up the floor before a hose line was in place? Remember that the view through their thermal imaging camera revealed a 20 m by 2 m strip of heat in the floor, there were no real signs of smoke and certainly nothing to indicate that that strip was 1.3 m deep, so I don’t believe it is reasonable to expect those firefighters to have known that the fire they were about to access was far bigger than the few dry chemical extinguishers they had gathered would hold. Why did the sprinkler get shut off? There were no real signs of fire, but plenty of water and the greater risk assessed by the responding officer was that of electrocution to his people. The

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decision was based on the balance of probabilities and arrived at with the information he had available at the time. Did shutting the sprinkler off cause the fire to spread? An assumption based on simplistic thinking would suggest that shutting off an operating sprinkler would allow a fire to develop and grow. I would agree with this if the sprinkler was installed and operating as it should. I don’t think this was the case in this particular incident. You may recall earlier that I wished I had taken a snapshot of the red pipe I saw at 45° to the partially collapsed ceiling early in the incident. On reflection, I believe that the sprinkler pipe had been severed during this partial ceiling collapse, perhaps by the weight of the system that provided the warm air curtain at the entrance to the store. If this was the case then the sprinkler system would have been pumping water out of an open-ended pipe before it reached any operating heads, if in fact any heads had even activated before a collapse and if in fact there were even any heads installed in the location of the fire. The latter two points were never established conclusively, in my mind. Reinforcing this theory is my distinct recollection of the water flowing from the front door early in the incident; it was almost over my above-ankle-high firefighting boots, but even more telling was that it was cold and clear. Just ask any firefighter what water run-off looks like from a sprinkler system that is suppressing a fire and they will tell you that it will usually be warm and most certainly black or dark in colour. I will leave the judgement to you. One thing all firefighters know is that fires give us the test just before they give us the lesson, and that is why our industry is particularly hard on itself when it comes to analysing our performance and identifying areas that we can improve upon. This type of fire doesn’t occur that often so it was imperative that we looked long and hard at what worked well for us and what we could learn about ourselves in order to improve each time our trucks roll out the door.

Lessons learnt There were many lessons learnt, as there always are when we respond to an uncontrolled environment. As an industry, we are quick to embrace contemporary equipment such as thermal imaging cameras, but do we put enough effort into providing adequate training? Not only do we need to show our people how and when to use them, but also how to interpret what they see when using them. As we become more dependent on ever-changing technology, our procedures can become reliant upon them. Therefore, the equipment must be very robust and not fail or, at the very least, we must ensure we understand the limitations of technology so we don’t develop unrealistic expectations of its capability.

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Operationally, we have revisited our entire Standard Operating Procedures system to ensure they are relevant and easily applied, and we also reviewed our arrangements with power companies to be certain we have the most effective systems in place when we need to disconnect power supplies. We learnt that, by utilising a real blend of expertise both from within the agency and from other stakeholder agencies, we could put together teams that really expedited the return of many city businesses to their owners and operators, which is so important for community recovery. No single agency can handle an incident of this complexity from start to resolution, including recovery. Sharing of resources and integration into your management team of key people from participating agencies at an early stage is crucial. This enables us all to communicate and understand each other’s challenges and drivers well before the job occurs. Establishing relationships is 90% of preincident planning. It is important that the departments within the agency that have a role to play, like building safety and fire investigation, are included in the incident management structure early on. Often the skilled and experienced people in these areas are referred to only before and after the fire and are overlooked as being important contributors during an operation. To achieve seamless integration into the command structure they must be a part of the pre-incident planning process. Not only are your own agency personnel integral, but so are your partner agencies. The fact that our command personnel were on a first name basis with key people from Tasmania Police, Ambulance Tasmania, SES, Aurora Energy and the range of other agencies that were involved enabled immediate positive and effective action. Complex planning and exercising, while vitally important, cannot be undertaken at the expense of some of the more traditional practices (such as routine site familiarisations). It pays to never forget the basics and, while the urban environment is constantly changing and appropriate emphasis must be placed on systems to keep abreast of that change, we need to take care that our rapidly changing environment doesn’t have an impact on ‘bread and butter’ operations. If you pressed me for a single lesson to pass on, it would be this: never, ever underestimate the level of scrutiny that will be applied in an inquiry and ensure you engage, early in the piece, a representative team that can really prepare a good case for your agency and, importantly, prepare your people. The Hobart Myer fire was a high-profile incident and one that quite literally went to the heart of our capital city. This meant that many individuals and agencies wanted to contribute in some way – that is what Australians do. The coordination of not only the offers of help but also of those who had varying and sometimes conflicting legislative obligations called for strong, high-level leadership. It was particularly challenging to balance the political pressure to return people to their

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businesses, and hence the city to normal, against ensuring that premises were actually safe to be reoccupied. In closing, I urge all of our leaders in the emergency management sector to never let the conflicting and increasing demands on your agencies distract you and your people from your core business. Do not underestimate the impact an inquiry of some sort will have on your organisation, and plan for it. Review your legislation and ensure it enables your people to undertake their roles with professionalism and integrity, in the knowledge that they will be protected for doing the right thing. Embrace technology, but ensure your people understand its uses and limitations. When pre-incident planning and exercising, build relationships and imagine what could be possible, not just what you have always done. For those that are wondering, I did get to Olivia’s 18th birthday party just a few minutes before a car accident took out the power substation just down the road. The resulting loss of power meant the venue had to be closed, ending the party rather abruptly and very prematurely. The result: a distraught 18-year-old and about 100 primed-up teenagers looking for a place to party on. We don’t do birthday parties anymore!

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4 The aftermath of the Christchurch earthquakes, 2011 Stuart Ellis AM Chief Executive Officer, Australasian Fire and Emergency Service Authorities Council

Introduction The Christchurch earthquake on 22 February 2011 was a tragic event that devastated the CBD and some suburbs of that picturesque city. Many lives were lost and the damage was extensive. While New Zealand is expectant of earthquakes, Christchurch was not quivering with anticipation. It was not built on known fault lines and was not considered a high risk within New Zealand for major earthquakes. Even with the previous earthquake event in September 2010, the city was not expecting a further quake of the magnitude and consequence that struck on 22 February the following year. The city, together with the emergency services, was overwhelmed. Incident management for this event was not conducted as ‘a level 3’ incident or in any form that had previously been managed in New Zealand. It was effectively managed at a Canterbury regional level, but drew on resources from across both the South and North islands. With the relocation of the National Commander of

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Civil Defence and Emergency Management (CDEM) to Christchurch, it became a national effort and was further supported by a range of international resources. Rarely are incidents managed on the scale that became the Christchurch response to the 22 February earthquake. Unlike the Black Saturday fires in Victoria in 2009, the response and recovery in Christchurch were managed as one massive incident. With hundreds of personnel operating out of the Emergency Operations Centre, it became a campaign event of significant proportions. I was invited to join a New Zealand review team that was charged with providing an independent review of the Civil Defence emergency management response to the February 2011 earthquake in Christchurch New Zealand. According to the Review of the Civil Defence and Emergency Management Response to the 22 February Christchurch Earthquake, the purpose was ‘from an emergency management perspective, identify the practices that should be reinforced, and identify the processes and policies that warrant improvements’. The Review was contracted by the Director of CDEM and the full report, which was completed in June 2012, was subsequently accepted by the New Zealand Government. The team completing the Review (Ian McLean, David Oughton, Stuart Ellis, Basil Wakelin and Claire B. Rubin) conducted interviews with over 200 people involved in the response, over the period from November 2011 to April 2012. The original Review report was one of a number completed after the earthquake. This chapter draws heavily on that report, referred to as the ‘Review’ in the text. Conclusions from that report, together with my subsequent reflections on incident management during that overwhelming event, make up this chapter. That said, the observations and lessons identified below are mine alone and reflect a presentation given by me after the Review was released. Like other major incidents, when systems and individuals are placed under significant and sustained pressure, ‘cracks’ in performance will occur and observations and lessons to improve performance are exposed. The comments, observations and analysis made here reflect considerations at the time.

The earthquake The response to the 22 February 2011 earthquake was greatly influenced by the earthquake being one of a series, following the initial event on 4 September 2010 with a magnitude 7.1 shallow earthquake centred near Darfield, 40 km west of the Christchurch city centre. There were very few injuries and no directly attributable fatalities, but substantial damage to buildings (especially unreinforced masonry and infrastructure). Between September 2010 and February 2011, there was a series of more than 32 aftershocks causing further damage, closure of the central city and power outages.

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At 12.51 p.m. on Tuesday 22 February 2011 in Christchurch a magnitude 6.3 earthquake struck that both structurally and socially altered the nature of the city and in particular the Central Business District (CBD). The shaking from the earthquake was brief but its peak acceleration was amongst the greatest ever measured. The CBD in particular was severely affected, with 169 dying there and a further 16 losing their lives in the suburbs. Many houses were damaged, totalling 10 000 beyond repair and a further 90 000 requiring significant work. The major impacts of the 22 February 2011 earthquake on the people of Christchurch were deaths and injuries arising from the collapse of buildings; distress, misery and financial loss due to damage to homes; discomfort and great inconvenience from a lack of sanitation facilities; loss of jobs and businesses because of damage to buildings; damaged schools, universities and training centres; disruption of almost every kind of social activity; and churches, sports grounds, theatres, clubs and bars damaged, resulting in the social activities dependent on these facilities being severely hampered. Sewerage systems and water and electricity supplies were significantly disrupted over large parts of the city. Liquefaction affected the eastern suburbs, generating silt estimated between 350 000 tonnes and 500 000 tonnes, contributing to major damage in the sewerage system. Household toilets were unusable in areas with major damage to sewerage reticulation; across the whole city their use was advised against because of damage to mains and pumping stations. The water supply system was also affected and many homes, again more in the liquefied areas, had no supply. Rockfalls damaged houses in Port Hills, Redcliffs and Sumner, destroying some and making others too hazardous to inhabit. The New Zealand Treasury advised in 2011 that the cost of damage to property was over NZ$30 billion, plus an estimated NZ$10 billion for upgrading to higher standards during rebuilding, inflation and business disruption. What is unusual about the impact, is that nearly all damaged homes remained habitable (despite many being highly uncomfortable, cold and often damp). Most buildings in the CBD were damaged beyond repair – the CBD was closed off for over a year with major effects on businesses – and sewerage and water supply services were so severely damaged primarily because of liquefaction. In the immediate aftermath of the earthquake, police, fire, ambulance, defence, health services and the utilities, referred to appropriately as ‘lifelines’, established control, rescued those who were not already saved by members of the public, searched for and recovered the bodies of those who had died and generally kept the public safe. Together with council staff they brought order from the chaos of the day. The scale of the event and volume of calls from a traumatised population seeking assistance placed great strain on emergency service operations. The overall efforts of individuals and agencies were commendable and on many occasions

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courageous. This chapter concentrates on elements of incident command at a strategic and a tactical level. It does not address the effectiveness of the emergency services responding to an event of such magnitude and complexity – that could not be considered in a single chapter. Members of the public and career and volunteer firefighters carried out most of the initial rescues before Urban Search and Rescue (USAR) teams arrived. Thereafter, while largely resuming normal fire and rescue protection of the city and region, local firefighters continued to respond to community requests for assistance across the Canterbury region. USAR teams from New Zealand, Australia and many other countries (United States of America, Britain, China, Japan, Singapore and Taiwan) took up the more technical search and rescue operations, including facilitating entry to damaged buildings. It should be highlighted that in such events, when conditions are overwhelming, emergency service responders are affected as much as other citizens. Mobility was severely limited and most of the rescues were by citizens who happened to be close by at the time. Initial help for those in need was mostly provided by neighbours, community organisations including marae and churches and by the then recently emergent voluntary organisations like the ‘Farmy Army’ and the ‘Student Army’. The resilience of the Christchurch community was very evident. The scale of the disaster and the need for national resources led to a Declaration of National Emergency.

What is not addressed in this chapter The full Review report completed in 2012 details and analyses many aspects not addressed here in detail. I have made brief reference below to public information and USAR operations as they have direct implications for incident management.

Public information Twelve hundred and sixty-nine journalists were accredited during the response, with a further 177 staff in the Response Centre providing 24/7 liaison. The resources required in a traumatised disaster zone to support such numbers were substantial, with many reporters serving overseas viewers, rather than local Christchurch residents. I have real concerns regarding how much of this ‘information effort’ was directed to sustaining an insatiable media beast, which in a First World country feeds a hungry international media pack around the world 24 hours a day. Those who needed most media attention were local Christchurch citizens wanting to know when the next load of fresh water would be available for pick up from the local oval. I am unconvinced those in most need were best served, despite very impressive efforts by the local Mayor and media staff, but I also note that, within the limitations of their technical capacity to reach local

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communities with no electricity, the media made considerable efforts to tell the people of Christchurch what they needed to know. The overall view was that the information management immediately after the event did generate public confidence in the emergency management response, and at the same time supported public safety and positively influenced public behaviour, assisting in shaping public expectations.

USAR operations The New Zealand Fire Service (NZFS) conducted its own report into USAR and this issue was further considered by the Review. Insufficient opportunity exists here to analyse USAR operations and ample information is available in these other reports. Perhaps the most critical learning from an incident management perspective is to integrate specialist capabilities such as USAR, aviation and rapid damage assessment within Incident Management Team (IMT) operations, identifying them as a specialist capability but not unique. These, together with all other capabilities, need strong operational control, planning, information and intelligence, clear tasking, reporting lines and logistical support. None is so unique that it needs to operate independently.

Lessons learnt The actions taken immediately before, during or directly after the civil defence emergency to save lives and property and to help communities recover, referred to by the Ministry of Civil Defence and Emergency Management (MCDEM) as the ‘response’ to the February 2011 earthquake, seamlessly morphed into recovery so that it is difficult to separate one from the other, and for incident management both phases are considered as one event for the purposes of this chapter. People and organisations initially responded from Christchurch, then the Canterbury Region and then from across New Zealand. International assistance arrived quickly including both USAR teams and police. There are nine issues I wish to discuss related to incident management: 1 2 3 4 5 6 7 8 9

Train your people in the endorsed system and use it. Make it crystal clear who is in control. Consider a national, pre-formed team. Establish sectors for large events. Analyse information to generate intelligence. Build IMT capability from the bottom up. Make modifications to CIMS (AIIMS). Manage logistics. Reflect on IMTs of any size at any level.

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1.  Train your people in the endorsed system and use it In 2011 New Zealand used a derivative of the Australasian Inter-service Incident Management System™ (AIIMS) called CIMS (Coordinated Incident Management System), which has been adopted by government agencies including emergency services and police. AIIMS and CIMS were fashioned on the US National Incident Management System (NIMS) used by forest firefighters that in itself was derived from the military staff model. In essence, it is a functional system for managing any operational activity and identifies a range of activities that need to be completed concurrently to efficiently and effectively manage complex activities, generally referred to as ‘incidents’ by emergency managers. These functions include command and control (with each term having specific definitions), safety, liaison, planning, operations, logistics, public information, intelligence, investigation and finance. Common principles that are promoted when using AIIMS and CIMS include: • flexibility • management by objectives • functional management • unity of command • span of control. The Director of the CDEM resumed the role of National Commander (which he had previously delegated to a subordinate) and deployed to Christchurch the day after the earthquake to take control of the response, bringing together the Christchurch City Council (Council) and Canterbury Civil Defence Group. This was a significant gesture by the New Zealand Government, similar to sending Major General Alan Stretton to Darwin after Cyclone Tracy. It signalled a national response was being committed. The Director of CDEM with a small number of staff, council and the local Civil Defence Group operated as a joint IMT (more a regional control centre) for two months out of an ‘alternative’ Emergency Operations Centre (EOC) named the ‘Christchurch Response Centre’, being the Christchurch Art Gallery Te Puna o Waiwhetu. The originally designated EOC survived the earthquake but was in a vulnerable location and, as the event evolved, was far too small. At its peak around 500 people were working at the ‘alternative’ EOC. It was an unprecedented challenge for emergency services in New Zealand. With a level of dysfunction existing in local CDEM structures and between CDEM and the Council, there was a need for a national figure with ‘mana’ (gravitas) to take the lead. The lack of pre-planning for such a move of the National Commander to Christchurch caused difficulties in establishing the Response Centre. Operating out of the EOC in the Christchurch Art Gallery brought together warring factions and unfortunately this was never resolved. The result was a degree of confusion, inefficiency and duplication, which in part manifested itself with sections

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of the IMT being isolated within different galleries of the EOC. Cohesion was never fully achieved despite the efforts of many. The internal organisation of the Response Centre departed significantly from the structure set out in the National CDEM Plan and indeed as reflected in the CIMS manual. While the merits of what evolved can be debated (the differences between what was planned and what occurred are depicted below), the National Commander needed to adopt a structure that, in his view, worked best under the circumstances, noting the magnitude of the event, the unprecedented creation of an IMT of that size and the prevailing local politics. This was the decision of the commander on the spot. There was also the consideration that to reorganise the Response Centre two days after the event had occurred (when the Director of CDEM took charge as National Commander in Christchurch), would have been a major disruption at a time when the focus was on field operations with the hope of still saving lives. The result was, however, a dysfunctional IMT operating in an EOC located in the foyer and a series of viewing rooms within the Christchurch Art Gallery. The consequence was that the IMT never provided optimal assistance to the National Commander it was established to support. What the Christchurch City EOC had as a planned structure is depicted in Figure 4.1. The proposed structure was balanced and closely followed the CIMS doctrine. While somewhat different to AIIMS particularly with the inclusion of ‘Welfare’, it was a functional arrangement with clear responsibilities. It appeared a wholly practical approach to managing emergency incidents. Although the intended EOC structure was clear (Fig. 4.1), the actual structure that evolved at the Response Centre after the earthquake developed to accommodate the existing tensions between the Christchurch City Council and the local CDEM organisation. A comparison between the planned and actual structures reveals several differences (Fig. 4.2). My understanding of the two directorates was that the Christchurch City Council staff would be accommodated in the Operations Directorate and the Canterbury CDEM staff in the Planning Directorate. While this may have accommodated the local politics, and indeed they operated out of separate gallery rooms in the Christchurch Art Gallery, it led to frustration by those who had been trained in CIMS because the structure created was inconsistent with the doctrine and led to confusion and duplication, which was never optimal. Numbers in the Response Centre became problematic and also hindered a clear operational focus. At its height up to 500 staff operated out of the Response Centre and it became unwieldy as a workplace. Large numbers of these staff (such as up to 50 data entry staff) could have completed this work off site and reduced the numbers and pressure on the EOC, which operated within the cordon of the badly damaged CBD. This was further aggravated by a widely reported lack of clarity about the EOC organisation, perhaps because it grew rapidly and few, if any, knew how it was structured. Those that did know appeared unable or unwilling to explain it to others.

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Controller

Controller’s assistant

Recovery manager

EOC manager Safety

Planning and intelligence

Operations

Situation analysis unit

Council infrastructure services

Logistics

Public information

Welfare

Supply unit Media liaison

Neighbourhood support

Environment Resources unit

Emergency services

Facilities unit

Web team

Catering unit

Support unit

Health services Information display

Planning unit

Management support

Building evaluation and rescue

Work and income

Housing New Zealand

Ground support unit

Salvation Army

Finance unit

Welfare liaison officer Computer systems

Message dispatch Communications unit

Telephone systems

Radio operators

Fig. 4.1.  CDEM proposed emergency management framework.

There was also confusion about who to contact on various issues and it was reportedly difficult to locate and engage with the relevant Response Centre person other than by locating and physically visiting the relevant people to maintain communication. Logistics was fragmented across and within the divisions, and later this dysfunction was well tested by the lack of portable toilets and inadequate sanitary arrangements that plagued parts of the city for an extended period. Furthermore, the majority of Council staff were not trained in CIMS and senior Council managers were placed in key functional positions within the operations directorate of the IMT. Junior Council staff who were trained in CIMS were not appointed to the positions where they had training and experience due to their hierarchical position within the Council staff structure. This proved problematic as effective Council managers do not necessarily transition into successful IMT staff during a natural disaster. As Dutch Lenard, a renowned researcher and advisor on emergency management, has identified on various occasions, including during the Victorian Bushfires Royal Commission in 2010: ‘During an emergency, what counts is your

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Fig. 4.2.  Actual organisation structure at the integrated Christchurch Response Centre.

experience and expertise and qualifications as an [IMT] emergency leader – and that is all that counts. However, the person with the highest rank in a given office, chosen for capacity to build the organisation and its capabilities for response, is not necessarily the person best qualified to lead it in a moment of intense stress and disruption.’

2.  Make it crystal clear who is in control It was my impression that New Zealand had a less-developed identification of responsibilities for emergency response than I had seen in other countries. What appeared to be lacking on 22 February 2011 was clarity before the event occurred, as to who was responsible for incident types, or who would take the lead, or the importance of one agency or individual being recognised as the lead agency or Incident Controller in the first instance. Admittedly, at sites such as the CTV building collapse where there was a fire, multiple rescues from building collapse and resultant deaths, more than one agency had responsibility for elements of the response. That said, it is the responsibility of the senior people present to either take control or identify who will. This needs to be workshopped and practised well so that it is seamlessly enacted during an emergency. Regardless, at any emergency of any scale, one individual in one service needs to takes control and make it clear they are acting as Incident Controller for that site. This is in accordance with CIMS doctrine, and, depending on the size and complexity, an IMT may need to be set up to assist in controlling the specific response. This is a responsibility across police, emergency services and government agencies to document clearly, assist training and avoid duplication. Achieving well-defined ‘default’ positions can still lead to some circumstances where discussion between agency commanders may modify these responsibilities for

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control of multi-agency emergency incidents. But let there be no doubt of the requirement and, if a particular circumstance is unusual, the need to establish a clear control arrangement at the time.

3.  Consider a national, pre-formed team It was clear from the response to the 22 February earthquake that many people who were called upon to manage or staff the Response Centre had neither the training nor the capability to lead during a major emergency, despite their skills to do quite different jobs in normal times. The problem was compounded by the fact that regions in New Zealand, and also in Australia, have relatively few significant emergencies. Therefore, Incident Controllers and key IMT staff do not get sufficient live emergency experience to sustain a high level of skill. To overcome this deficiency the Review recommended that a small cadre of personnel be identified and trained nationally to establish a pool of senior emergency management positions available to form an IMT during natural disasters. Pre-formed IMTs have now also been put in place in several Australian states and of course North America. In New Zealand, it was proposed that this small number of personnel be highly trained in catastrophic event management. The personnel would be drawn from CDEM, fire services, police, New Zealand Defence Force and even private organisations such as logistics companies. They would carry on with their regular jobs for much of their time but maintain their emergency management skills through education, training and regular exercises. It is anticipated that this approach would provide a much more effective capability for high-end emergency management than bringing people together at the time or, indeed, attempting to maintain a larger number of personnel at a lower level of readiness. Focusing resources on maintaining a small team that can readily deploy where required appears optimum. The merits of pre-formed teams are: • Individuals are selected to complement a given team, ensuring you have the right complement of capabilities. • Team members are familiar with each other and whom they will be working with. • Individuals’ strengths are known so there is added confidence. • There is no need for a team to go through the ‘form and storm’ process when an IMT is established; this has occurred previously during training. • Resources can be directed to provide most benefit to a small number of team members. • Leave and other absences can be planned and balanced across the team.

4.  Establish sectors for large events Across Christchurch as this disaster unfolded, there were only two formal IMTs established and maintained: the Response Centre, which had overall control and

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supported the National Commander, which at its maximum involved 500 personnel from multiple agencies and was in place for two months; and the USAR IMT, which was manned almost entirely by NZFS USAR staff for the several weeks it operated. On reflection, that seems an amazing arrangement but at the time it totally exhausted NZFS USAR staff. There seemed to be a reluctance of overseas USAR staff to take responsibility in the NZUSAR IMT and by NZUSAR staff to accept support from other areas of NZFS. Although USAR was managing operations in the ‘red zone’ across the CBD, the Response Centre had overall responsibility for the CBD and greater Christchurch. There were no sectors established and no subordinate IMTs outside the Response Centre apart from USAR. While there may have been ‘control or operations points’ at major rescue sites for a time, these were never formalised and further IMTs were never established. There were opportunities to develop sectors across Christchurch City, managed by tactical level IMTs reporting to the Operations Division at the Response Centre. This would have devolved local control during the response and subsequent recovery phases. In accordance with the CIMS manual, establishing sectors (a defined portion of an overall incident) would have decentralised some operational control and allowed the Response Centre to manage the more overarching and strategic issues, while allowing tactical management to proceed. Dividing the tactical control into ‘sectors’ across the city would also have delegated to ‘Sector Commanders’ many of the issues raised through the Response Centre to the National Commander. These Sector Commanders could have reported to Operations and managed tactical level issues in recognised sections of the city. Quickly establishing incident control at major rescue sites would have assisted in clarifying control arrangements and enhanced operational integration. At complex, multi-agency incidents, this requirement is paramount. Perhaps two sectors could have been established dividing the CBD, with a further two or three sectors to manage response and recovery in the east, the south and the remainder of the city. Attempting to manage emergency response across a large geographical area, as well as a multitude of tactical and more strategic issues from the one Response Centre, was highly challenging and not consistent with incident management doctrine.

5.  Analyse information to generate intelligence It became evident that by late into the night on 22 February 2011 there was already significant information available to the EOC but there was no good situational awareness. One week after the earthquake, the amount of information gathered was impressive. This came from police and emergency services, 111 calls, the Red Cross and then the council call centre, surveys conducted in the field, contractors, individuals passing on knowledge of infrastructure, and subsequently from the media. It was enhanced by a further major information collection activity

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involving visiting households in the suburbs most affected and asking a series of 12 questions. The information collected was subsequently collated by up to 50 data processors located in the Response Centre. Even though all this information was being gathered, it failed to be appropriately stored or adequately analysed. This lack of analysis was not informing controllers and agency commanders to make the best operational decisions. In essence they were not being supported by good intelligence – the ‘product’ of analysed information. There did not appear to be one area within the EOC which was considered the most reliable source of information and the Review was advised that information was not generally well displayed. Whether it was because of dysfunction between Planning and Operations, the rotation of people through roles or the lack of training, there appeared to be a great deal of information being collected but it did not appear to directly assist key decision-makers. This is not unusual for any major disaster but the military forces and police have well-established ‘intelligence cells’ manned by operators trained in analysing large amounts of information from disparate sources and identifying trends, predicting likely outcomes and particular risks. There appeared to be a lack of understanding by Operations regarding what was meant by ‘information’ and ‘intelligence’. Many IMT staff referred to both interchangeably; this did not support decision-makers. ‘Information’ is the raw data that may be acquired from a wide range of sources, whereas ‘intelligence’ is information that has been evaluated and analysed by trained staff. Information gathered by the Response Centre would have included: • • • • • • • • • •

weather advice information from the police reports from USAR data from surveying suburban impact from the earthquake information from contractors reporting on buildings and infrastructure advice provided by callers to the council hotline reports from spontaneous volunteers reports from the media reports from business owners and residents New Zealand Defence Force advice.

While information is potentially useful, it can, and in Christchurch appeared to, swamp decision-makers. In its raw form it is often unhelpful. In order to provide useful intelligence, information needs to be verified and information from different sources needs to be compared and reviewed. Incident management personnel (including the Incident Controller), once trained in intelligence management, provide IMT staff with their priorities to enable intelligence staff to direct their efforts in specific areas. One week after the earthquake an Incident Controller’s intelligence priorities could have included:

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• • • •

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accounting for all missing persons providing support to badly impacted suburban areas confirming building safety to allow business owners to retrieve vital assets restoring essential lifelines services, particularly water and sanitation.

This would have informed intelligence staff to focus on sources that generated information for these priorities. They could have then analysed that information to identify likely challenges and trends. During the event, the lack of intelligence was not a result of insufficient staff numbers (capacity) but of insufficient training in producing intelligence (capability). In addition, there was no strategic plan for formation collection and intelligence analysis. What the National Commander and key directors required by way of intelligence does not appear to have been stated clearly enough and this led to an uncoordinated information collection effort. In Australia in 2013 intelligence as an AIIMS function was still being established. The Australasian Fire and Emergency Service Authorities Council has spent considerable resources to finalise the AIIMS Intelligence Course, which is now available to member agencies.

6.  Build IMT capability and control from the bottom up Neither the police, fire service, CDEM nor Council considered that a degree of control was established until about six hours after the earthquake. At that time, while there was extensive ongoing searching, five specific sites involved concentrated rescue efforts: 1 2 3 4 5

ChristChurch Cathedral CTV Building PGC Building Hotel Grand Chancellor Press Building.

While internal ‘command’ was in place within police and fire as individual services commanding their own people, there were unresolved incident control arrangements between the services at those major rescue sites where an overall Incident Controller was not appointed. The Review considered that priority should have been given to ensuring that tactical level incident control was in place before establishing a regional incident management team, and if this required an executive officer from NZFS to be at a major rescue site to achieve it, then so be it. The lack of clear incident control was most evident at the CTV Building site. CIMS is designed to develop from the bottom up, so the most senior person on site was responsible for establishing incident control. My understanding is that this did not occur at the CTV Building and the senior fire service and police representatives undertook various roles and activities concurrently. While there

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appeared to be several reasons why this occurred, the sheer size of the collapsed building meant that observation across and around the site was not easy. A fire was burning in the lift well at the rear of the site and this added a degree of complexity. Regional level staff focused on establishing a Regional level IMT, when incident control remained inadequate at the CTV site in particular. While undoubtedly a challenging scenario and beyond the experience of all fire staff, the Review concluded that priority needed to be given to ensuring that tactical level incident control was effective in the first instance and that this should have been checked at the Regional level. While visits were made by Regional staff, they did not identify the inadequacies of tactical level incident management. This should have been done before diverting resources to Regional and strategic considerations. At about 6 p.m. on 22 February, some six hours after the initial earthquake, there appeared to be two Incident Controllers at the CTV site: a Police Senior Sergeant and a NZFS Senior Station Officer (SSO). Police indicated they considered the Senior Sergeant was in control and it appears that the SSO may have been too personally involved in the physical hands-on operations to be effectively in control of the site, even though a fire existed in the lift well of the collapsed building. It became evident from subsequent discussions with those involved that no one was clear who was in charge. What was deceptive was that there appeared some semblance of order, with physical ‘chains’ of people moving debris that could be handled and contractors with knowledge of the building being on site. What was lacking, however, was a single control site for what no doubt was already a complex, multi-agency operation with lives lost, lives at risk, heavy equipment in use, a fire burning and aftershocks occurring. A joint control point with the senior police and fire representatives was required. The absence of a clear Incident Controller is contrary to CIMS principles of command and control, and places all personnel involved in an unenviable position. Further lives were lost and there was the inevitable coronial inquiry. Despite the best efforts of all involved and significant bravery of those on site, a lack of leadership and compliance with incident management doctrine in establishing clear incident control was a critical deficiency. I am reminded of attending my first vehicle accident and seeing the officer in charge standing to one side, assessing the risks and setting tasks for the fire crew. He was clearly in control of the rescue, not directly hands-on, liaising with police and ambulance, and reviewing the circumstances as they changed. The danger for us all is that, while we can identify our role clearly in that circumstance, in something far more complex the principles need to be acted upon, but we can so easily be drawn into the detail. If responsibilities for various incidents can be allocated to services well in advance, as is the case in many jurisdictions, then who needs to be in control is identified before the incident occurs. There should be a clear and unambiguous national identification of which agency is responsible for managing the range of emergency incidents from fires, rescues and searches to vehicle accidents. This will assist in training and will become the default position for all emergency services.

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There may be circumstances, such as an absence of appropriate staff, where the default position cannot apply. In such circumstances, formal agreement on site needs to be reached and a single Incident Controller needs to be appointed and clearly identified in the role. .

7.  Make modifications to CIMS (AIIMS) I have been critical of adjusting the CIMS structure for this particular event at the Christchurch Response Centre, by deviating from the planned structure in Figure 4.1 aligned to CIMS doctrine and evolving a unique structure depicted in Figure 4.2. This may have accommodated local politics but was at the expense of efficiency, clarity and duplicated effort. That said, the Review team identified additional functional areas not reflected in CIMS (AIIMS) doctrine that they considered needed greater prominence. This was to better position CIMS (AIIMS) as a framework to manage urban events of a scale and magnitude such as the Christchurch earthquake. In doing so, it would better link the emergency response to the community and non-government organisations. The areas identified as requiring greater representation are: • business continuity: the preservation of business and jobs being a major consideration within the IMT once the environment is safe • community wellbeing and community volunteering: seamless linkages of community organisations and volunteer groups into the IMT that have strong self-management capability. Business continuity It became evident that the needs of the business community and the preservation of jobs were not the initial focuses of the Response Centre. This was understandable as public safety was paramount and aftershocks continued for months after the 22 February earthquake. The result, however, was that businesses were denied access to the CBD for many weeks. In addition, businesses that took the initiative and did relocate out of the CBD to another site to the west had little support from the Response Centre to undertake this move. Without business needs becoming a specific objective during recovery, significant long-term damage to many surviving enterprises could have resulted. The preservation of businesses and jobs needs to be made a major objective of the recovery, particularly when a CBD is affected, and these considerations need to be fully integrated into IMT planning and activities. It needs the establishment of strong links with local business groups and councils. This could be enhanced by a senior business liaison person being included in the IMTs. Community wellbeing or community volunteering The work done by community organisations, particularly in severely affected or isolated suburbs, was of immense value during the response and recovery phases.

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The organisations included existing community organisations not usually associated with civil defence, such as churches, community associations and marae, as well as voluntary organisations dealing with emergencies of different kinds, such as volunteer fire brigades and the Coast Guard. The ‘Student Army’ and the ‘Farmy Army’ were organisations of a quite distinct and different kind, having sprung up in the response to the 4 September earthquake. The Response Centre did not easily manage its relationship with these groups initially, but linkages improved once good liaison was put in place. The community groups in the suburbs had little or no contact with the Response Centre except indirectly through police and volunteer fire brigades. It was abundantly clear to the Review that the incident management structure in place at the Response Centre needed to be modified to provide a way for such groups to ‘plug in’ to the response and recovery they sought to assist. CIMS and AIIMS need a function or sub-function that specifically accommodates and assists community groups and spontaneous volunteers. This would benefit not only tasking and provision of resources but also information flows. In such a devastating event, these resources become as significant, if not more so, than aviation and our incident management structures need to reflect their importance in order to best use their capacity in a coordinated way. The Review suggested it be referred to as ‘community well being’ as often it gains a ‘welfare’ title that does not adequately reflect its function. During this event two type of volunteer groups were identified that are not clearly ‘labelled’ by emergency managers: organised volunteer groups such as community, church and marae groups, together with volunteer organisations like the ‘Farmy Army’ and the ‘Student Army’, which evolved under strong leaders and are able to play a significant role. CDEM culture appeared to devalue these organised resources, and categorised them with more ‘spontaneous volunteers’, such as well-meaning individuals with limited skills who walked in off the street and ‘wanted to help’. Organised volunteers are a valuable community resource, which need to be effectively tasked by IMTs and need to be recognised as being well engaged in the response and recovery efforts. The key learning is that large, self-organised volunteer groups, although they are not members of emergency services or formal NGOs, are likely to be an important element of a response effort when other resources are overwhelmed and undoubtedly will become critical elements of the recovery effort. They will probably be extremely well engaged with the community and their leadership and management must be left within the group. The role of the IMT is to ensure that explicit tasking is allocated, understood and accepted. The reporting of completed tasks should be recorded and fed into the IMT operations and planning sections. They also need to be recognised as a significant resource for information gathering and dissemination in times of emergencies.

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8.  Manage logistics The Review report considered logistics in some detail and elements are reflected here. This is because the somewhat delicate issue of sanitary arrangements across the city became a major concern. Not surprisingly, when the earthquake occurred water and sewerage pipes were severely disrupted in many areas of the city. Sewage came to the surface in some areas and did not drain in others. Mixed with the broken water mains this became a major health issue for the city. The National Civil Defence Emergency Plan at the time did not have a section dealing with logistics. What was included in the CIMS manual was not detailed information. While logistical support to assist the firefighting crews and USAR teams was excellent, the broader logistical support to assist the city and suburbs was more problematic. The basic issues of providing food, water and shelter were generally well handled, although in some of the worst hit areas the resilience of some communities was sorely tested for the first few days. Portable toilets and chemical toilets, however, became a major issue for the recovery effort. From a community perspective, it took much longer to source adequate portable toilets and subsequently chemical toilets to use inside the home. This delay appeared to be aggravated by the involvement in logistics of three distinct groups within the Christchurch Response Centre IMT. In normal circumstances within a single IMT these would have been processed in a single logistics section. Communications between the logistics sections were further complicated because the different logistic and procurement sections were not co-located and indeed were spread across the Art Gallery site. Information sharing upwards and the passing of specific tasks to the National Crisis Management Centre in Wellington was also sub-optimal. It became apparent to the Review that the scale and diversity of procurement and other logistics requirements after the February earthquake went far beyond anything that had been envisaged in local CDEM planning or even at a national level. In particular the need to purchase abroad, together with the need for a very speedy response, demanded knowledgeable and experienced logistics expertise, together with access to resources available in commercial logistic companies. Under CIMS the logistics function follows a logical process. Operations or planning identifies a specific problem and identifies ways to resolve that problem and obtain the necessary approvals. If the agreed solution requires goods or services then the Logistics section is tasked with identifying suppliers and sourcing the goods or services required, agreeing on a price, placing an order, arranging delivery (freight and, if from abroad customs, biosecurity and whatever is needed) and arranging storage or distribution on arrival. The group tasked with the restoration of the water and sewerage infrastructure quickly identified the extent of damage and recognised that sizable supplies of portable toilets and chemical toilets would be needed and that sanitation was going

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to be a major problem. This information, however, did not lead to an appropriate ‘intelligence’ assessment to advise the Logistics section of the size and implications of sourcing tens of thousands of portable toilets and chemical toilets. The detail is not important here, but the lesson to be drawn is for the IMT to be honest enough to understand its own limitations and nimble enough to engage the ‘nonemergency specialists’, in this case commercial logistics specialists, that are best placed to overcome significant challenges. Significant for the eventual success of logistics in the Response Centre was the arrival of the General Manager for Toll Logistics New Zealand. He describes his involvement to the Review as a ‘fluke’ brought about because he had been informed by a KiwiRail acquaintance that there was a need for experienced logistics knowhow in the Christchurch Response Centre IMT. He went to the EOC and offered his services. He had the full support of his Australian head office and spent nearly six weeks providing his expertise in the IMT, making a significant contribution to sourcing, procurement, delivery and distribution activities. His ability to negotiate with overseas suppliers, coupled with his detailed knowledge of arranging international charter flights and sea freight, of customs clearance and biosecurity import requirements, were critical in minimising the time needed to get assistance for Christchurch.

9.  Reflect on IMTs of any size at any level The situation faced by the National Commander on arrival in Christchurch the day after the earthquake was overwhelming. He faced a dysfunctional Response Centre trying its best to establish order out of chaos. With the benefit of reviewing those circumstances and reflecting on the many other operational reviews I have been engaged to comment on, I would advise the following to Incident Controllers: • Make IMT appointments based on merit. IMT appointments should be made based on incident management training and aptitude to work in an environment where there will be a lack of information, time pressures and personal hardship. The administrative seniority of individuals is not as relevant as training, aptitude and performance in an operational environment. Excellent administrative managers will not necessarily adapt to being good operational staff; this became evident when senior Council staff expected detailed briefs and information, which would be appropriate in a normal workplace but was just not possible days after a natural disaster. • As far as practical, talk to all the IMT on arrival. That may not be possible on a single occasion. Work will still need to be done; people are likely to be operating on shifts; they may not all be in the one location; but it is essential that your IMT sees you, hears you and understands your intent. If that cannot be achieved, expecting them to work hard in support of you will become

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• •

•

•

•

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increasingly difficult and cliques, divisions and a lack of concentrated effort may follow. This was a simple but fundamental request made by members of the IMT in Christchurch. Ensure everyone wears both a name tag and a title. The key players are likely to know who is who, but many others brought in to assist will not; this is particularly so with support staff asked to take minutes, maintain logs and undertake reception duties. Without establishing and maintaining this simple discipline, any IMT, large or small, will lack efficiency. Distribute a phone directory and redistribute it as often as is practical. In the early stages this may need to be daily. Appoint a Chief of Staff. This appointment is not currently in the AIIMS or CIMS manuals but it should be. Military operations have used it for years and politicians have seen the wisdom of the role. The National Commander arrived with a small staff who provided his office with immediate support and, although they were rotated in a post titled Chief of Staff, the role and function of the position was not clear to them or others. What was needed was a strong character with experience at a senior level to coordinate staff functions, ensuring the National Commander’s intent was put into action and handling the politics of the EOC. Such a position acts with the authority of the Incident Controller, with the role to ensure that decisions once made were put into action, completed and not duplicated across the staff; understanding the commander’s intent; and following through on the detail. A Deputy Incident Controller in a conventional IMT may well adopt this role and I would encourage this to occur. Keep all in the EOC informed. When a significant event occurs in the IMT, it needs to be brought to the attention of all. This may be able to be done electronically on everyone’s screen but if the IMT is not too large and in a single location, someone calling out: ‘Attention in the IMT’ and ‘I want you all to know that xxx has occurred’ may be just as effective. Objective-based IMT briefings. Keep IMT briefings to being objective based, not ‘going around the table’. Going around the table and inviting everyone to speak is fine in administrative staff meetings. But when time is short and clear outcomes are sought, it is highly inefficient. Only those that can contribute to specific outcomes need speak during the early stages of IMT briefings. Ensure the meeting time to action time is 1:4. I have seen IMTs spend 45 minutes in a meeting and then meet again on the hour, allowing only 15 minutes to progress an outcome. If you are going to meet on the hour, which early during an incident may be realistic and necessary, keep the meeting to 15 minutes and the ratio of meeting time to taking action 1:4. Maintain two log books. While recording actions and decision in logs is tedious and time-consuming it has become a necessity. The larger the incident,

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the more it is necessary. Maintain a ‘ship’s log’ – a record of what is occurring across the IMT; individuals also need to maintain their own personal logs of their actions and decisions. Physical layout is critical to the success of any IMT. The physical isolation of functions leads to an inability to achieve a common operating picture and inhibits coordination. The EOC quickly exceeded the room previously occupied as the Council EOC and staff were occupying the Art Gallery foyer. This began an unplanned expansion through much of the Art Gallery complex, requiring gallery staff to remove art works as emergency management personnel occupied additional space. Some gallery rooms were quite some distance from other IMT staff and undoubtedly isolated. Quickly establish a single ‘knowledge wall’ that maintains critical information for all who work in the IMT. I was reminded by a military commander that he expects to enter an operational headquarters (IMT) and be able to identify what is occurring and the immediate challenges by observing the ‘knowledge wall’: where maps and diagrams are displayed, a log book is recording key events, key objectives are listed, resource commitments are evident and time frames are referred to. This is the foundation of a common operating picture and a commander should not require a detailed briefing if the appropriate information is displayed inside the EOC. Manage by walking around. As the Incident Controller, wherever possible manage by walking around. If you hope to extract the discretionary effort of those working to support you, visit them. This will not be achieved through emails and broadcasts. If you can call them, call. Only email or pass a message through others when there is no alternative. Appoint a functional leader throughout shift operations. Even when operating on shifts, as occurred in Christchurch for many weeks within the Response Centre, a specific person needs to be appointed as Incident Controller, Planning Officer, Operations Officer, etc. Rotating people through roles within an IMT, with no individual having the designated appointment, is disruptive and inefficient. Planning may never be taken up, decisions can be adjusted or overturned, staff may respond to one individual in the role but not another, and there can be a general lack of continuity. Those who occupied the positions at other hours would have authority to deal with issues that came up, but only within policies and precedents set by the incumbent. Manage shift handovers. Handovers are always a vulnerability. The more handovers there are (for example, three eight-hour shifts), the more opportunities that information can be lost, misinterpreted or misunderstood. Minimising handovers helps, but having a clear checklist is essential. Not changing the entire IMT at the one time also has merit but can be problematic logistically. In Christchurch there were usually three handovers a day, at 7 a.m., 3 p.m. and 11 p.m., to accommodate eight-hour shifts.

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Recommendations There was a range of recommendations identified by the Review. Some were self-evident: that only those with CIMS training operate within IMTs; and that, while established EOCs are preferable, an initial EOC can be established anywhere. I have identified eight major recommendations that in my view reflect the essence of the learnings for incident control from the Christchurch earthquake. Summarised below, these are: 1 Use the system and structure your people have trained with and reflect the same principles at all levels. 2 Clarify and practice the command structure for controlling emergencies. 3 Enhance potential IMT capability through pre-formed teams. 4 Divide large events and don’t manage as a single incident. 5 Analyse the available information to produce intelligence. Do not underestimate the training and resources needed to do this well. 6 During a large disaster, build IMT capability from the bottom up. 7 Review existing CIMS and AIIMS structures and learn what other functions should be included to maximise incident management capability. 8 Be prepared to engage with non-emergency specialists such as commercial logisticians.

Conclusion The consequences of the Christchurch earthquake of 22 February 2011 identified a range of incident management issues for improvement in New Zealand. Like the Black Saturday fires in Victoria in 2009, these tragedies offer important lessons to incident management professionals in any country. We need to acknowledge that these overwhelming events thankfully do not occur often. When they do, we need to adopt an approach of learning, not blame, and extract all we can from these experiences. The circumstances are very difficult to replicate in exercises and that is why reporting on the natural disaster learnings and focusing on incident management issues warrant time and effort. Undoubtedly at some time we will again be overwhelmed by another major natural disaster. My hope in writing this chapter, however, is that the lessons learnt in Christchurch justify close scrutiny and application in every jurisdiction. The potential exists, without large cost or disruption, for lessons identified here to be applied throughout New Zealand and Australia.

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5 A highway cyanide spill at Tennant Creek Leigh Swift Station Officer, Northern Territory Fire and Rescue Service, now retired

Introduction Living in the ‘golden heart’ of the Northern Territory as a firefighter has its challenges. After 7 February 2007 my understanding of what cyanide was, how you worked with it and what resources you needed to deal with it after a spillage changed forever. For the next 10 days I would become Operation Officer at an incident that was not like anything I had been involved with before. I received a call from the Tennant Creek police station that a road train carrying cyanide had crashed about 130 km north of Tennant Creek on the Stuart Highway. The cyanide pallets that it was carrying in containers had broken from the bags and the boxes that they were stored in for transport and had come to rest on the side of a waterway. It would later be found that, of the 18 boxed cyanide bags it had held within, 12 remained in the container semi-intact. The other six boxes had been released from the container during the rollover. The contents of some of the six boxes were intact

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and remained encased in their woven bags, but other boxes had been destroyed so that the cakes of cyanide were scattered from where the product first left the containers and where impact first took place to where the container came to rest on the western side of the highway down the embankment. The driver was uninjured and the prime mover and first trailer were undamaged. Not having seen cyanide before, we noticed what looked like small cakes of white soap, like the type you get in motels, spread all over the place. Since we had not encountered an incident involving cyanide before, the truck driver was questioned over and over again on procedures for working with the product and what was best practice.

The challenges Tennant Creek Fire Station is one of five track stations in the Northern Territory. The track stations are manned by permanent members consisting of a Station Officer and a minimum of one Leading Firefighter (LFF) with an Auxilliary Firefighter (AFF, paid a retainer) and volunteers (VFF). At the Tennant Creek fire station we attend a wide range of incidents and can travel huge distances for chemical incidents and road crash extrications. Our furthest travel distances to boundaries are to the east on the Barkly Highway to the Queensland border (490 km), to the north on the Stuart Highway to Dunmarra Wayside Inn (355 km), west on the Buchanan Highway to Western Australia border (990 km) and to the south on the Stuart Highway to Barrow Creek (215 km). We hastily met with police to arrange a plan of attack for scene safety and to stop all vehicle movement through the scene. The Elliott police sergeant, who was in Tennant Creek at the time, was briefed on distances to keep vehicles and the public away from the scene and left for the incident in the pursuit car to look after the southern roadblock. Meanwhile another police member from Elliott had been informed of the situation and was heading south to look after the roadblock north of the incident. Contact had been made with the company transporting the product through the Northern Territory and also with the manufacturer of the product, which was a Queensland-based company. The police, the fire service and the emergency services had also been notified of the situation that we were dealing with. At 1.45 p.m. an AFF and I took various types of protective clothing and headed off to investigate the scene further and to speak to the uninjured driver, leaving the Emergency Response Area of Tennant Creek to the captain of the AFFs and VFFs as the LFF was on leave. The AFF and I spoke of various things on the way to the job but we were very wary of what we may find and what we could do. We arrived at the scene at 3.05 p.m. after driving past the cars at the roadblock that had been established by the Elliott police sergeant more than a kilometre from where the

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trailers of the road train had crashed. People were out of their cars and mingling with others at the roadblock. The day was clear and hot as is normal for that time of the year, with temperatures over 40°C. Daytime temperatures like this are not uncommon in the summer months in the Territory. The maximum protection personal protective equipment (PPE) that we put on are encapsulated, vinyl-like suits with a big plastic window to look out of. The suit is worn over your regular uniform and is zipped up and airtight, with a breathing apparatus worn on your back. It is like being in a sauna, where you sweat profusely anytime you are inside it, let alone when in 40°C. When wearing the various types of PPE you constantly require rehydrating and it is also of great importance to monitor your fellow members as well as yourself. In a situation like the one we were confronted with, where we were uncertain about the best practice precautions to be taken, Northern Territory Fire and Rescue Service (NTFRS) members were always taught to dress up first. Initially we put on the personal protective clothing that would give us the maximum coverage, with the understanding that we might later dress down to lesser such clothing once we had confirmed that it would provide sufficient protection for the product we were working with. The accident occurred in the lowest part of a gully on a straight stretch of road on the Stuart Highway with the road climbing through the hills both to the north and the south. The road was about 6–8 m above the waterway where the trailers had come to rest. Driving down the hill from the roadblock, the driver explained to us what had occurred. He said that a small car had been trying to pass him going down the hill and was taking a long time to do so. When the car was about halfway along the second trailer, the third trailer dropped off the road and onto the dirt, which flicked the trailer with a sideways movement. He went on, saying he would normally have slowly pulled towards the middle of the road and beyond to straighten up, but with the car there he just had to wait for it to pass. The movement of the trailer got worse and it kept flicking back and forth on the dirt before sliding off the road all together. Approaching the scene we could see that the second and third trailers, which had steel containers on them, had slid down the concrete embankment and finished up on the other side of a waterway. There were long scrape marks on the concrete embankment and the concrete was broken up from the impact of the trailers, which had hit a wall and flipped over before coming to rest on their sides. The trailers had detached from the first trailer and the prime mover which were about 100 m north of where we pulled up and on the left-hand side of the northbound lane, undamaged. The second trailer had stayed intact, still connected to the third trailer. The doors were forced open when it collided with the embankment, but the product was still stored in woven bags and boxes within the steel container. The third

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trailer had come to rest about 5 m to the north of the water course; it had crashed into a raised area of stones and rocks. The container had come off the third trailer and the doors, which were at the back and the sides of the container, were bent and twisted and had been forced open on impact. While there appeared to be a lot of cyanide pallets on the rocks and stones, most of the product was still secured in the bags and plywood boxes within the disfigured container. Looking at the plywood boxes within the containers and those that had come from it we could clearly read the stickers attached: ‘Sodium Cyanide Solid, UN. # 1689’, with a diamond identifying toxic and/or corrosive material, the skull and bones crossed at the top of it. We took lots of pictures of the scene as we walked and stepped around the product lying on the rocks, and back on the other side of the waterway where the trailers first collided with the embankment. The driver was looking at the trailers and containers and seemed surprisingly relaxed, considering all he had gone through. The AFF and I were looking at each other and the scene, and were more concerned with how much of the cyanide had gone into the water. Broken timber boxes could be seen floating on the top of the water and some of the woven bags were hanging over into the water. We wondered how cyanide reacts in water. Was there any other danger to us? How much was still in the containers? We spent about 25 minutes photographing anything that we thought could assist with the recovery process as we spoke in muffled conversations to each other through our breathing apparatus. When we got back to where the police were located on the southern roadblock we gave the camera to police officers who had come up from Tennant Creek and who headed back to Banka Banka station some 30 km away to the south at 4.30 p.m. There the pictures were emailed to the Tennant Creek police station and then distributed to the manufacturer of the product, the transport company, and the management of police, fire and emergency services to determine an action plan. We could have these pictures with stakeholders all over Australia within four hours of the reported incident in a remote part of the Northern Territory. We went back onto the scene to recover personal items belonging to the truck driver, and liaised further with the police sergeant about what could be put in place overnight. What of the people at the roadblock? How were they going to be looked after? What were their possible needs? Did they have food supplies? At 6.32 p.m. we headed back to Tennant Creek with the truck driver, who we would take to the hospital for a health check on our return. As we left we noticed that the Department of Planning and Infrastructure (DPI) had put out the road closure signage to assist the police at the roadblocks. The driver was taken to hospital for a check-up at 8.30 p.m. and was reported to be in good health; he was released a couple of hours later. The next morning (Thursday, 8 February) we received information from the police that the company who made the sodium cyanide pallets had staff at the roadblocks awaiting our arrival so they could view the scene. After meeting

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personnel from the manufacturer of the cyanide we were advised by them that the product was very toxic and that it would affect a person when it was inhaled, swallowed or absorbed through the skin. It was recommended that Tyveck™ disposable overalls with rubber boots and gloves be worn as minimum PPE with respirators to be used when dust particles reached levels of 10 ppm (indicated when warning beepers sounded). We set off to the scene accompanied by a crew from St John Ambulance with a 3000 L tanker, in vehicles towing trailers carrying whatever we thought we might need in this Hazmat incident. We arrived at 1.48 p.m. to see a longer line of vehicles at the roadblocks, with people out of their cars and others seeking whatever respite they could with the temperatures once again forecast to reach 40°C with a slight breeze coming from the south-east. An action plan, which involved first getting the second trailer back up on to the road and then the container with the contents intact, was established. It was also established that none of the trailers and containers was to be removed from the cordoned off area until they were all decontaminated using water. The firefighters present set up the decontamination zone to the north of the scene. This was an area that people working in the ‘hot’ zone would come to remove the PPE they were wearing before they left the zone. Then after leaving the decontamination zone they went to a first aid area where they were checked over by St John Ambulance members, who kept records of each check-up. There were also safety zones to the north and south of the incident on the road, put into place to establish working areas. Logistics were arranged to get equipment and personnel to the crash scene. Triple side-tipper road trains were brought to the site from Katherine (450 km), Mt Isa (800 km) and Tennant Creek. Excavators were brought from Tennant Creek and Katherine; and a front-end loader, water tanker and graders were brought from nearby Helen Springs pastoral station. Grass fire units, four-by-four dual cabs and utes with trailers were provided by Bushfires NT (BFNT) and NTFRS. The Northern Territory Emergency Service (NTES) sent a troop carrier with a communications trailer attached. Various other hired vehicles were also obtained to commute personnel to and from the crash site. Personnel at the scene came from Alice Springs, Darwin, Katherine and Tennant Creek, as well as Mt Isa and Gladstone in Queensland. From the second day of the incident, meals were provided on site at breakfast and lunchtime from Renner Springs Desert Inn, which also supplied most of the rehydration at the site. Anyone who came through Tennant Creek was given the task of getting as much water and sports drink bottles or satchels as they could. Ice was very important for trying to keep things cool with the extremely hot temperatures we were all working in. There was also a 100-tonne crane being sent from Mt Isa, along with other road trains and side tippers, by the freight company, which was employed to carry the product to assist with the clean-up and recovery processes. We waited in Tennant

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Creek for a crew of firefighters from Alice Springs to arrive before we left town shortly after midday. Setting up the crane to lift the containers and the trailers back onto the roadway took nearly an hour. Extraction of the second trailer and container commenced at 3.15 p.m. The trailer was cut from the container using oxy-acetylene equipment. It was lifted up to where it was suspended over the waterway by chains connecting it to the crane. There it was decontaminated using water from the fire tanker. When the hose-down was complete, the trailer was left to dry in the sun before being lifted to a storage area on the other side of the road. The container from the second trailer, which was primarily still intact, was lifted onto the north-bound lane of the highway and left overnight. During the afternoon another truck with containers had arrived on site; inside was a forklift which would assist with the unloading of the damaged containers’ contents into the new containers. At 5.55 p.m. the crew working in the ‘hot’ zone were decontaminated on exiting the zone, and health checks were conducted and logged. The crane was re-stowed and moved off to the side of the highway. At 6.10 p.m. personnel at the scene headed to Renner Springs Desert Inn for meals and accommodation in various types of vehicles and trucks. On Friday, 9 February the crews from Renner Springs arrived on scene at 6 a.m. Food and drinks were given to the police members on the roadblocks and to the BFNT member, who informed them of the overnight rain that had fallen on the site. When checks were conducted there was found to be high levels of cyanide recorded on the road in the ‘hot’ zone. As a result of this the members present overnight were given health checks while the road was decontaminated and made safe. Four firefighters from Darwin, who had flown to Alice Springs and then driven to Tennant Creek the afternoon before, headed up to the site the next morning, arriving on site at 7.30 a.m. Shortly after their arrival it was decided to move personnel and equipment to the south of the ‘hot’ zone due to a change in the wind and the blustery conditions. The wind change meant that any product that became airborne would have been blowing over the recovery process, and for the people assisting with it this was not an ideal situation to be in. The members that went back to Tennant Creek overnight replenished supplies that were needed at the incident and at the Renner Springs Desert Inn, which had become very busy with all the tourists stopping there as well as the personnel from the crash site. We finally got underway at 11.10 a.m. and headed north up the highway. Just the other side of the Bootu Creek Manganese Mine turn-off we could see a large column of smoke in the distance, and as we got closer to the site we could see the fire was in the hills to the north-west of where the crash had occurred. This was later to become a threat to the site and the personnel within it. A fire crew composed of BFNT and NTFRS members, along with a grader from nearby Helen Springs pastoral station, was deployed to stop the fire.

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In Alice Springs an Emergency Operations Centre (EOC) had been established, with managers from the police, fire service, emergency service and stakeholders that could assist with the situation we were facing and logistically support the crash site with whatever was required. We were also able to report back at several planned times during the day with updates from the site via satellite phones. Communications out of the crash site were important to maintain accurate information about what was occurring during the day with all stakeholders. As a result of this, all information out of the site was now being channelled through the Incident Controller for efficiency. The EOC had informed the Incident Controller of a possible road around the site which was showing up on maps they were supplied with in Alice Springs. In consultation with the EOC and after sending out personnel from the DPI and NTFRS, it was clear the road that they were looking at was a road that had already been driven on when assessing the fire that was in the hills early in the incident and was some 250 m to the north of where the crash had occurred. As this was the major north–south road through the Territory, having the highway closed for the days and only open in the night was causing some concerns to travellers and transport companies. There was another option around the site by using the Tablelands Highway, which had 400 km of tarmac and the remaining 623 km was dirt. Another alternative was continuing up to the Carpentaria Highway which was all tarmac but narrow in places, with an additional 780 km before reaching the Stuart Highway. In consultation with the EOC we were tasked with ensuring that the road was open for vehicle movement by 10.00 p.m. that evening. During the day the ISO water tanker was filled from the waterway, decontaminated and driven north. Decontamination had been conducted on the second trailer and the contents of the container had been removed. A triple road train with side tippers had been manoeuvred into place to be filled with contaminated soil and cyanide pallets from the south side of the waterway. When this was happening all work other than the loading of the contaminated soil stopped due to dust and airborne particles in the ‘hot’ zone. The crew given the task of halting the path of the fire in the hills to the north-west returned triumphant at 7 p.m. At 7.15 p.m. the loading operation was shut down after the filling of the second tipper. Decontamination of personnel took place and the equipment in and around the zones had started to be packed up to meet the deadlines we were under for the re-opening of the highway. Tarpaulins were put over the cyanide pallets that were still visible, weighted down and checked again to make sure the product was going to be safe and away from any curious public as they went through the zone. At 8 p.m. the highway was re-opened for vehicle movement. Police had informed each vehicle travelling through the zone to keep to a slow speed of 40 km an hour, to not stop and to keep to the one side allocated. The personnel at the

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scene headed back to Renner Springs along with the north-bound traffic which was allowed to continue with their journey first. I left for Renner Springs at 9.30 p.m. with a lot of vehicles still coming from the south through the zone. Heading north the build-up of cars on the northern side of the roadblock was well over 2 km long. I, along with the majority of other personnel at the site, slept that night at the Renner Springs Desert Inn. Crews arrived at the crash scene from Renner Springs at 6 a.m. the next day. Roadblocks and restricted areas were re-established. The members that were on the scene overnight were decontaminated and had health checks, and then went back to Renner Springs for breakfast and some well-earned sleep. Dust had been raised as a result of vehicle movement through the scene overnight, so a caustic solution was sprayed over the road to get the road surface back to the safe conditions that the site was left in the night before. At 8.15 a.m. the crane was back in position to lift the third container from the crash site. Once the container was extracted, it was found that, of the 18 boxed cyanide bags it had held within, 12 remained in the container semi-intact. The other six boxes had been released from the container during the rollover. The contents of some of the six boxes were intact and remained encased in their woven bags, but other boxes had been destroyed so that the cakes of cyanide were scattered from where the product first left the containers. At 9.15 a.m. the doors were cut from the container using oxy-acetylene equipment, decontaminated and lifted to the side of the road. At 10.50 a.m. the container had also been decontaminated and placed with the doors to the east side of the road. At 10.50 a.m. the Katherine ambulance crew from St John Ambulance had exchanged places with the Tennant Creek crew. Initially the Katherine St John crew planned to go back to their station immediately once they were aware that a replacement crew was being sent for them. However, they were asked to stay until this crew had arrived to keep coverage on the site. Maintaining paramedic coverage on site was vital, considering the conditions we faced. At 12.50 p.m. work commenced on lifting the undamaged bags from the crash site into a new container for transport. All of the disentanglement and the loading of damaged containers, as well as the removal of the product still intact, was performed by the product manufacturer’s crew, which was sent to perform that duty. At 2.20 p.m. the first crew of firefighters wearing PPE was sent into the scene to pick up the larger cyanide pieces and pallets. This recovery effort took about three hours. These crews also assisted with decontaminating the forklift, crane, the third container and the pieces cut from it as they were loaded onto trailers to be sent from the site. During the afternoon a crew of four NTFRS members had arrived from Darwin to assist with the clean-up. At 6 p.m. decontamination of all members in the ‘hot’ zone had recommenced after they had tarped down and covered over any exposed product. This was completed at 7.30 p.m. and was again followed by health checks

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that were conducted and logged by St John Ambulance. 10 p.m. saw crews leave for Renner Springs and Tennant Creek, with the road opened again for vehicle movement that had been stopped at Three Ways and Renner Springs roadhouses by police and DPI. Security was left on the crash site for public safety issues. Our goals for Sunday, 11 February were to ensure that all stakeholders were aware of what we were trying to achieve; remove tarpaulins and coverings from the night before from the cyanide; check the road to see if decontamination was required after overnight vehicle movement and make safe before any other movement on the road was conducted; continue the filling of the sandbags to stop water run-off as a result of the decontamination work that was being done over the road and the waterway; try to get both triple road trains loaded, tarped and on the road; fill the 20 000 L tanker of contaminated water and get on the road. A spokesman from the manufacturer of the product briefed all the new personnel on site of the dangers associated with working with cyanide. The nearby Warrego Mine site (45 km west of Tennant Creek) had recently ceased operations. However, it was considered a possibility that it could accommodate the hundreds of tonnes of contaminated soil from the crash site. The arrangements for this were finalised in a meeting between several Northern Territory Government departments, the owners of the Warrego Mine site, the manufacturer of the cyanide and the Northern Territory Police and NTFS. After tests were conducted and public safety issues regarding the transportation of the contaminated soil to the Warrego Mine had been discussed, the first road train with three side tippers was decontaminated and headed off to Warrego. These triple trailers that side tipped need to have a curtain or tarpaulins over the top of the tipper to prevent dust or soil being blown out of them during transportation. These coverings were put on by a crew wearing PPE. Two and a half hours after the first road train had departed, the second road train was also decontaminated, tarped and ready to leave the crash site. Later that day at 6.40 p.m. another 20 000 L of contaminated water from the waterway was ready to leave to go north in the ISO tanker. Three 1000 kg bags of soda ash were delivered to the crash site during the day to assist with the recovery process. On Monday, 12 February at 6.45 a.m. a triple road train that was tarped overnight was sent on its way to unload the contaminated soil; each of these road trains trailers carry 20–30 tonnes. Another ISO tanker had arrived and was being refilled from the waterway by a small portable pump sitting on the edge of the water with a hose running up to the tanker. At 1.10 p.m. the original crew from Alice Springs was relieved by other Alice Springs members, and a crew from BFNT also headed off back to Katherine. Happy snaps of all who worked at the crash site were taken as personnel came and went from the site as camaraderie was strong with those who attended. Road trains continued to be filled by a front-end loader that had a large bucket on the front that quickly lifted soil that would otherwise take a very long time to

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load with shovels; ‘Thank heavens for that,’ we all agreed. The plan was to remove all the soil from the area, including the waterway, once it had been emptied; then testing would be conducted to see where the product had seeped. Some of the tarpaulins that were sent to the site and had been sourced in Alice Springs were found to be too old and tore very easily, so more were requested to be on site the following day to cover those road trains that did not have pull-over curtains on the top of each trailer. On Tuesday, 13 February when we arrived from Tennant Creek tarping of the trailers started with some other tarpaulins that were sourced the day before in Tennant Creek. At 8.15 a.m. testing of some of the excavated work was done to see how much more soil needed to be removed from the area to the south of the waterway. At 8.30 a.m. the first road train of the day was ready to head off after retarping had been conducted. One of the ISO tankers had returned from the north; it was positioned ready for filling from the waterway. It was filled with the remaining water, which in the end was bucketed out and tipped into the tank. Traffic lights were being assembled at either end where the original roadblocks were located to assist with traffic flow at night when the road was re-opened. These lights were later, in the daytime, determined to be unsuitable because of the way they were programmed to flash. On Wednesday, 14 February two double and three triple road trains were filled and headed off to Warrego Mine site early. We did have the odd problem: one with a flat tyre on the front-end loader which was re-inflated after acquiring a compressor from nearby Helen Springs Station; and then we had a request from the EOC to allow free passage to a road train that would be escorted through the scene mid-afternoon by police transporting milk for Darwin. The first double that commenced filling at 7.35 a.m. returned for another load at 2.30 p.m. Filling and preparing loads of soil for the road trains took place throughout the day. And it turned out to be the most productive day we had removing soil from the site. We left the site that day at 7 p.m., collectively knowing that the work completed today would go a long way towards reaching a finishing point on Friday; it was now a real chance due to the amount of soil that had been removed that day. On Thursday, 15 February the road trains were loaded like clockwork just like the day before. Everyone now knew what they were doing and things were being carried out with military-like precision. Decontamination of the road trains was completed by washing down the dirt and dust that had fallen onto the trailers during loading of the soil, by spraying them down with water from the fire tankers we had on site. Tarpaulins were then either pulled or tied into place by personnel wearing their PPE and SE400 breathing apparatus with a canister on the masks. Evaporation was a huge factor in the decontamination of the product from equipment and alike. As we had been working in days of 40°C or more, there was no issue with evaporation. During the day more tests were conducted at various

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points throughout the now very deep hole that had been dug around what was the old waterway. Every day on site, crews were informed before leaving about what was achieved during the day and any incidents that occurred. We left for Renner Springs and Tennant Creek at 6.25 p.m. knowing that, should the tests from the environmental people and the chemist representing the manufacturer agree to samples being taken tomorrow, it would be our last day at the site. On Friday, 16 February at 10.35 p.m. personnel received a pleasant surprise to find that the police and fire service had sent high-ranking officers to the scene from Alice Springs. Up until this point all communication that had been done with these members was by a satellite phone at the EOC some 630 km away. ‘Look who has turned up after all the hard work has been done’ was one comment said in jest as they congratulated the personnel for the work they had done over the past 10 days. One of the two excavators that had been working at the site was removed from the very big hole it helped to create; decontamination was performed and it was loaded on to a low loader for transport. Its companion was left in the hole as further tests were being conducted by the chemist and environmental people to see how many parts per million were left in areas that were excavated. At 12.38 p.m. it was agreed that the acceptable levels required had been achieved and paperwork to this effect was then signed off by the stakeholders that were present. We left the scene at 4.25 p.m. with the road being officially declared open again at 4.30 p.m. with a press release through the EOC. Everything that the NTFRS had used on site went back to Tennant Creek that afternoon and over the weekend vehicles were cleaned, equipment checked and plenty of rehydration by the members was conducted as they reflected back on the events of the past 10 days. In the end, 1480 tonnes of contaminated soil was transported to Warrego Mine after 8 tonnes of product had been lost from the third container. One hundred and ten thousand litres of contaminated water was removed from the waterway and transported to the mine in the north where the original shipment of cyanide had been heading. Less than two weeks after we had left the scene, anyone driving past would not have known what had happened as all the rehabilitation work to the site had been completed.

Lessons learnt We all learnt from the experience and will be better equipped in knowing what to expect should something like this happen in the future. Communication with the manufacturer of the spilled cyanide was of utmost importance in establishing what safety precautions were needed on the crash site. Before we started working with the product and with the personnel sent to the site

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by the manufacturer we had no idea what we needed to wear except for what was indicated to us by the Dangerous Goods – Emergency Response Guide, which generally would have been excessive. The manufacturer was able to provide advice on what PPE was required for each specific task, including disentanglement of the components of the crashed vehicle, washing down of trailers and containers, and product recovery (tablet, diluted, boxed). They advised on the PPE needed by excavator operators, crane operators, road train drivers, crews doing washing down of members and equipment, and crews tarping down and washing down road trains. It was also important to ensure that the information was communicated to crews when they rotated personnel. Communication with stakeholders was an area that was initially challenging but here lessons were learnt. Communication in and out of the scene was by satellite phones. At the beginning of the response, each attending company or service (transport company, product manufacturers, police, fire, NTES, BFNT, St John Ambulance) was sending out information and the result was contradictory reports and uncertainty, with no real control over what was being sent out by the stakeholders. They were reporting what they thought was happening to management and other companies. All communications out of the site were stopped so that continuity of the messages being sent out could be guaranteed. This then stopped speculation or false messages about what the Incident Controller and the stakeholders at the site were trying to achieve. Scheduled information times were then established with the EOC that was set up in Alice Springs. Stakeholders at the scene would meet before these times and convey what was required at the scene and how the operational side of the incident was going through the Incident Controller. Basic requirements at the scene took a long time to be put into place due to distance, availability or an item simply not being sent. Generally what was asked for from the Incident Controller at the scene arrived, but a lot more could have been done to make the recovery task a lot easier for the members at the scene and also to keep morale high and decrease the time the incident was taking. Toilets were never sent; a fully equipped CBR container remained in Darwin throughout the incident; a police mobile communication centre arrived six days into the incident and did not function correctly; and a communication trailer from NTES arrived on scene but did not get used as the incident was nearing completion. Staffing was always going to be an issue due to the location of the incident. Alice Springs, the closest major centre, had a capacity of 26 operational staff. In Darwin, the capacity was also tested, pushing to the limit the number of members that were available to attend for any period of time. Family life, and the number of shifts being worked, separated us from our normal hours, emotionally affecting those who were able to attend. Capacity also affected what hours were worked at the scene, as the pool of members to call on was just too small.

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In addition to roads, a fixed wing plane – landing on a nearby cattle station airstrip – brought other appliances (tanks, grass fire units and utes), hired vehicles and members to the scene. Plant and equipment were great concerns. We scraped together whatever equipment and appliances we could – front-end loaders, excavators, a 100-tonne crane, road trains, 10 000 and 20 000 L water tankers – from all over the place, with each operated by the company they were sourced from. For example, we had to find tarpaulins to cover the side-tipping trailers that were not fitted with pullover curtains; and there was a complete CBR container ready and able in Darwin, but it was not deployed due to it being the only one available and potentially needed in Darwin. A mobile communication vehicle sat idle in Alice Springs, and it occurred to nobody to use it until halfway through the incident. Then, when deployed, it was discovered to be not operational. Toilets and showers were also overlooked. Having more fire-related equipment available for a Hazmat event like this one is a financial decision that governments and organisational management need to consider … and it’s one of those decisions that would certainly require extensive consideration due to the amount of equipment used and the duration of time it was engaged for. Where would it be stored? Darwin? Alice Springs? Katherine? Tennant Creek? Shortages of personnel and resources that were available to the Incident Controller greatly affected why the incident was run during daylight hours only and not continually over 24-hour periods. There was also pressure to make sure that the road was open as soon as possible so the backlog of motorists and road trains carrying freight and supplying daily requirements to Darwin to the north and Alice Springs to the south as well as the towns in between could be reduced. Access through the scene was requested on one occasion to allow a road train of milk from Queensland to pass through, heading to Darwin, so all equipment and work stopped for three hours and the road was made clear. Side-tipping road trains, which were used for transporting the product out of the scene to the mine site that was receiving the contaminated soil, were sourced from far and wide and were all that was available at the time. This did cause some concern as the majority of the tippers did not have pull-over curtains to stop dust and product from blowing away during transit. So tarpaulins were then sourced to cover the soil, with crew members then being deployed to cover and tie down the tarpaulins of the tippers, taking more time. Due to the location of the incident, catering for the personnel at the scene was managed from the Renner Springs Desert Inn about 20 km away to the north. We worked closely with the roadhouse to ensure that staff were equipped with sufficient resources to provide meals for crew and for the passengers in the vehicles stopped at the roadblock. Crew members that were being accommodated at the

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Tennant Creek Fire Station were often asked to bring supplies for the roadhouse with them from Tennant Creek. The Station Officer was designated to arrange daily for the crew members to have breakfast and lunch at the scene and an evening meal for those that were accommodated at the roadhouse. Accommodation was another issue that was looked after by this officer, along with the tasks he performed on site with crew members coming and going and the changeover of crews. Crews were generally arranged though the EOC and most of the travel arrangements for arrivals and departures from the scene were then liaised through the Incident Controller. There were several issues identified by St John Ambulance during the course of health checks before and exiting the ‘hot’ zone. It was found that one of the personnel from the company who manufactured the product had high blood pressure and was not allowed into the site until it had returned to a safe or normal level. In addition, the police sergeant who had been at the southern roadblock initially and was on site for most of the incident reported not feeling well. After he was given a check-up he was advised by St John Ambulance to go to the Tennant Creek for further tests. Later on we were informed he had heat exhaustion. St John Ambulance records of the event would show that two people working on site were diagnosed with heat exhaustion; two others had suffered cyanide exposure, while two others were refused entry due to high blood pressure levels. On 28 occasions personnel were required to rest and drink more fluids due to their medical observations being at unacceptable levels before entry into the ‘hot’ zone. This often delayed operational crews from entering the scene and delaying scheduled work for extended periods of time. In all 76 personnel entered the ‘hot’ zone and some of these people entered several times a day throughout the time of the incident. A further point to note with regard to personnel being sent to work on site in a situation like we had was their capacity to work. Some members who were trained to wear breathing apparatus but were unable to wear it due to health issues were sent to the scene, or were not fit to enter the scene because they needed medication that they had accidentally left behind. They needed to be 100% operational and able to perform any tasks that were asked of them. Repetition of messages about safety was found to be necessary. Transport and plant operators had little regard for the direction and procedures that were put in place. A ‘she’ll be right, mate’ attitude was common. On several occasions they were informed to stay in the cabins of their road trains while they were being filled by the two front-end loaders or they would need to go through the process of decontamination that was taking place with all other members working in the ‘hot’ zone. On at least three occasions disregard for procedure occurred and on two of these occasions it was the same driver. Plant operators as well as members working in the ‘hot’ zone wore warning devices supplied by the manufacturer that sounded when the product was disturbed enough to be a safety issue when airborne.

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Training for this kind of remote Hazmat incident can only be simulated, and by using your imagination as to what may or may not occur. While standard drill exercises – reading out of a dangerous goods book or watching videos – prepare you for what could happen, they do not address many of issues that we dealt with. Enacting policies and procedures, and practising them regularly, can only assist in being prepared for the real thing. Industry leaders should seek out and interrogate the responders who attended this incident, engaging their knowledge and experiences to assist with any similar event in the future.

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6 Firefighter entrapment during routine hazard reduction burn at Mount Kuring-Gai Bob Conroy Director Conservation Operations, Office of Environment & Heritage, NSW

Introduction On Thursday, 8 June 2000 on a calm winter’s afternoon, a routine hazard reduction burn being conducted by the NSW National Parks and Wildlife Service (NPWS) at Mount Kuring-Gai, north of Sydney, went tragically wrong. A crew of seven NPWS firefighters were entrapped on the ground by a headfire from a prescribed burn that they had just lit along a track known locally as the Wallaby Track. This burn was conducted north of Merrilong Avenue on the north-eastern side of Mount Kuring-Gai and on the western edge of Ku-ring-gai Chase National Park (Fig. 6.1). The primary objective of the burn was to reduce the risk of bushfire damage to nearby residential properties by reducing fuel levels and thereby reducing the intensity of any bushfires emanating from the park.

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Of the seven staff members involved, three lost their lives on the fireground from smoke inhalation and were incinerated. Four others suffered smoke inhalation and critical burns but were able to self-evacuate to the staging area at Merrilong Avenue, Mount Kuring-Gai where they received assistance and first aid treatment from local residents, and from other NPWS staff members and officers from other agencies. These four NPWS officers were hospitalised later that day. One of those injured subsequently died in hospital as a result of his injuries eight weeks later (4 August 2000). The three surviving officers spent many painful months and years recovering and recuperating from serious burns and other related injuries. Thirteen months after the tragedy and while one staff member was still hospitalised, a coronial inquest took place to determine the cause of the incident. The inquest, which began on Monday, 16 July 2001, lasted five weeks with the Coroner handing down her findings on Friday, 14 December 2001. A WorkCover investigation was also conducted under the provisions of the then New South Wales Occupational Health and Safety Act 1983, resulting in the NPWS being prosecuted and substantially fined under the Act for safety policy and systems failures. The tragic loss of four lives under such benign weather conditions had and continues to have a very profound impact on families, friends, colleagues and local residents. It certainly remains a very powerful and painful memory for me. Until this incident, most firefighter entrapments arose as a result of major bushfires burning under extreme weather conditions with large fire fronts and poor visibility (for example, Rothermel 1993; CFA 1999; Mangan 1999; Cheney et al. 2000), and not from the conduct of routine hazard reduction burns under benign weather conditions. The occurrence of this incident was a major shock and wake-up call not just for NPWS, but for other firefighting agencies also. Significant changes in firefighter safety were put in place after the Mount Kuring-Gai incident, regardless of whether it was for a prescribed burn activity or suppressing a bushfire. Notably, one of the outstanding actions arising from the Mount Kuring-Gai incident, and one which was particularly requested by family members, was promoting the lessons learnt from this incident, more actively informing firefighters of the risks associated with burning and ideally reducing the risk of such an incident ever happening again. This chapter represents a further opportunity to implement that request. My role in this incident was both personal and professional. I was previously employed as a ranger, fire management officer and manager of this park, and many of those staff involved in this incident and their families were colleagues and friends. As the Director now responsible for this area, I was asked to coordinate the NPWS response and investigation into this incident, to work closely with other authorities and to take the lead on behalf of NPWS in the coronial inquiry and WorkCover investigation.

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Location and description of the area Mount Kuring-Gai is one of several small suburbs on the Govetts Range, which divides the Berowra Creek and Cowan Creek catchments within the Hornsby Local Government Area and is about 34 km north-north-west of Sydney (Fig. 6.1). The suburb of Mount Kuring-Gai has a population of about 8700 and straddles the M1 Pacific Motorway. Mount Kuring-Gai is adjacent to and west of the Ku-ring-gai Chase National Park. The incident site is near a narrow track (the Wallaby Track) on the northern side of a small hill in Ku-ring-gai Chase National Park at grid reference 56 H 327672E 6275426N and is about 250 m east of the M1 and about 650 m north of residential properties in Merrilong Avenue at Mount Kuring-Gai. The Wallaby Track starts at the rear of residential properties in Merrilong Avenue and heads in a northerly direction roughly following the 175 m contour around the hillside for about 650 m, then in a westerly direction for about 230 m until there is a junction in the track marked by a small cairn of rocks. At this junction, the track divides into a southern (the Uphill Track) branch and a western branch. The Uphill Track pinches back and rises steadily in a south-easterly direction up a 10–15° slope through a small rock shelf and then continues for some distance to a larger rock shelf. It then continues to a cleared site on top of the hill where an old house and tennis court once existed. The western branch heads a further 200–250 m along the contour and rises slowly (about 5°) through some dense vegetation towards the M1. This branch became increasingly less obvious as a walking track and at the time was very overgrown in places. The distance from Merrilong Avenue to the small cairn of rocks at the track juncture is about 890 m and took 10–12 minutes to walk.

Topography The topography in the park is characterised by sandstone and shale slopes between 10 and 25° over an elevation range of 0–200 m and sandstone plateaux with slopes of 0–10° with occasional rock outcrops and hanging swamps. Eastern and southern slope aspects are usually moister than western and northern aspects. At the incident site, the slope ranges from about 15° near the Wallaby Track through to about 20° on upper slopes where rock ledges are present. The incident site has a NNW to NNE aspect.

Vegetation The vegetation in the Mount Kuring-Gai area is primarily dry sclerophyll forest on mid to lower slopes with low woodland/low open woodland vegetation

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Fig. 6.1.  Location of the Mount Kuring-Gai incident. The base map of this image is sourced from Land and Property Information 2015 (http://www.lpi.nsw.gov.au/) and is licensed under CC BY 3.0 (https:// creativecommons.org/licenses/by/3.0/au/legalcode).

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communities and some smaller areas of closed scrub/scrub heath on the upper slopes (for example, between the incident site and the M1). There are three threatened plant species growing within the area that was proposed to be burnt: Darwinia biflora, Tetratheca glandulosa and Lasiopetalum joyceae. The operation was planned so as to burn some of these D. biflora and L. joyceae plant populations but to exclude other nearby populations. This was to provide a diversity of disturbance regimes for research and conservation purposes.

Fire history The bushland within and surrounding the Ku-ring-gai Chase National Park is very fire prone with frequent and often intense bushfires. The area has a very high, fine fuel loading potential (Table 6.1), very flammable fuel types, steep slopes, regular occurrence of extreme fire weather during the bushfire danger period (October to March) and large areas of vulnerable urbanbushland  interface. The proposed burn area had not burnt for about 17 years. The last major bushfire in this area occurred in 1983. Arson is a frequent occurrence in this area. Since 1995–96, the area had been identified by the Hornsby Ku-ring-gai District Bush Fire Management Committee as a priority for hazard reduction treatment.

Pre-burn planning and approvals The policies and procedures for planning and conducting this prescribed burn in the park were contained within the NPWS Fire Management Manual (NPWS 1990). Specific policies and procedures in the manual which applied to prescribed burning operations were included in sections such as Equipment Standards; Fuel Management; Health Safety and Welfare; Prescribed Burning; Training; Visitor Safety; and Weather. Table 6.1.  Fine fuel sampling at Mount Kuring-Gai. Southerly aspect t/ha

Easterly aspect t/ha

Northerly aspect t/ha

Ridge top t/ha

1

27.15

36.75

23.80

20.50

2

30.55

42.35

45.25

N/A

3

23.00

33.85

32.65

N/A

4

N/A

N/A

23.95

N/A

31.41

20.50

Plot

Average SE t = 2 (95%)

26.90 ±4.0

SE = standard error, t/ha = tonnes per hectare

t/ha

37.65 ±5.2

t/ha

±9.0

t/ha

N/A

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The burn was initially proposed for the 1995–96 fire season. It was approved in principle by the local bushfire management committee, but was not implemented at that time because of unsuitable weather conditions and resources being committed to the implementation of other higher priority burns in the area. The burn was ‘rolled over’ in 1997, 1998 and in 1999, pending the occurrence of prescribed weather conditions, particularly in relation to wind direction. This was because of the proximity of the proposed burn area to the very busy M1 and safety concerns for traffic arising from possible smoke drift across the motorway. The burn was originally planned for a much larger area of about 170 ha. The first stage involved an area of about 37 ha at Mount Kuring-Gai and this was considered the highest priority within the larger burn area given its proximity to residential properties. The objective of this prescribed burn was to provide protection for the residential properties on the north-eastern side of Mount Kuring-Gai. The burn was also to provide protection to threatened species habitat by reducing the longerterm frequency of fire affecting their habitat. In October 1997, an Incident Action Plan (IAP) for this burn proposal was prepared by NPWS. The IAP, although not strictly required according to AARFA (1992) guidelines which were current at that time, contained the same format as the Australasian Inter-service Incident Management System™ (AIIMS) proforma for a Type 2 Incident, being a common format for bushfire planning rather than for prescribed burn planning. This format was also of a higher and more detailed standard than that required by NPWS policy and procedures for prescribed burning at the time. However, although the IAP proforma considered burn objectives, alternative strategies, resources required, general incident information, safety considerations, threats, weather prescription, operational strategies, tactics and notifications, the information that was provided by NPWS officers on the proforma was scant and incomplete, particularly by the standards of today. As a result, much of the coronial inquest focused on the inadequacy of the IAP and maps. The fireground map that was used to brief crews was a free-hand schematic sketch of the fireground showing common IAP key operational aspects of the proposed burn, including access routes, assembly areas, location of threatened species, and fireground sectors. This map was developed from a sketch map from an earlier vegetation report (Doig 1997). Key locations such as the Control Centre (CC), Assembly Area (AA), sector boundaries, areas not to be burnt and ignition lines were shown. The boundaries of the prescribed burn are shown in Figure 6.2 as follows: • Western Boundary – a track running along the eastern side and parallel to the M1 • Northern Boundary – east from the M1 rock wall into an unnamed creek; then descending down the catchment and along the creek to a point about 70 m

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Fig. 6.2.   Map showing locations of sectors and other fireground information at Mount Kuring-Gai. The base map of this image is sourced from Land and Property Information 2015 (http://www.lpi.nsw.gov.au/) and is licenced under CC BY 3.0 (https://creativecommons.org/licenses/by/3.0/au/legalcode).

beyond the first creek junction (at approximately GR 32796E 627520N) where a rake-hoe line ascends the hill towards the Mount Kuring-Gai Trail • Eastern Boundary – from the creek, a rake-hoe trail ascends the hill in a southerly direction for about 220 m and then veers in a south-westerly direction (to avoid threatened plant species locations) for about 650 m towards Merrilong Avenue and roughly parallel to and 30–150 m north of the Mount Kuring-Gai Trail • Southern Boundary – a cleared fire break at the rear of houses in Merrilong Avenue and then west to the M1. The eastern and southern boundaries were tracks constructed for this proposal and located so to assist with the protection of certain identified threatened species habitats: those of Tetratheca glandulosa and Lasiopetalum joyceae; and of Darwinia biflora respectively. The handtool lines were prepared as discussed below. At the time the Environmental Planning and Assessment Act 1979 (EPA Act) required an assessment of environmental impact for any ‘activity’ which may have an impact on the environment. The NPWS undertook a review of environmental factors (REF) in accordance with s.111 of the EPA Act for all prescribed burning

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activities, particularly where threatened species were known to exist in the area. To help inform the preparation of the REF for this burn (Blade 1998), the NPWS organised a botanical survey of the area proposed to be burnt (Doig 1997). Several threatened species within the original proposed burn area were identified and the actions described above were taken to manage their conservation. In May and October 1998, NPWS crews constructed handtool lines along the boundaries of the proposal. These lines were completed in 1999 and re-cleared in April 2000, as part of a practical exercise for participants on a NPWS Basic Bushfire training course. The burn was originally planned to commence on Tuesday, 6 June subject to favourable weather conditions. On Monday, 5 June 2000, a NPWS works crew was sent to again freshen up the handtool line on the eastern side of the proposed burn. Weather forecasts were continually monitored on 5 June. As the wind direction was predicted to be from the south-east on 6 June, the burn was postponed due to the possibility of smoke drift across the M1. The weather was continually monitored on 6 June and a decision to proceed with the Mt Ku-ring-gai burn on 7 June was taken later that evening. Local NPWS crews were organised to attend the burn together with support from other NPWS workplaces. Other authorities, including the Hornsby Ku-ringgai Fire Control Centre, NSW Police, State Rail Authority, Roads and Traffic Authority and Fire and Rescue NSW, were notified by phone on the mornings of both 7 and 8 June 2000 of the proposed activity.

Burn operations Wednesday 7 June 2000 There was a total of 23 NPWS staff deployed on this proposal on Wednesday, 7 June 2000. Support from other agencies was not required. A NPWS Incident Controller and Divisional Commander (DivComm) were appointed. There were three crews, each led by an experienced Sector Boss (or Crew Leader) and each consisting of six or seven crew members, with two or three in each crew being trained but inexperienced in burning operations. Staff assembled at the nearby NPWS Mount Colah depot on the morning of Wednesday 7 June 2000. Sector Bosses and most crew members were briefed on the proposed operation of the burn. A sketch map was distributed to Sector Bosses and copies were provided to some crew members. Following the briefing, Sector Bosses made operational arrangements for transport to Mount Kuring-Gai. Before leaving the depot additional equipment such as webbing belts, overalls, water bottles, helmets, chinstraps and gloves were obtained for several staff who had not yet been issued this equipment, as for some this was their first burning operation.

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There were several staff who had recently completed the basic fire modules but had not previously attended a fire and required further field experience in the company of more experienced firefighters. It was intended that this burn operation would be used as an opportunity for these staff to gain that further field experience. Accordingly, these crew members were assigned to experienced Sector Bosses to ensure adequate supervision, instruction and direction in what was required. Later that morning, a further on-site meeting was held at the staging area near the rear of houses at Merrilong Avenue, where the DivComm further briefed Sector Bosses and crew members on the strategies and tactics for each crew on the day. The fireground was divided into three sectors (Fig. 6.2): 1 Sector 1 commenced at the M1 and ran in an easterly direction following the course of the creek gully on the northern boundary of the burn proposal, then rising uphill to connect to the eastern handtool line 2 Sector 2 commenced at the northern end of the handtool line adjacent to the Mount Kuring-Gai Trail, and headed south-west towards Merrilong Avenue. 3 Sector 3 commenced from the back of the houses in Merrilong Avenue, extended uphill in a westerly direction towards the M1 and then ran parallel to and east of the motorway in a northerly direction to the main creek line, which ran east below the rock wall. Sector 1 crew and Sector 2 crew commenced lighting in different directions from a point midway along the handtool line, commencing at about 12.30 p.m. At the same time Sector 3 crew was preparing to light Sector 3, but given the wind direction (west to north-west) the crew needed to wait for sufficient burn coverage in Sectors 1 and 2 before lighting up. Cat 9 tankers had been set up on the Mount Kuring-Gai Trail to help control any spot-overs from Sectors 1 and 2 with a stand pipe connection from Mount Kuring-Gai and pump relay along the Mount Kuring-Gai Trail. Several spot-overs occurred across the handtool line in Sector 1. One covered about 50 m2, north of and near the ignition point. Another much smaller spot-over area also occurred nearby. Two very small spot-overs also occurred midway down the rake-hoe trail towards the creek line. However, resources were sufficient to quickly contain these spot-overs, particularly given the mild weather conditions on the day. While control lines had been completed in Sectors 1 and 2, it was concluded that because of insufficient burn depth in these sectors the lighting of Sector 3 had to be postponed until the following day. All crews had left the fireground by about 6.00 p.m.

Thursday 8 June 2000 On 8 June 2000, a total of 21 NPWS staff were tasked to this burn. Once again, resources were considered sufficient and other agencies were not required to assist with the implementation of this proposal.

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The same Incident Controller and DivComm were reappointed. There were two Sector Bosses appointed for Thursday, 8 June. Sector 1 Boss was assigned the same six crew members from the previous day. A new Sector 3 Boss was appointed and assigned 11 crew members amalgamated from available staff from Sectors 2 and 3 from the previous day. There was no Sector 2 crew. A briefing was held at about 8 a.m. at the NPWS Mount Colah Works Depot. An updated fire map, indicating areas burnt from the previous day, was used for this briefing and these updated maps were circulated to crew members. At about 9.45 a.m., the Sector 1 crew commenced the day by inspecting, deepening and mopping up areas burnt the previous day in Sectors 1 and 2 on the eastern side of the gully and some unsuccessful attempts were also made to burn the western side of the gully. Meanwhile Sector 3 crew commenced burning from the rear of the houses in Merrilong Avenue towards the M1. In the afternoon, the Sector 1 crew undertook the task of further deepening or expanding the burn by walking along the Wallaby Track through the middle of the proposal, with the intention of eventually exiting to the M1 as indicated on the IAP map. This strategy had been discussed as a possibility earlier in the day but, while the track was marked on the map, nobody on the fireground was aware of its exact location or condition; it had not been previously checked. Because of the difficulties in achieving sufficient depth to the burn earlier in the day four Sector 1–2 crew members were allocated drip torches for this task. Sufficient depth and intensity were still proving difficult to achieve along the southern and eastern aspects of the burn area so it was eventually decided to light and deepen the burn on both sides of the track as they proceeded along it. At the same time, some of the Sector 3 crew were also given the task to deepen the burn along the top of the hill in their sector. As the Sector 1–2 crew continued burning along the Wallaby Track, the Sector Boss had instructed one of the crew members to scout ahead. The scout discovered that the track as marked on the map became heavily overgrown as it exited towards the M1, but found a more trafficable track section which pinched back and headed upslope towards the top of the hill. The scout examined both options and located himself on a rock outcrop along this track section and communicated with the DivComm who was near the M1 in Sector 3. The DivComm instructed the crew to continue along the marked route on the map to the motorway, noting that the top of the hill to the south was being burnt by the Sector 3 crew. The Sector 1 Boss and crew members eventually caught up with the scout along this upslope section of track but very quickly found themselves at risk from being overrun by a fire front burning intensely below them. The suddenness of this threat was apparent in the statements that were made later to the police. It appears from these statements that the crew became very concerned about their safety. At this stage the fire was reported to be moving very quickly and of medium to high

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intensity with flame heights of 2–4 m. The Sector Boss then instructed the crew to lie down together on a partially cleared rock outcrop. Although it is still unclear as to what happened next, it appears that some crew members were unable to sustain the heat and smoke from the headfire in this position. Crew members reported being protected by others, but the heat and smoke became too much to bear, and eventually crew members broke from the huddle with some heading downslope, some upslope and some moving cross-slope. Four crew members eventually then joined up, all badly burnt and in shock, with some needing to shed still burning uniform items. They then assisted each other back along the Wallaby Track towards the staging area at Merrilong Avenue, with some walking ahead in order to urgently raise the alarm. The DivComm was still located with the Sector 3 crew near the M1 and at about 2 p.m. could partially see and communicate with the Sector 1–2 crew below the motorway. At about 2.15 p.m. the DivComm became concerned when he observed blankets of thick heavy smoke smothering the crew and saw evidence of a fast moving headfire overtaking the crew’s last known location. The DivComm was eventually able to establish contact with the Sector 1–2 scout who advised that crew members were lost, others were hurt, that they were self-evacuating to Merrilong Avenue and that ambulances were required. The DivComm immediately contacted emergency services. A search party for the three missing crew members comprising fire brigade, police and ambulance service officers was assembled. The search party was led by the senior police officer and began moving into the bush along the Wallaby Track. A short time later, the search party located the three deceased crew members. The area was then declared a crime scene and investigations were subsequently conducted by the police on behalf of the Coroner. The three bodies were retrieved from the area at about 12.40 a.m. on 9 June 2000. Further investigations and site inspections were conducted over the next several days and weeks.

Weather Weather recordings for 8 June 2000 from Hornsby, Terrey Hills and Mount Kuring-Gai are shown in Table 6.2. These weather readings indicate a low fire danger index, a moderate drought index, light winds throughout the day, mild to warm temperatures, moderate humidity and a light but variable wind direction – overall fairly benign weather conditions ideal for conducting a prescribed burn. NPWS officers located at the M1 at the time of the incident confirmed that there was only light wind on the fireground during the afternoon of 8 June 2000. However, a shift in wind direction at about 2.10 p.m. which aligned the wind direction with the aspect (north-north-west to north-north-east) at the Mount Kuring-Gai site may have explained the sudden increase in fire behaviour,

1400

1400

1400

1410

1410

1410

1420

1420

1420

Mount Kuring-Gai

Hornsby

Warringah

Mount Kuring-Gai

Hornsby

Warringah

Mount Kuring-Gai

Hornsby

Warringah 16.1

14.5

18.3

16.1

14.5

18.6

16.4

14.5

18.6

Temp (°C)

FFDI – Forest Fire Danger Index; BKDI – Byram–Keetch Drought Index; RH – Relative Humidity

Time

Weather station

Table 6.2.  Weather observations 8 June 2000.

0 5

51.1

2

2

0

2

5

0

2

Wind speed (km/h)

47.8

49.9

51

48.1

50.4

50.8

49.1

50.7

RH (%)

12

2

10

12

5

7

12

0

10

Peak wind speed (km/h)

250

8

296

2

20

64

179

31

246

Wind direction (degrees)

2.6

3.7

3.2

2.5

3.7

3.2

2.7

3.6

3.2

FFDI

4.9

88.5

53.9

4.9

88.5

53.9

4.9

88.5

53.9

BKDI (mm)

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which later collapsed as the wind changed direction again. The crews may not have been aware of shifts in wind direction because of their topographic positions and the effects of dense vegetation in the area.

NPWS internal investigation I was asked by the Director-General to cooperate with the NSW Police and Coroner, to work with other authorities and to coordinate the overall NPWS response to this incident. An internal team of specialists within NPWS was then appointed to support staff and to help analyse and investigate the Mount KuringGai incident. The team made numerous inspections of the site of the prescribed burn and spoke with other NPWS staff involved in the planning and execution of the burn. Documents relating to the planning of the burn were collated and reviewed, and weather data from nearby sites were also examined. Statements made to the police by staff following the incident were also analysed to help understand the circumstances that may have contributed to this incident. We gratefully accepted an offer from the Rural Fire Service (RFS) to supply specialist investigators to examine and report on the origin and development of the fire paths in the vicinity of the tragedy and also the services of a chaplain to support our employee assistance provider in counselling grieving family and staff members. The RFS (Warringah/Pittwater) assisted the investigation by developing a series of maps of the incident area and surrounds. Using global positioning system (GPS) data the maps they prepared showed the position of various tracks within the area of the prescribed burn, the perimeter of the section of the burn area where the incident occurred and the location of the deceased. A copy of this report (Strathdee 2000) was provided to NPWS and to the Coroner. The purpose of our investigation was to prepare a report to the Coroner and to WorkCover outlining what improvements had been made to minimise the risk of any such incident ever happening again by implementing changes to our fire management policies and practices (NPWS 1990, 2001). A report on fire behaviour from the Bushfire Research Unit of CSIRO (Cheney 2001) was also provided to the Coroner.

Coronial inquest NSW Police also conducted an investigation into the incident on behalf of the Coroner (Eager 2001). Police took statements from NPWS staff on the night of the incident and on the following day. Police also collected items of equipment and some personal property from the site. The incident site was filmed and photographed and various measurements were taken. Statements were also obtained from neighbours, NSW Ambulance Service officers, NSW Fire Brigade

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officers and RFS officers. NPWS documents including the IAP and sketch map, personnel and training records, and fire management policies and procedures were provided to the police. The coronial inquest was conducted in accordance with the Coroners Act 1980 (NSW). The Coroner’s functions under the Act include fully investigating any unnatural death, sudden death from unknown causes or suspicious death from unusual circumstances. Three barristers were appointed representing different family members, together with a barrister representing WorkCover, a police sergeant assisting the Coroner, and two barristers representing NPWS. The Coroner in the company of barristers undertook site inspections of the M1, Merrilong Avenue, the Wallaby Track and the Eastern Perimeter Track on 7 August. The inquest commenced at the Coroners Court Westmead on 16 July and ran for five weeks with several adjournments and finished on 30 November. The Coroner called about 40 witnesses. Several issues were identified and explored under cross-examination, including: • the adequacy of planning and preparation for the proposed burn • the spot-overs that occurred on 7 June 2000 • communications during search and rescue operations, including black spots and recording of messages • the time taken for emergency services to travel to Merrilong Avenue • fire training and experience of crew members • the adequacy and attendance of crew members at briefings held on 7 and 8 June • the venting of drip torches on the fireground • planning for staff safety including the provision of qualified first aid officers within each crew • approvals for and the chain of command for prescribed burning operations and the roles and responsibilities of NPWS staff involved in the burn • deficiencies with the fireground map (no contour lines, no grid references or compass bearings, refuge areas were not marked, tracks not accurately depicted, and other deficiencies) and its updating and circulation to crew members • the lack of ‘field-truthing’ (checking the accuracy in the field) of the maps provided • the tactic of lighting both sides of the Wallaby Track • the adequacy and condition of NPWS fire uniforms and equipment • weather conditions and behaviour of the fire causing the incident • the Incident Control System, its structure, functions, inconsistencies in terminology, implementation and use including the function of a staging area and fire control centre.

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Phil Cheney from CSIRO was called by the Coroner to report and provide expert evidence on fire behaviour during the course of the inquest (Cheney 2001). In the absence of a specific fire behaviour guide for the Mount Kuring-Gai area, Mr Cheney undertook an analysis of fire behaviour using a burning guide developed by CSIRO for Eucalyptus sieberi forests in south-coastal areas of New South Wales (Cheney et al. 1992). Mr Cheney commented, however, that the use of such guides is not precise.

Coroner’s findings On 14 December 2001, the Coroner handed down her findings relating to the tragedy. The Coroner stressed that the role of any inquest is not to apportion blame, but to determine the manner and cause of death. The Coroner found that three NPWS crew members died on 8 June 2000 at Mount Kuring-Gai in New South Wales of smoke inhalation sustained during a prescribed burn in the Kuring-gai Chase National Park. The Coroner also found that one NPWS crew member died on 4 August 2000 at Royal North Shore Hospital St Leonards in New South Wales of septic thrombocytopenia, overwhelming sepsis and cardiovascular collapse as a result of the prescribed burn on 8 June 2000. The Coroner concluded that the fire on 8 June which resulted in these deaths was caused when a prescribed burn ignited by NPWS personnel became uncontrolled. The Coroner commended members of the crew for assisting and leading each other from the fireground; commended local residents for rendering aid to the injured; and commended the Sector Boss for attempting to shelter members of his crew. The Coroner made 17 recommendations as a result of the inquest. Several of the recommendations had already been addressed and implemented during the course of the inquiry and as part of a major review of NPWS fire management policies and procedures after the incident. The Coroner’s recommendations were: 1 That hazard reduction burns/prescribed burns to be undertaken on NPWS lands not be undertaken before the plans for such are reviewed and approved by people qualified in such burns. It is not sufficient that such burns be approved by a senior officer. That senior officer must have knowledge relevant to prescribed burns, hazard reductions or bushfire. 2 That no hazard reduction be undertaken in any area where ground crews are to be utilised without such area being inspected and ground truthed to ascertain safety areas, exits, potential hazards, and so on. 3 That people undertaking duties at prescribed burns should be totally familiar with the incident control system and the relevant duties ascribed to positions under that system. 4 That usage of titles or terms not identified under the Incident Control System no longer be used within the NPWS in relation to fires.

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5 That all people assigned to attend a prescribed burn be notified well in advance of such a burn to permit their attending the fireground with suitable safety equipment and sustenance. 6 That a full briefing be carried out with all persons who are to undertake a prescribed burn. Such briefing is to include topographical features, safety areas, exit points, and other relevant features in accordance with the NPWS Incident Control System. All members of the crew are to be given a relevant map and be encouraged to seek any information from those carrying out the briefing that may be relevant to their own safety. 7 A senior officer to check and verify that occupational health and safety issues have been addressed before prescribed burns are undertaken. 8 At every prescribed burn, an effective control centre is to be established which is to be staffed by a person who: • has an advanced first aid qualification and relevant medical equipment • has the capacity to communicate with the fireground and senior officers • has been fully briefed as to the burn • has been supplied with a list of all personnel involved in the burn and their ascribed roles. 9 That the NPWS develop or assist in the development of a suitable method of testing drip torches to ensure they are manufactured to such a standard to withstand such heat that they not become dangerous during a fire. 10 That the NPWS has available to the Incident Controller, for any burn, information as to the level of training undertaken by crew members who are to undertake a burn and to allocate to each person a more qualified officer to act as their mentor. 11 That no person be permitted to enter a fireground unless suitably attired. 12 That, to this end, all recruits be issued with and trained as to the care and maintenance of new and appropriately sized fire clothing, including two-piece Proban®-treated suits and undershirts, fire-resistant footwear, goggles, masks, gloves and helmet. The recommendations contained in the report of Mr Richard Donarski of the RFS are commended to the Minister. 13 That consideration be given to personnel on the fireground to be issued with a personal and portable fire protection blanket. 14 That the NPWS stress to staff that safety of personnel is paramount at all times. Should any one person undertaking prescribed burns or any burn be concerned as to any aspects of safety, they are to be encouraged to bring this to the attention of those who are in authority. No burn is to be undertaken until the concern raised has been considered or addressed at the highest relevant level. 15 That a review be undertaken of the NPWS communication equipment and the effectiveness of use of such equipment on firegrounds, including that the efficacy of a fire relay base be considered.

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16 That there be kept at all times during the prescribed burn or hazard reduction a log of radio and other communications to indicate actions taken on the fireground so that they can later be considered and assessed. 17 That the NPWS assist other firefighting bodies in formulating a burn guide for the Sydney Basin. The NPWS response to these recommendations is outlined in Table 6.3. However, NPWS moved quickly to implement several improvements including: • a full review of the NPWS fire management training program • development and circulation of new Standard Operating Procedures that provide for the preparation of fireground maps for all prescribed burns and bushfires • development of new field-truthing procedures to check the accuracy of the maps as well as the marking of fireground access, escape routes and safety refuges • inclusion of mandatory crew briefings and uniform checks for all staff involved in a burn • production of a new format for prescribed burn plans, including details on medical evacuation arrangements, safety messages, emergency communications and contact arrangements.

Staff attendance at the coronial inquest Many staff were interested in attending the full inquiry. However, the courtroom was small and it was decided that only those NPWS staff members called to give evidence, together with a support person, would be permitted to attend. A NPWS executive led legal team attended each day. It was also decided that a NPWS media officer would also attend to manage media interests and to provide regular reporting back to NPWS staff via the NPWS intranet. Two staff member representatives were nominated to provide support and to coordinate staff attendance and support at the court. Information about the role of the State Coroner and the coronial process was also provided to those called to give evidence. In addition it was thought that a gathering place away from the media and tension of the Coroner’s Court, but near to the court was required. As a result, a space within the Parramatta River Regional Park was established where staff and family members could gather, have refreshments and be supported. A small bus was provided for transport to and from the court.

Other issues During staff briefings it was emphasised that we should not pass judgement on what our fellow officers may say during the course of the coronial inquest. We encouraged everyone to speak their mind and to be unfettered in stating how they perceived the events that unfolded on 7 and 8 June and on related matters as we

• Full operational briefings for prescribed burns are now mandatory for all NPWS staff and must be confirmed in an Operational Checklist by the person conducting the briefing.

Crew briefings

Burn planning

Inter-agency coordination

Role definition

• A major review of all NPWS fire management training programs has been conducted to ensure they align with National Standards for the Public Safety Training Package.

Training

• NPWS, in conjunction with the other fire authorities has also recently developed ‘Joint Guiding Principles for Prescribed Burning’. These principles are now applied to all prescribed burns irrespective of land tenure and fire authority. They are particularly useful for the coordinated implementation of the large number of cooperative burns undertaken in NSW involving RFS, NSW State Forests, NPWS and NSW Fire Brigades. The adoption of standard procedures for the mapping and marking of the fireground will be considered as part of this process.

• A comprehensive approval and auditing process for these plans has also been established.

• Burn plans must now record information on fuel loads including average fuel loads, description of the fuel arrangement, description of terrain, maximum and minimum daily and nightly temperatures, relative humidity, fire danger index and drought factor, and – before ignition – confirmation in an operational check that fuel moisture levels fall within prescription.

• NPWS has adopted a new Prescribed Burning Operation Plan format and procedure for all prescribed burn proposals.

• NPWS and RFS are to develop and introduce joint training and certification for Incident Management Teams and key roles to establish mutual understanding and minimum standards.

• NPWS proposes to establish specialist operational teams in each of the NPWS regions across NSW. Their main focus will be to undertake specialist firefighting activities. These teams will be required to integrate with other firefighting agencies in NSW, such as the RFS, NSWFB and NSW State Forests during the conduct of incident operations.

• NPWS is to establish specialist Incident Management Teams in each NPWS region across NSW. These teams will be given specific training in their specialist roles and will be available to assume these roles during incident operations including bushfires and prescribed burns.

• To avoid role confusion, each person and their precise role, responsibilities and tasks must now be documented as part of the burn planning (specifically in the Prescribed Burn – Plan of Operations, Part 4, ‘Resources’).

• NPWS has reinforced the need to conduct fire preparedness days in all NPWS regions. On these days, instructions and practice of surviving entrapments will be given as a standard.

• NPWS recognises the value in formalising a buddy system for inexperienced firefighters and will develop instructions for this as a priority.

• Audits of prescribed burns are now being undertaken. Inspections and audits of operations in the field are also being completed. Multi-agency audit teams, currently comprising NPWS and RFS officers, have conducted spot-audits of fire operations of all firefighting agencies at bushfires to ensure compliance with fire management protocols and practices. The audit teams are to report to the CEOs of each agency.

Audits

• Briefings must include a full brief on information provided on the maps and any amendments to maps, for all fireground personnel and the Incident Management Team, reinforcement of ‘Safety First Briefing Material’ to all firefighters before the shift, and a debrief at the end of each shift.

NPWS improvements since 8 June 2000

Issue

(Note: Some of these initiatives have since evolved and been refined.)

Table 6.3.  NPWS response to issues raised during the course of the coronial inquest and WorkCover investigation into the Mount Kuring-Gai incident on 8 June 2000.

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• The revised Fire Management Manual provides for the checking of the fireground, access, escape routes and safety refuges. Information regarding these features is to be provided to crews during briefing sessions.

• NPWS checklists have been amended to reflect that the location of first aid facilities must be included in the briefing. All firefighters are already required to carry a personal first aid kit.

• The new format for prescribed burn plans incorporates safety messages, the identification of safe areas, refuges, exit points, medical evacuation arrangements and the specification of emergency communications and contact arrangements.

First aid

Rescue

• A personal Incident Log Book is currently being designed by NPWS to allow positions from Incident Controller to Crew Leader to maintain communication logs.

• Communication black spots are a hazard and if they can’t be eliminated, crews must be notified of their location.

• Communication plans must be prepared.

• The revised Fire Management Manual requires all radio system equipment to undergo an annual maintenance check before the fire season.

• NPWS adopted a comprehensive approach to risk management including the adoption of a strategic plan and policy covering occupational health and safety, accident and injury reporting, and risk planning (fire management is a part of this).

• The Fire Management Manual was revised to prompt the Incident Controller to consider the appointment of a Safety Advisor to support the Incident Management Team.

• Safety First briefing material and Fire Watchout Lists were included in the new prescribed burn plan formats. The Fire Management Manual provides strict guidelines on preparation, planning and crew briefing including checks on uniforms, maps and safe operating procedures (such as length of shifts) as well as fire warning signs. A NPWS Field Incident Notebook and Fire Watchout List pocket aide-mémoire have been produced.

• Sector Bosses were identified as being responsible for ‘field-truthing’ fireground maps (walking the area to check accuracy of maps).

• Draft standard operating procedures related to fireground mapping and marking were prepared for approval and incorporation within the NPWS Fire Management Manual.

• Fireground maps must be prepared for all prescribed burns and bushfires.

• Additional protective equipment is now being provided to all firefighters in the form of flash hoods and heavier gloves.

• Circulars have been provided to staff to inform them how to care for and preserve the effectiveness of their firefighting equipment.

Field-ground truthing

Communication equipment

Safety

Maps

• All NPWS firefighters must be equipped with uniform and equipment complying with relevant Australian standards. This includes Probantreated jackets and trousers or overalls, helmets, gloves, boots, flash hoods and smoke masks.

Uniforms and equipment

• The revised Fire Management Manual also states that crew leaders must ensure crew members use and wear protective equipment properly before entering the fireground.

NPWS improvements since 8 June 2000

Issue

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Incident Management in Australasia

all have different perceptions and comments to make and each is as valid as the other. We emphasised that it was up to the Coroner to consider and to weigh this evidence in terms of reliability on the balance of probabilities. Staff expressed concern about the apparent hostile and confrontational atmosphere of the inquest. They felt that it was having an adverse effect on the health and wellbeing of NPWS witnesses and was not assisting with the process of getting to the truth. We reminded staff that barristers representing WorkCover and the families also needed to be confident that they were getting to the root cause of this incident and that aggressive cross-examination was part of that process. We advised staff that the Coroner was keeping a watchful eye on all witnesses and was sympathetic and supportive to witnesses who were struggling with emotions and having trouble in answering questions. We also advised staff that the NPWS barrister would object if a line of questioning is unclear or misleading, and we also reminded staff of the counselling and support services that had been put in place.

Coronial debrief A staff and family debrief on the Coroner’s findings was held on 19 December 2002 in order to provide an opportunity to discuss the findings and to outline the next steps that we would undertake. This proved to be a very worthwhile process in terms of establishing a common understanding of the Coroner’s findings and of the government’s response.

WorkCover investigation The WorkCover Authority undertook a separate investigation of the incident in accordance with the NSW Occupational Health and Safety Act 1983. WorkCover officers interviewed several NPWS personnel in the course of their investigation, including myself, and NPWS documents relating to personnel, training and fire policy were provided to the investigator. WorkCover prosecuted NPWS for its failure to provide safe systems of work and failure to provide the necessary personal protective equipment, training, instruction, information and supervision of crew members involved in the Mt Ku-ring-gai Incident. NPWS pleaded guilty and was fined.

Support services Counselling Counselling support was heavily promoted, encouraged and made available where required to those staff and family members immediately after the incident and in the many months that followed. Support was also provided to staff during the coronial inquest and WorkCover investigation.

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The support provided by the RFS Commissioner, RFS Executive, and the RFS Chaplaincy and protocol services, especially in the organisation of state memorial services, funeral services and dedication ceremonies, was especially valued and appreciated by everyone at NPWS. We also organised training for staff members in the effective use of the Employee Assistance Program. The course targeted those staff (supervisors and others) who believed that they would benefit from special training in helping colleagues who might experience stress and anxiety during the coronial process. Accommodation, transport, meals and mobile phone support was provided to staff and family members where required for the purposes of visiting hospitalised crew members, participating in staff briefings and attending the coronial inquest. Staff members were also supported and encouraged to visit hospitalised crew members and to attend funerals and other ceremonies. Every effort was taken by myself and other managers within the NPWS to support staff and family members over a long period of time.

Regular staff and family member briefings Seven staff and family member meetings were held between July and September 2001 to keep staff and family members apprised of the wellbeing of colleagues, to give an opportunity to ask questions, to be constantly encouraged to seek counselling support if required and to be updated on issues arising from the coronial and WorkCover investigations. A regular newsletter was also developed and circulated to staff and family members and a web page on the NPWS intranet was established to facilitate internal communications and circulation of daily updates on the progress of the coronial inquest.

Staff relocation I also facilitated the transfer or secondment of staff out of affected workplaces at their request. This allowed affected staff to continue to work with NPWS but not in areas with the stress of constant reminders of missing colleagues or of the circumstances leading up to the incident.

Return to work plans The NPWS Rehabilitation Co-ordinator worked with supervisors and staff on return-to-work plans for those crew members unable to immediately return to work and in providing ready access to counselling services.

Peer support group A peer support group was established consisting of self-nominated NPWS officers prepared to act as a 24-hour, seven days a week peer support network for affected crew members and colleagues if required.

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Coordination group A Post-Incident Coordination Group was established involving management, staff representatives and legal, safety and media specialists.

Memorials and dedications Formal and informal ceremonies were held to commemorate the four NPWS officers who died in this tragic incident, including a service held at Sydney’s St Andrew’s Cathedral, a bush sanctuary was established at Forestville for one of the crew members, memorial awards were initiated, a memorial seat was constructed by NPWS staff in the park overlooking the site and a monument was organised by local residents at Mount Kuring-Gai. In subsequent years, annual memorial services were held on the anniversary of the incident, and after 10 years this became part of the World Ranger Day commemorations held on 31 July each year.

Lessons learnt As a result of the comprehensive review of the incident, NPWS put in place several revised policies and procedures relating to fire management which addressed the issues raised during the inquest, the WorkCover investigation and the Coroner’s recommendations. These procedures particularly focused on prescribed burn planning, prescribed burn operations, safety and incident management. We informed and sought advice from the NSW Bush Fire Coordinating Committee (BFCC) on the improvements which we had already made in NPWS, together with the improvements we intended to make in the near future (Table 6.3). We also proposed that the BFCC support joint agency initiatives to enhance safety during fire management operations in New South Wales. These and other initiatives were all supported by the BFCC and implemented throughout New South Wales (Table 6.4). While many of these initiatives have since evolved and been refined since 2001–02, the incident was the catalyst to major reforms to prescribed burning operations and firefighter safety generally, and most are still in place today. Probably the most significant lesson learnt for us was in relation to the development and use of a more comprehensive IAP specifically for prescribed burning. Before this incident, NPWS prescribed burn plans were generally much less sophisticated than those required for bushfires and were sometimes absent altogether. Despite the fact that there was greater opportunity to prepare plans for these scheduled activities and that weather and resourcing were more reliable and predictable, much less attention was given to safety, communications, fireground organisation and discipline around the implementation of these apparently ‘safer’ activities. An element of complacency regarding the implementation of fire

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management policies and procedures had incrementally crept into our organisational culture. Attendance and acceptance of staff being on the fireground without the correct personal protective clothing and equipment would be unheard of today. The Mount Kuring-Gai incident transformed our thinking in regard to the dangers associated with the use of fire in bushland settings. The need for careful planning and especially discipline around the implementation of policies and procedures when using fire as a management tool was a significant lesson learnt. As a result of this incident, major improvements were made to the format and content of NPWS prescribed burn plans, with greater attention to detail on such matters as the requirement for a qualified plan developer and approval authority; inclusion of fireground safety messages including Fire Orders, Fire Watchout List and LCES, an early version of the LACES acronym (Lookout, Awareness, Communication, Escape Routes and Safety Refuges); listing of notifications to other authorities; detail on pre-burn tasks and completion dates; communication arrangements, operational checklists including crew briefings, equipment and radio checks, safety messaging; details of fire weather and fire behaviour predictions; and an outline of the organisational structure on the fireground. NPWS fire management policies and procedures were also refined particularly around training for both firefighting and incident management team personnel and for equipment standards. A new approach was also adopted for the preparation and circulation of IAPs and fireground maps. A new symbology, which required the standard identification of safety refuges, escape routes, grid lines, scale bar, hazard marking and fireground sectorisation on fireground maps, was developed. Over the next several years, the NPWS IAP for prescribed burns was further refined and eventually a common inter-agency IAP format and process, which contained all of the learnings and improvements developed following the Mount Kuring-Gai incident, was adopted in New South Wales.

Summary The Mount Kuring-Gai incident was a major wake-up call for NPWS and other fire authorities in New South Wales. Coming not long after the Linton Inquiry in Victoria (CFA 1999), this incident really focused our attention on the risks associated with the ‘Dead Man Zone’ (Cheney et al. 2000) in responding to bushfires and especially in undertaking prescribed burns. The ever-present threat of complacency, not just in residents in fire prone areas but also in firefighters, was also highlighted for me. There is a need for courage at all levels in demanding that standards and principles are maintained especially for safety equipment, briefings and provision of information. The need for ongoing analysis, learning and continual improvements and sharing of this information was also reinforced.

6. That a full briefing be carried out with all persons who are to undertake a HR, and such briefing to include topographical features, safety areas, exit points and other relevant matters in accordance with ICS. All members of the crew are to be given a map and encouraged to seek any information that may be relevant to their safety from those carrying out the briefing.

3. That people undertaking duties at prescribed burns be familiar with the ICS and duties ascribed to positions under that system. 4. That the usage of titles or terms not identified under the ICS no longer be used within the NPWS/fire agencies. 5. That all people assigned to attend a prescribed burn be notified well in advance of such a burn to permit their attending the fireground with suitable safety equipment and sustenance.

• Firefighting agencies are to develop burn plans, and have these approved by senior people with competency in planning and managing prescribed burns.

1. That hazard reductions to be undertaken on land under the control of firefighting agencies (e.g. NPWS) not to be undertaken before the plans for such burns are reviewed and approved by qualified person. 2. That no hazard reduction be undertaken in any area where ground crews are to be used without the area being inspected (ground-truthed) to determine safety areas, exits, potential hazards, etc.

• Operational burn plans are to include logistical arrangements for the identification of likely burn days and arrangements for food, water and transport. • Suitable dates are to be relayed to crews in advance of burns. • Personnel will not be permitted onto the fireground unless they are equipped with appropriate safety equipment as specified by the agency. • A full interactive briefing is to be conducted before the burn. It will be ensured that all crew who will conduct the burn will be present and given the opportunity to participate in the briefing. • A map will be supplied to each crew member at the briefing. • The burn plan briefing checklist is to include topographical features, safety areas, exits/access, lighting patterns and communication arrangements. • See also point 14.

• All operations to use ICS terms only including functional call signs.

• Operational burn plans are to include identification and assessment of hazards and refuge/access arrangements. • The Incident Controller is accountable for the inspection of the site and the assessment of hazards and for ensuring that the reporting of refuge/access arrangements is suitable. • The Incident Controller is to ensure crews are briefed on hazards and refuge/access before the burn. • Introduction to ICS to be included in all aspects of fire training. • Functions within ICS will only be assigned to people with relevant competency.

BFCC response

Coroner’s recommendation

(Note: Some of these initiatives have since evolved and been refined.)

Table 6.4.  NSW Bush Fire Coordinating Committee (BFCC) response to the Coroner’s recommendations into the Mount Kuring-Gai incident on 8 June 2000.

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• The senior officer designated by the agency concerned is responsible for approving the burn plan and must verify that all health and safety issues have been covered in advance of the burn, which includes that burn site is inspected, hazards identified and assessed in accordance with burn plan checklist and control measures adopted in advance of briefing for relay to crews. • The Incident Controller remains accountable for all aspects of the burn. • NPWS is to arrange in conjunction with other fire agencies a meeting with WorkCover to determine the suitability, content or otherwise of a possible Industry Code of Practice for Prescribed Burning Risk Assessment. 8. That at every HR an effective Control • The Incident Controller is to ensure a final full listing of personnel, location and roles to be performed Centre is to be established and staffed by a is available (a copy must be kept by the Incident Controller and at the control centre/control point if person with advanced first aid qualifications operational). and relevant medical equipment; who has • A person holding a Senior First Aid certificate is to attend each burn and be available for first aid and the capacity to communicate with the emergency response as deemed appropriate for the operation. fireground and senior officers; who is fully • Any additional people qualified in first aid should be identified at the briefing and noted by Incident briefed as to the burn; and who is supplied Controller and crew leaders. with a list of personnel involved in the burn and their ascribed roles. 9. That NPWS develops or assists in • Drip torches currently meet the relevant standard for portable fuel containers. (Richard Donarski, pers. development of a suitable method of testing comm.) drip torches to ensure that they are • Testing of drip torches was conducted on behalf of the RFS after the Ku-ring-gai Incident. manufactured to such a standard to • Agencies do not intend pursuing this recommendation further. withstand heat and therefore do not become dangerous during a fire. 10. That NPWS has available to the Incident • Personnel participating as crew members and not having the necessary competence during fire Controller any information as to the level of activities involving live fire are to be accompanied by someone who is competent on a one-to-one training undertaken by the crew members basis. who are to undertake a burn; and allocate • The Incident Controller should ensure through the relevant agency that people are competent to to each person a more qualified officer to perform the task allocated. act as a mentor. 11. That no person be permitted to enter a • The Incident Controller is to ensure all crew members have safety equipment in accordance with fireground unless suitably attired. agency standards. • The briefing is to emphasise that safety equipment must be worn during the burn.

Coroner’s recommendation 7. That a senior officer check and verify that occupational health and safety issues are addressed before the burn is undertaken.

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• A person will be appointed to monitor communication channels and log significant issues/incidents and report any emerging issues to the Incident Controller as a minimum.

• A working group has been established by NPWS to develop this guide before February 2003.

16. That there be kept at all times during any prescribed burn, or hazard reduction, a log of radio and other communications to indicate actions taken on the fireground.

17. That the NPWS assists other firefighting bodies in formulating a Burn Guide for the Sydney Basin.

• This document is to be referred to BFCC for consideration.

• A communications plan will be prepared as a component of all prescribed burn plans. This plan will specify the necessary equipment and planning to provide effective communications.

• Incident Controllers shall be responsible for ensuring all crew members take part in briefing sessions and are provided with an opportunity to raise their concerns before burn commencement.

• Operational burn plans and briefings will incorporate occupational health and safety issues as a driver for cultural change and to ensure safety concerns of crews are identified and addressed before implementing burns.

• All agencies believe that fire fighter safety is paramount.

• The agencies do not support the use of the US style fire shelters on safety grounds.

• Training will reinforce safety issues related to fire behaviour and practical steps to minimise risks of fire overruns.

• Agencies are concerned that the use of these items in the field could lead to excessive weight/heat stress.

• Portable fire blankets are provided within firefighting vehicles for use of crews.

15. That a review be undertaken of the NPWS communication equipment and the effectiveness of the usage of such equipment at firegrounds, including the efficiency of a relay base.

14. That NPWS stresses to staff that safety of personnel is paramount at all times. Should any one person undertaking prescribed burns be concerned as to any aspect of such safety they are encouraged to bring this to the attention of those in authority; no burn be undertaken until the concern raised has been considered and addressed at the highest relevant level.

13. That consideration be given to personnel on the fireground being issued with personal and portable fire protection blankets.

• A recommendation of a report of Richard Donarski (27 August 2001) is to be implemented, including the adoption of Australian standards for protective equipment for firefighting adopted by RFS, NPWS and NSW Fire Brigades.

12. To this end all new recruits should be issued with, and trained as to the care and maintenance of, new, appropriately sized fire clothing including two piece Proban-treated suits and undershirts, fire resistant footwear, goggles, mask, gloves and helmet. • NSW State Forests has developed its own standards for protective clothing.

BFCC response

Coroner’s recommendation

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The incident and related investigations and recommendations prompted the adoption of greatly improved safety policies and procedures during bushfires including the adoption of a new and more comprehensive incident action plan format and approval process for prescribed burns, joint agency operating procedures for prescribed burns, improvements and adoption of common mapping standards for bushfires, further investments by New South Wales fire authorities in fire behaviour and fuel research (for example, Project Vesta), reinforcement of the LACES safety acronym in crew member and crew leader training and in aidemémoires such as firefighter notebooks, and the establishment of a Safety Advisor position within the ICS framework. The management of staff and family welfare was a very important component of the NPWS response, and while many things were very well done, nothing could really have prepared us for this tragic incident. The Minister, NPWS DirectorGeneral and Commissioner of the RFS were all instrumental in providing leadership, flexibility and support in managing staff and family issues during and after this tragic event. The RFS chaplaincy service, NPWS corporate services, our counselling provider and the support provided by sister agencies in other jurisdictions were also particularly valued by all of us in NPWS. Without doubt, the strength and courage of affected staff and family members were the most outstanding and memorable feature of this tragic incident. In honour and memory of fallen colleagues: Mark Cupit, Claire Deane, George Fitzsimmons and Erik Furlan.

References AARFA (1992) The Australian Inter-Service Incident Management System: teamwork in emergency management. Australian Association of Rural Fire Authorities, Melbourne. Blade K (1998) Review of Environmental Factors, Environmental Protection and Prescribed Area Burning. Mount Colah/Mount Ku-ring-gai. Ku-ring-gai Chase National Park. North Metropolitan District. NSW National Parks and Wildlife Service, Hurstville, NSW. CFA (1999) Reducing the Risk of Entrapment in Wildfires. A Case Study of the Linton Fire. Country Fire Authority of Victoria, Melbourne. Cheney P (2001) Fire Behaviour of Ku-ring-gai National Park Prescribed Burn 8 June 2000. CSIRO Forestry and Forest Products, Kingston, ACT. Cheney NP, Gould JS, Knight I (1992) A Prescribed Burning Guide for Young Regrowth Forests of Silvertop Ash. Forestry Commission of New South Wales, Sydney. Cheney P, Gould J, McCaw L (2000) The Dead-Man Zone – a Hitherto Ignored Area of Firefighter Safety. Australasian Fire Authorities Council Annual Conference. September 2000, Adelaide.

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Doig R (1997) Review of Environmental Factors for a Prescribed Burn in the Mt Kuring-gai Area. NSW National Parks and Wildlife Service, Hurstville, NSW. Eager P (2001) Statement in the matter of: Mt Ku-ring-gai Hazard Reduction Burn on 8 June 2000. Goulburn Local Area Command, NSW Police Service, Sydney. Mangan R (1999) ‘Wildland Fire Fatalities in the United States: 1990 to 1998’. Tech. Rep. 9951–2808-MTDC. Missoula, MT, US Department of Agriculture, Forest Service, Missoula Technology and Development Center. NPWS (1990) Fire Management Manual. NSW National Parks and Wildlife Service, Hurstville, NSW. NPWS (2001) Fire Management Manual. NSW National Parks and Wildlife Service, Hurstville, NSW. Rothermel RC (1993) ‘Mann Gulch Fire: A Race That Couldn’t Be Won’. General Technical Report INT-299. Intermountain Research Station, Forest Service, United States Department of Agriculture, Ogden, UT. Strathdee G (2000) Fire Path Determination Mt Ku-ring-gai Hazard Reduction. 8 June, 2000. NSW Rural Fire Service, Homebush, NSW.

7 Large petrochemical fire in Adelaide’s industrial precinct Roy Thompson Incident Controller, South Australian Metropolitan Fire Service

Introduction Over hundreds of years many of the world’s greatest cities were devastated by fire and, to this day, fire remains one of humanity’s greatest threats and fears. To address these fears, government-funded fire services began to be formed just over 150 years ago and began to work with industries to try to prevent the outbreak of fire and mitigate its consequences. Around the world, rules that specify minimum fire safety standards were shaped. These rules mainly involve urban planning (a technical and political process concerned with the use of land, protection and use of the environment, public welfare and the design of the urban environment) and building codes (the protection of public health, safety and general welfare as they relate to the construction and occupancy of buildings and structures). The recycling industry is a relative newcomer to Australian industry, and appropriate urban planning and building code regulations providing guidance on many of the fire hazards associated with this industry are still being developed.

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Consequently large amounts of highly flammable materials such as tyres, plastics, paper, building materials, garden mulch and even used oil can be stockpiled by the industry and until recently went largely unregulated by fire safety practitioners. This situation was spectacularly highlighted to the Metropolitan Fire Service (MFS) on 13 March 2012, when Adelaide experienced a very large petrochemical fire in a waste oil recycling facility; it burned out of control in the heart of South Australia’s largest Industrial Precinct. I was Assistant Chief Fire Officer from the MFS, and was made the Incident Controller. This is my account of the incident, the subsequent lessons learnt and the policy changes that resulted.

Turn-out I was just heading back to my office after a superannuation scheme trustee board meeting when I received a page notifying the MFS Senior Management Team of a fire at a waste oil recycling depot. The depot was at Wingfield, South Australia’s largest industrial precinct located about 15 km north-west of Adelaide’s central business district. I was the on-call Assistant Chief Fire Officer (ACFO) for the week and immediately recognised that this was a job that could be very dangerous if it was not immediately controlled, especially on a 34°C day with strong northerly winds. With this in mind I thought I’d head up to the fifth floor Communications Centre (Comcen) to listen to the first arrival message. I hadn’t even got to the lift when my pager went off again, announcing that the incident had been escalated to a second alarm. I decided I’d better go and have a firsthand look at the incident and headed down to my car. I had just finished getting my turn-out gear on when my pager went off again and this time I was responded to the job. I notified Comcen that I was responding to the incident. It was the best out the door time I’ve ever had as a senior officer: four seconds! As I passed the high-rise buildings in the CBD I could see a huge plume of black smoke rising into the air and growing rapidly. Listening to the radio I could hear that other responding appliances were already starting to encounter very heavy traffic on South Road, which is South Australia’s busiest arterial road at the best of times. To avoid the traffic I chose a parallel route and only crossed over South Road when I was already in Wingfield.

Situation Around this time I heard the first situation report from the Incident Controller: ‘We have a large single storey structure, 60 m by 60 m, used as a storage facility for kerosene and fuels fully involved in fire, all persons accounted for.’

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There were significant roadworks nearby (this would play an important role later on) so the roadside workers were able to stop the traffic and let me through. As I drew near I could see the flames were now reaching 30 m high and I knew the radiant heat would be enormous, so I pulled up about 100 m south of the fire. Many people were running out of nearby factories and leaving the area. Two police officers were directing people away from the fire and had blocked the road to stop anyone from entering the vicinity. As I got out of my car, I saw that an on-call District Officer (DO) had already arrived. He told me that he had just been informed that there was a booster cabinet (a good water supply source) a little further down a side street and he was just going to tell a fire crew working nearby. As we progressed along the street, I saw a running fuel fire that was igniting vehicles parked in the street and the DO pointed out a large radio aerial on top of the administration building that was rapidly becoming engulfed in fire. The fire was also impinging on the overhead power lines; I had seen how quickly power lines can fail at another incident the year previously. As we reached a nearby fire appliance, I pointed out the imminent danger posed by the aerial and the power lines to the fire appliance and instructed the driver to quickly uncouple the hoses and move the fire appliance back 20 m. The DO and I assisted the driver to uncouple and as the fire appliance backed down the street the aerial fell directly where the appliance had been positioned only seconds before; that was a close call, the first of many that would occur on the day. The power lines didn’t last much longer and were starting to fail as the first elevated work platform appliance arrived. I pointed out the dangers to the aerial officer and directed the positioning of the aerial to protect some of the exposures.

Size-up The first two arriving Station Officers (SOs) were at that time Incident Controller and Operations Officer respectively and were retreating down the same street. They quickly provided me with an excellent handover briefing. They had already completed an accurate size-up; called for a fourth alarm; established the strategy as a defensive operation; established exposure protection as the primary objective; allocated four Sector Commanders (North, East, South and West); allocated a Staging Area; and documented their initial Incident Action Plan on their incident management kits. As a senior officer taking over as Incident Controller, I couldn’t have asked for a better initial set-up by these two officers – an outstanding job in the first 30 minutes of a difficult and rapidly deteriorating situation. Their initial decisions and actions set us in good stead for the duration of the incident and made my job much easier than it might otherwise have been.

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I formally assumed the position of Incident Controller and transmitted this across the fireground and back to Comcen. I took the first two arrival SOs with me to establish an Incident Management Team (IMT) one block back from the fire. At the end of the street I encountered another on-call DO, who was just arriving after completing a reconnaissance drive around the incident. He informed me that SA Police (SAPOL) were setting up their forward control point about 200 m west of the fire and he recommended the site as an excellent vantage point. We went to the recommended location and agreed that the location was ideal for observing the fire, and had plenty of room to set up a rehabilitation area and coordinate with other agencies. I established the Incident Control Point adjacent to the SAPOL forward control point and the SA Ambulance Service (SAAS) later set up their forward command point also adjacent. This proved ideal throughout the incident as it allowed for easy coordination with SAPOL and enabled our firefighters to have their health checked by SAAS as they went through rehabilitation. The SOs transferred the information they had on their incident management kits as well as in their heads on to the larger ‘type 2 incident boards’ hung on the outside of the command vehicle. This included a map of the incident, appliance locations, the designated sectors, Sector Commanders, radio channel for each sector, sector resources and tactical assignments. Between them they vigilantly tracked all resource movements and maintained critical information on the incident boards. They quickly understood my needs and were usually a step ahead of me; every time I began to request that a piece of information be recorded or updated they were already doing it. We seamlessly established such a good rapport that they remained not only my eyes and ears but also my left and right hands throughout the day as my planning and logistics officers.

Risks Once I assumed command at the relocated Incident Control Point, I revisited my thoughts on the overall situation and discussed the risks, objectives, strategies and tactics with the IMT. We categorised the risks into four major areas. The most obvious and immediate threat was the enormous radiant heat impinging on surrounding properties on all four sides of the fire (I later identified 16 industrial and commercial premises that were adjacent to the incident and within immediate risk from the radiant heat). We knew from experience that water supply is almost always an issue at large defensive operations, and I was aware from situation reports from all four sectors that none of them had sufficient water pressure or flow. (Liaison with SA Water would later confirm that we were already getting as much water as was available from the two water mains we had tapped into.)

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Due to the temperature on the day (34°C), relatively high humidity, a strong northerly wind, the radiant heat and the hard working conditions, wearing level two structural firefighting clothing meant that sustaining sufficient hydration of the firefighters was going to be a major problem. There would be large amounts of contaminated run-off water from the numerous exposure protection sprays, combined with the leaking petrochemicals, going into the stormwater system and threatening the nearby wetlands and wildlife. Unless additional water supplies could be achieved, applying and maintaining a foam layer to cover the entire incident to achieve extinguishment was not going to be possible. This meant that water was going to be the primary agent for defence against the radiant heat as well as for cooling the fire. Radiant heat, low water supply, dehydration and contaminated run-off persisted as the major areas of risk throughout the first day.

Objectives and strategy Following the initial evacuation of the area there was no longer life risk to the public, so the safety and welfare of the firefighters became the primary objective, followed by minimising economic and property loss of the surrounding premises, followed by the environmental protection of the nearby wetlands. These objectives dictated a defensive strategy.

Tactics Resources, including pumps, personnel and water, were distributed to the geographical sectors of the incident on all four sides and managed by four Sector Commanders reporting to the Operations Officer. The tactics for dealing with the radiant heat were to apply cooling water to the fire and protection sprays to the many premises being affected. This was achieved by the use of 64 mm handlines as well as ground, pump and aerial mounted monitors distributing the available water as best we could. In addition to the four geographic sectors dealing with the radiant heat and fire control, I also assigned three functional sectors, each headed by a DO, to deal specifically with the other primary risks. The issue of keeping the firefighters hydrated in these conditions was discussed and assigned to all Safety Officers to ensure firefighters kept drinking. A Rehabilitation Sector was established, which included liaison with SAAS to provide medical monitoring. One DO was allocated the Water Sector; the initial tactics to mitigate the water supply risk were to ensure we had accessed all the water supplies available in the area. A liaison officer from SA Water was called to direct as much water as possible

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into the area and ensure all water mains had been identified. The MFS fetch pod containing 1500 m of high-volume hose was called for to access a third water main, as well as the MFS 5000 L bulk water carrier. Four further bulk water carriers from the Country Fire Service (CFS) were used to set up a tanker relay to the North Sector. Also a 9000 L Skycrane helicopter was called in to assist with water bombing operations. Another DO was assigned the Environmental Sector to liaise with the Environmental Protection Agency (EPA), Port Adelaide/Enfield Council and the MFS Hazmat Team to identify the stormwater drains, and formulate control measures to mitigate the risks to the stormwater system and to the nearby wetlands, which were less than 500 m away. Due to the large roadwork project nearby, we were able, using the earthmoving equipment on the scene, to create a large dam to the east of the incident to collect the water and petrochemical run-off and protect the wetlands and wildlife. The capturing of the run-off in this way also enabled the petrochemicals floating on top of the water to be pumped off and taken away for recycling; this reduced the risk of both fire and contamination – this process continued for several days after the fire.

Organisational structure At this stage the IMT was headed by me as the Incident Controller and included the Planning Officer keeping the map and Incident Action Plan up to date; the Logistics Officer liaising with the Staging Officer and the MFS State Coordination Centre Fire for provision of fireground resources; the Rehabilitation Officer; the Water Officer; the Environmental Officer; and the Operations Officer with Sector Commanders North, South, East and West reporting to him. I transmitted a fifth alarm in order to supply sectors with the additional resources being requested and a little while later a sixth alarm to facilitate recycling and rehabilitation of crews. This meant that every MFS resource (33 appliances and 140 personnel) in the metropolitan area of Adelaide was now committed to the incident with back-up volunteer crews supplied by the CFS staffing many metropolitan stations. Several CFS appliances and personnel were also at the incident. The State Emergency Service (SES) had also offered support and had set up tents to provide shade and wind protection for the IMT and the Rehabilitation Sector. On the arrival of Deputy Chief Officer, I provided a briefing on the Incident Action Plan and he assumed the roles of State Coordination Centre Fire liaison and MFS Media Spokesperson. His Staff Officer offered to liaise with the CFS to arrange an aerial water-bombing attack (I had used a Skycrane helicopter at an incident nearby 12 months earlier and knew the nearby wetlands could be used as a water source for this purpose with permission from the local council). The Staff

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Officer assumed the role of Liaison Officer for the 9000 L Skycrane until a CFS Aerial Attack Supervisor arrived at the Incident Control Point.

Communications On-scene communications were managed by assigning Government Radio Network (GRN) tactical channels to the geographical sectors (North, East, South and West) as well as functional sector channels and the command channel. Mobile phone communications were severely limited, probably due to a large amount of civilian traffic on local cell towers. Senior level liaison with SAPOL, SAAS, CFS, SES and other functional services including SA Water, SA Power Networks, EPA, the Technical Advice Coordinator, the gas supplier and the Salvation Army (supplying catering for the incident) was effectively maintained using face-to-face communication and periodic briefings. The Media Team were kept very busy with media enquiries coming from all over the world, as well as organising television and radio interviews, and media releases for the print media, and issuing public safety warnings and notifications, and updating our social media interfaces. This required two media staff at the State Coordination Centre and one at the incident to coordinate media briefings at the scene.

Control Risks, objectives, strategies and tactics were continuously monitored and confirmed throughout the day between the IMT and Sector Commanders. Directions were provided by me as the Incident Controller to the geographical and functional sectors via the command channel. Regular situation reports and requests for resources were effectively maintained throughout the incident via the Sector Commanders, who apart from providing informative situation reports also developed tactics and managed whatever resources I could assign to them in what was often the most harrowing of circumstances for the crews under their command. ‘Red flag’ warnings are used to gain radio priority and notify all sectors of critical safety information. During the incident there were three red flag warnings from Safety Officers; the first of these notified of a running fuel fire that was affecting vehicles parked in the street, one of which was marked as an LPG-fuelled vehicle. There were also four other large trucks parked further down the street; our Eastern Sector organised to have these towed out of harm’s way. The second red flag notified of an uncontrolled gas-fuelled fire in the South Sector; this was controlled after gas supply contractors arrived and isolated the mains gas supply for the street. The third occurred about 2.5 hours into the incident when one of the fuel storage vessels began venting furiously, followed by a large explosion that produced

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a 100 m high mushrooming ball of flame. The intense radiant heat was felt hundreds of metres away and a 2 m diameter by 25 mm thick steel silo lid, weighing several hundred kilograms, was blown nearly 100 m to the east, landing between two nearby factories onto a tandem trailer, flattening it to the ground. One of the aerial officers was at that time making a temporary fix to the monitor control arm in the cage, tying it in place using a piece of rope. He had removed his gloves to tie the rope just when the explosion occurred. He had just enough time to duck down inside the cage as the radiant heat washed over him, but he sustained burns to the back of the one hand that he still had on the monitor control arm. The sector Safety Officer issued a ‘mayday’ transmission while ordering the cage be lowered to the ground to assess what injuries had been sustained to the operator as a result of the explosion. I saw him stand up in the cage while it was still being lowered to the ground and I was relieved to see that he had not been killed. It was, however, a few anxious minutes before we knew that he had received a nasty burn but no life-threatening injuries – a great testament to the personal protective clothing that he was wearing.

Capability The ability to continually meet resourcing requests by Sector Commander was managed via liaison between my IMT, who as I mentioned earlier were usually one step ahead preparing resources, and the Staging Officer, who ran the busiest and most effective Staging Area I have ever had the good fortune to have at my disposal and, of course, in liaison with the State Coordination Centre and Comcen, who also had to arrange fire coverage for all the empty stations. Stocks of foam supplies were brought to the Staging Area so that it would be ready for use if sufficient water pressure became available or when the fire subsided sufficiently to get close enough with the water pressure available. Adelaide Airport fire-tenders were also considered and made available should they be required. The deployment of the high-volume hose via the fetch pod increased the water supply by accessing a third water main 1500 m away and contributed to slowing the progress of the fire towards the east. Engineering support by the way of refuelling and fixing minor breakdowns was carried out by the Engineering Manager, whose performance greatly assisted us all throughout the incident.

Assessment Throughout the first few hours the fire continued to burn unabated and the primary objectives remained firefighter safety, followed by exposed premises protection from the radiant heat and environmental protection from the run-off.

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Hydration of firefighters in the North Sector remained difficult as they were largely cut off from the rest of the fireground by uncontrolled fires burning to the east and west of their position and a freeway behind them. Exposure and attack lines were difficult to maintain due to the lack of water; consequently, the fire continued to spread throughout the original premises and impinged on several petrochemical pressure vessels. The fire was still continuing to grow and one adjacent property on the eastern side was consumed by fire with two others damaged. I was concerned that the fire would continue to spread eastwards and designated a North Eastern Sector with three general purpose pumps under a fifth geographic Sector Commander to protect a large commercial property in that area. Soon after the explosion, the 9000 L Skycrane helicopter arrived and started deluging the fire. This proved to be the most effective strategy for minimising the radiant heat on surrounding exposures and reducing the intensity of the fire impinging on the petrochemical pressure vessels. With the primary attack being supplied by the Skycrane, there was a noticeable escalation of the fire when the Skycrane was away for almost an hour, refuelling at the local airport.

Evaluation Use of foam was continually evaluated throughout the day, but considered to be ineffectual unless a sufficient water pressure could be provided that would cover and maintain a foam blanket over the burning petrochemicals. The aerial waterbombing attack would also have to stop as 9-tonne bombing loads from above would break up any foam blanket. After about five hours the fire had diminished sufficiently for two aerial appliances to move closer to the fire and provide an adequate water pressure to start applying a foam blanket. As discussed earlier, the run-off from the fire was prevented from reaching the nearby wetlands, but the temporary dam had to be increased in height and capacity several times throughout the day, using earthmoving equipment from the road works project. The pumping off of the petrochemicals continued for several days after extinguishment. The MFS Hazmat Team worked extremely hard, even helping with the distribution of drinking water and food. They provided excellent advice while continuing to monitor the run-off and the toxic smoke plume throughout the day; their efforts contributed greatly to averting a potential environmental disaster by protecting the nearby wetlands, the wildlife and the reputation of our fire service. After what felt like two hours but was actually over six, the Deputy Chief Officer suggested that he assume the role of Incident Controller, so that I could drive around the incident with my replacement ACFO and then hand over Incident

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Control to him. During this reconnaissance I had the opportunity to thank some of the crews who had worked so hard, putting their own personal safety at risk. The firefighters certainly looked how I felt and many had worked themselves to exhaustion; six firefighters were placed on saline drips in rehabilitation to rehydrate. We had thrown literally everything we had at this job – the biggest fire the MFS has had to deal with in many years – but it had been worth it. We had saved 16 neighbouring properties, hundreds of jobs and the economic value associated with these businesses as well as protecting the nearby wetlands and wildlife. I was exhausted but very proud of our efforts and the service we provided to our community on a fire of this magnitude, intensity and complexity. I was also pleased to be quoted by the Minister for Emergency Services in the South Australian House of Assembly saying, ‘At the press conference this morning Roy Thompson, Assistant Chief Officer with the MFS, said that it was the worst fire he had been to in his 25 years as a firie and one of the largest we have seen in Adelaide in many years. Roy commended all personnel from across emergency services on their high level of commitment and for the exceptional collaboration under extreme circumstances.’ The fire continued to burn and flare up from time to time throughout the night, but the foam attack was having a good effect and most of the fuel had burnt out by the morning. The salvage operation and environmental protection controls, however, went on for another four days and the EPA continued to monitor the wetlands for petrochemicals for 12 months to ensure that there were no ill effects from the fire.

Reflection I have been to many large fires from a personal perspective and to quite a few as the Incident Controller so I am familiar with the adrenaline effect both at the job and ‘coming down’ afterwards. However, I noticed that this one kept me quite restless for three or four days, especially as the request for media interviews persisted for a few days, and it was a full week before I was really back to normal and felt like I could objectively reflect on the events of that day. Fortunately one of my colleagues was doing his doctoral thesis on operational decision-making and interviewed me in detail about the incident, capturing the information for his thesis and providing me with a detailed and contemporaneous record that I referred to in order to write this story. In hindsight I am pleased with my overall decision-making, communications and actions during that day; this has increased my confidence as a leader and as an Incident Controller. But it is really the fantastic teamwork demonstrated by so many people on the day that defines this incident for me, and provided the safe systems of work for our firefighters in very difficult circumstances, and achieved very good outcomes for our community.

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For professional development there’s no better learning than ‘on the job’ and there’s no better breeding ground for strong and respectful relationships than in the ‘heat of the fire’; I am incredibly grateful for the friendships and great working relationships across many agencies that grew out of this incident. Finally, although I have told this story from my perspective, I hope I have adequately conveyed that I was just one of hundreds of people from many agencies involved during and after this incident, all of whom demonstrated outstanding and exemplary professionalism and whom it is my privilege to have as friends and colleagues.

Lessons learnt From an agency perspective, the MFS has learnt many lessons from this incident and introduced substantial changes as a result to policy, procedures, training and equipment. For instance, firefighter dehydration was recognised early as a major risk and medical monitoring was provided at the Rehabilitation Sector by ambulance officers, but in spite of best efforts to keep firefighters hydrated, it was very disturbing and not acceptable to have to resort to saline drips to rehydrate firefighters. As a result, the MFS has developed a memorandum of understanding with SAAS to provide, as a standard practice, medical monitoring of our crews as they come through rehabilitation. A rehabilitation policy and procedure has been developed along with training and equipment and the MFS now sends a ‘rehabilitation pod’ to protracted incidents. The allocation of a Rehabilitation Sector is now standard practice at all greater alarm incidents. A site handover procedure and form that identifies contact information, identifies risks, details control measures and ensures that residual risks and liabilities are explained to owners before a site is handed over from the MFS has been developed and implemented. Our Media Team used the goodwill of several non-operational staff who contributed their invaluable skills for the duration of the incident. This was recognised as an effective and efficient way to quickly expand resources in this area and the Media Team has now incorporated additional people with training and equipment into an on-call and back-up media capability. As a result the MFS continues to develop its capability in this important high-growth area of emergency services and improve public information and the use of social media tools. A debriefing process of several hundred personnel who attended the incident over the five days was conducted. While the process was useful in capturing some of the lessons learnt, it was not a very efficient or effective way to debrief this many personnel. A new Post Incident Review online survey that enables individual crews to sit down after an incident and analyse it in detail using a standard process was developed. Quantitative and qualitative data is gathered from this process,

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enabling agency-wide analysis and leading to evidence-based decision-making and ongoing improvements in policy, procedures, training and equipment. The post-incident review and analysis of the incident reinforced the MFS decision-making model and demonstrated the value of the Staff Development Framework and especially the First Arrival Officer Program and Senior Firefighter Year Two Program, which both the first and second arrival officers had completed and demonstrated their learning in the best and most practical way possible. It was, however, recognised that senior officers had not had similar development for some time. Consequently, all senior officers have since completed the North American ‘Blue Card’ accreditation as an interim measure while the higher end of the Staff Development Framework is still being developed. The MFS Command and Control Standard Operating Procedure has incorporated the ‘Blue Card’ Senior Advisor role and details responsibilities to assist Incident Controllers at large, complex incidents.

Future The MFS is in the process of adding a new fleet of combination aerial/general purpose pump appliances to its metropolitan fleet; these will provide far greater capacity for large exposure protection with large remotely controlled monitors reducing the risk to firefighters of unnecessary exposure to vapour explosions experienced at this type of incident. General purpose pump appliances have also had improved range, remotely controlled, roof-mounted monitors fitted for large exposure protection. While the sectorisation of the incident assisted greatly in maintaining effective radio communications, it was identified that Sector Controllers need two radio pockets on their level two personal protective clothing (PPC): one to communicate within the sector and one to provide situation reports on (be that to a Sector Commander, Divisional Commander or the Incident Controller, depending on the organisational structure). New PPC is now specified with two radio pockets and current PPC will be retrofitted. To ensure the MFS continues to protect precious wetlands and wildlife, firefighting foam is being changed over to the new EPA-approved and recommended type. As previously mentioned, the higher end of the Staff Development Framework is still being developed. Work is underway to ensure the continued alignment of MFS operational doctrine and decision-making embedded in the higher end of the Staff Development Framework with the Australasian Inter-service Incident Management System™ (AIIMS) level two and three Incident Controller accreditation. This will ensure that senior officers are not only able to continue to develop and maintain Incident Controller level two and three skills and accreditation to meet the needs and expectations of the South Australian

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community, but will also be able to contribute these skills to other jurisdictions to the benefit of all Australian communities in times of crisis.

Summary As discussed earlier, the recycling industry is a relative newcomer to Australian industry and the lessons learnt from this type of incident will help to inform a future urban planning, building code and environmental regulatory framework. Following this incident, the government brought together the major stakeholders working in and with the recycling industry to review the planning, licensing and regulations pertaining to large recycling and waste transfer facilities. This has been led by the EPA, but includes the MFS and the broader recycling industry in developing and reviewing fire safety systems as well as safe working and environmental practices. The aim is to create a sustainable industry that brings prosperity and economic value to the state while caring for the environment and ensuring the health and safety of other businesses, firefighters and the wider community. A good example of this is the MFS Built Environment Section working together with the local council’s Building Fire Safety Committee and this particular waste oil recycling depot’s civil engineers to completely redesign much safer and sustainable future waste oil recycling facilities. Some of the new designs include separation and bund walls between flammable products; holding vessels with internal foam injection as well as external and overhead deluge systems; additional firefighting water provided by on-site tanks with electric and diesel pumps and booster connections; and under the entire site an innovative double concave foundation surrounded by a bund wall channelling run-off through a central drain, with run-off pumped to a holding tank that is accessible from the road to be pumped off if required. The MFS believes these fire safety systems will go a long way towards, if not eliminate altogether, the likelihood and consequence of any future incidents at this site. Another example is the development of an industry standard by the MFS and EPA for the storage of building material waste. Following several large fires at a recycling bulk waste transfer facility (also at Wingfield) the MFS developed an industry standard for the storage of flammable materials such as building waste. Storage must be in rows (called ‘windrows’) of no larger than 20 m by 8 m, not more than 4 m in height and with a minimum 8 m separation between windrows. The standard also calls for temperature monitoring and daily reporting to reduce the risk of spontaneous combustion. The windrow size facilitates the quick access of heavy plant to pull the piles apart should they start to overheat. The EPA has stipulated this standard as a licensing requirement, and meets regularly with the MFS and industry representatives to evaluate the effectiveness of these measures.

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Although these measures may have greatly mitigated the particular risks in these cases, much still needs to be done across the broader recycling and bulk waste transfer industry as these types of incidents are still happening across Australia quite regularly.

8 Thirty per cent of the entire state: Victorian floods, 2011 Trevor White Chief Officer Operations, Victoria State Emergency Service

Introduction The 2011 Victorian floods broke what had been a long period of drought and produced significant consequences for Victorian communities. The floods affected most parts of Victoria between early January and late March. During this period I undertook the role of State Flood Response Controller and was relieved from time to time by my Deputy Tim Wiebusch. This flood would push many boundaries, and the impacts and consequences on communities were outside the bounds of what our emergency management system was able to cope with, based on previous history. In spite of a commitment to collaboration across the sector, many gaps in our capability were exposed throughout the event. Many lessons were learnt and this contributed to what has been the biggest change in Victoria’s emergency management arrangements since the disastrous Ash Wednesday bushfires in 1983.

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Background From September 2010 to the end of February 2011, Victoria experienced some of the worst flooding the state has ever seen. During the September 2010 floods, up to 250 mm of rain fell in the north-east and up to 100 mm in western parts of the state, causing flooding that affected more than 250 homes and businesses. The Victoria State Emergency Service (VICSES) received over 5000 requests for assistance. This event marked the end of a very long drought and provided a timely reminder that Victorian communities were still vulnerable to the threat of flooding. During October, November and December, there were further rain events that affected some communities multiple times and this continued the saturation process of what had, until recently, been a barren and parched landscape. The year 2010 ended up being the wettest year since 1974, when Victoria was affected by devastating floods, and it was the fifth wettest year ever recorded. During the 2011 floods, Victoria was affected by significant rainfall that occurred over three periods. Between 9 and 15 January, 100–300 mm of rain fell across two-thirds of the State (Fig. 8.1), resulting in major to moderate flooding in north, west and central parts of the state. It was also the wettest start to a year since records began with river height records in the Wimmera, Avoca and Campaspe catchments exceeding all previous records. Between 4 and 6 February, tropical moisture and extreme rainfall fell across metropolitan Melbourne, and over a 48-hour period Mildura recorded 178 mm and Lyndhurst in Melbourne’s south-east recorded 187 mm (Fig. 8.2). Percentage of mean 400 300 200 150 125 100 80 60 40 20 0

Fig. 8.1.  Rainfall in January 2011 as a percentage of average mean rainfall (1961–90). Source: Bureau of Meteorology, Commonwealth of Australia.

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Percentage of mean 400 300 200 150 125 100

Fig. 8.2.  Rainfall in February 2011 as a percentage of average mean rainfall (1961–90). Source: Bureau of Meteorology, Commonwealth of Australia.

On 22 and 23 March, the Latrobe Valley recorded falls of 100–150 mm and Wilsons Promontory recorded 370 mm at Tidal River. Even though the country had been extremely dry and rainfall had a lot of soil to soak into, the volumes of rain received in January and February 2011 were so significant that the ground became quickly saturated, resulting in enormous run-off into water storages. This left almost no space for water authorities to accommodate excess rainfall run-off and many of the storage reservoirs had to begin spilling water, flooding rivers downstream of catchments. Overall, about 30% of the state, encompassing 70 local government areas, was affected by some form of flooding or storm damage. This event affected 140 townships within 35 municipalities, which suffered significant cost and disruption to regional, urban and rural communities. To put the scale of the event into perspective, between 1 January and 17 March 2011, VICSES responded to more than 17 547 requests for assistance. That’s about half of what the service receives in an average year. While Incident Control Centres (ICCs) were operational for 42 days, the bulk of operational activity occurred between 12 and 24 January and again between 4 and 8 February. The final report of the Victorian Floods Review, conducted by Mr Neil Comrie AO APM (Comrie 2011), summarised the significant impact of the floods, noting both tangible and non-tangible damage, including: • nearly 4000 houses damaged • 4000 businesses and primary producers affected

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10 000 personal hardship grants made more than $269 million in agriculture sector losses about $176 million in lost tourism revenue about 1500 km of local roads closed during the floods rail services disrupted an ongoing psychological toll.

All in all, gross damages as of October 2011 were estimated at $1.3 billion. During this period, VICSES volunteers and other agencies responded to more than 600 flood rescues. Many of these were due to motorists entering floodwaters or being caught unaware of rising floodwaters. Most people have no real perception of the enormous force and power of water and cannot imagine being swept off their feet. Very little water also has the power to lift a vehicle off its wheels and sweep it away, putting the occupants in extreme danger. Several people also had to be rescued from their homes when the risk of over-floor flooding threatened to isolate them for days. At Charlton, for example, it was reported that 80% of the town was underwater and about 700 of the town’s 1300 residents were moved from their homes. The 2011 floods placed a significant strain on the state’s emergency management capacity and tested our capability, revealing several shortcomings. During January and February, the State Control Centre (SCC) was operational for 42 days and, at the peak of the event, eight ICCs were established concurrently, with sixty-seven 24-hour shifts and eleven 12-hour shifts required to support the operations and provide command and control. Throughout the event a total of 10 ICCs were established in the following regions: • • • • • •

Grampians at Ballarat, Horsham and Ararat Loddon–Mallee at Bendigo and Swan Hill Metropolitan at Mulgrave South West at Geelong and Warnambool Hume at Wangaratta Gippsland at Bairnsdale.

Before the floods It’s important to set the context of flooding and flood management in the years preceding the 2011 floods, as it had a big impact on the nature of the event. After close to 14 years of drought and accompanying bushfire activity, floods were the last thing on most people’s minds. In fact, it was difficult to solicit a lot of interest in flood mitigation and management. That was understandable in many respects, but it’s often said and known that, after a long drought, floods will follow. I, along with many others, wondered if we would see the day where some of our significant water storages such as Dartmouth, the Hume Dam and Eildon Weir would return to the storage levels enjoyed in the late 1980s.

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The drought had taken its toll on many Victorian communities, with not only farmers being affected, but also many associated downstream industries and the small communities that service much of rural and regional Victoria. Many communities were really struggling – the provision of water for domestic purposes had become a real problem for many townships and rural areas saw stock levels that were severely reduced or depleted. The Black Saturday Bushfires in 2009 were the horrific culmination of the extended drought and extreme weather conditions. In the months that followed, as many communities struggled to recover from the effects of the fires, there were signs that the situation was beginning to turn and the drought would break. Planning and readiness for floods was not in the front of many minds in the community and VICSES had to work hard to engender interest in the topic. We had to be very patient and persistent to keep flood discussion on the agenda and at times it was difficult. We had an ally in the Flood Plain Management Group at Department of Sustainability and Environment (DSE) as it was keen to work with anyone who showed a real interest in flood planning and readiness. We also managed to develop strong relationships with staff at the Bureau of Meteorology and Melbourne Water. Victoria had been flooded on occasions before the prolonged drought. Widespread flooding had occurred in Gippsland in 1998 and in 1995 the Geelong region, including the major Victorian city of Geelong. In 1993 Victoria’s northeast, particularly Benalla, was hit hard with flooding in a large number of homes and business. VICSES was formed as a statutory authority in 2005 and, as the newly formed Executive Team the following year, one of our priorities was to be actively involved in many facets of flood management. That meant getting involved in a range of committees and forums to influence planning and mitigation. An early priority was to develop a state flood emergency plan that addressed the key accountabilities of VICSES in floods and highlighted the important roles fulfilled by support agencies. Both the Chief Executive Officer (CEO) Mary Barry and I played an active role in this at state level, with regional managers continuing their hard work, strengthening relationships with catchment management authorities (CMAs) and other water management bodies and local municipalities. Some aspects of flood planning had attracted limited investment in many areas of the state, but we could not be deterred and started building networks with key stakeholders within and outside of Victoria. By the early part of 2007 we had developed an initial version of the State Flood Emergency Plan and, as is the case with all plans, the most important outcomes were the networks made and the planning process itself. In late June of 2007, the plan got its first test with a significant flood event in the Macalister Valley in Gippsland, affecting towns from Licola to Maffra and further downstream into the Gippsland Lakes. Unfortunately the small town of Newry, unaware of the

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floodwaters until they arrived, was flooded. The residents of Newry were given little warning that the town was in imminent danger of being flooded, leaving residents unable to contemplate property protection measures and numerous helicopter rescues had to be undertaken. A review of the 2007 Gippsland floods, conducted by the Emergency Services Commissioner Bruce Esplin (Esplin 2009), identified that there was uncertainty around accountability for the issuing of warnings to the community and improvements were required in the dissemination of information to the community. It was also identified that VICSES lacked available flood intelligence and, where information was available, VICSES was unable to use it to best effect. The need to strengthen the relationship between agencies and clarify their responsibilities was also identified by the report. It was clear we had a lot more work to do to ensure VICSES could mount a strong, holistic response to a flood emergency. It also meant we had to continue our endeavours to attract support for investment in community education and engagement activities.

The management of floods Victorian river systems generally flow from the high country in the Great Dividing Range, north to the Murray River or south towards the sea. Floods along the northern river systems, once they leave the ranges, generally move quite slowly towards and along the Murray River. Past floods have shown that flood peaks will take days and, in some cases, weeks to reach some towns along the Murray. Floods along southern rivers tend to move more quickly, giving communities less time to prepare, although this shortens the agonising wait for the flood peak to arrive. In Gippsland, the lakes system is subject to tidal influences, which can cause floodwaters to peak and recede several times over a span of days. This can be frustrating for local communities and requires well-constructed, informative community advice. Storm surge during periods of extreme weather can often exacerbate the effects of riverine flooding in coastal areas. Flooding is often described as a highly manageable hazard where risk can often be established based on past events. As floodwaters are often slow-moving there is an opportunity to provide early advice to communities to enable them to take action to prepare their property and, if they choose to, relocate. On the other hand, it has been well documented that no two floods are exactly the same and history has demonstrated that these known, previous flood extents can be exceeded. The traditional way of describing flood risk to communities has been to talk in terms of the ‘one in 100 years’ flood extent or, put simply, the means of describing locations where there is a 1% chance of being flooded each year on average. Flash flooding regularly occurs in Victoria as a result of intense thunderstorm activity or concentrated heavy rainfall and there is little opportunity to warn

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people. Such rapid rainfall also often creates large volumes of water that is trapped with little opportunity to drain away. The management of floods in Victoria and, indeed, most of Australia involves many stakeholders and complex arrangements. In Victoria there are floodplain management bodies within the Department of Environment, Land, Water and Planning (DELWP), CMAs and several water industry bodies that regulate and manage the supply and distribution of water for domestic, industrial and agricultural purposes. While there are extensive land use planning and development regulations and guidelines in place, the regulations and consideration of the implication of flood plain development have not had the same influence as seen with development controls in bushfire prone areas.

Issues and challenges in managing the 2011 floods The following sections explore many of the flood management issues encountered during the response to the Victorian floods of 2011.

Command, control and coordination of the flood response Unfortunately two lives were lost during the floods; one boy lost his life while playing in water and an elderly man died after being found in a flooded home with his wife. Given the number of flood rescues carried out, it was fortunate that there was not more loss of life. This was in stark contrast to the terrible events in Queensland during January 2011, with many lives lost and thousands of people affected. Due to their enormity, the Queensland floods put people on notice across the country, so there was already a degree of anxiety and sombre weariness in the Victorian community as floods started to develop and unfold in early January 2011. In the first week of flooding, it was not anticipated that this event would drag on for almost three months and affect almost one-third of Victoria with devastating consequences on many communities. VICSES units worked tirelessly for several weeks. The initial severe flooding in January was followed by another bout in February due to tropical moisture coming from the north of Australia in the wake of Cyclone Yasi, dumping heavy rain in places that had already been hard hit. My Deputy Tim Wiebusch was totally committed and alternated with me as the State Flood Controller throughout the floods and our regional managers and their staff worked tirelessly to maintain the best possible presence of VICSES, leading and participating in the incident control teams. As the weeks dragged on, we found ways to overcome some legislative hurdles to allow other agency members to undertake command and control roles, and this was greatly appreciated. CEO Mary Barry and my Executive Management Team (EMT) colleagues from VICSES were a great support throughout the event,

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making sure that the organisation continued to function with critical ‘business as usual’ activities. As State Flood Controller in 2011 I operated from the SCC in Melbourne and worked with three regional controllers situated in Bendigo, Ballarat and Moe. ICCs were established in several locations; however, it became evident during the later stages of the floods that some ICCs were trying to manage flood operations that were too far away from the on-ground commanders. VICSES was strongly supported by other agency personnel, although many of the VICSES members in command and control roles had limited experience and often had insufficient resources to manage all of the issues that needed to be addressed at Division and ICC level. In spite of this, VICSES and other agency members at all levels did an outstanding job in maintaining critical command and control functions for an extended period of unprecedented flooding over vast areas of the state. At the time of the 2011 floods, there was no provision within VICSES legislation or the Emergency Management Act 1986 to allow the VICSES Chief Officer Operations to take wide-ranging actions to assist control. This arrangement was in stark contrast to those in place for response to fire where the Chief Officers have strong legislative authority that supports them in managing their responsibilities. At one stage I was consulting with the Country Fire Authority (CFA) Chief Officer, to formally request support from CFA to allow the CFA Chief Officer to use his powers to assist me as State Flood Controller in taking action to breach levees to divert the flow of water away from areas where there was potential for negative community consequences to occur. The State Flood Controller’s Statement of Intent was formulated to provide guidance to Incident Controllers on our priorities: • protection and preservation of life • community warnings and information • protection of: ➤ critical infrastructure and essential services ➤ residential property ➤ economic production and livelihoods ➤ environmental and conservation values ➤ safety and welfare of displaced persons • effective transition to recovery. The then-Fire Services Commissioner (now Emergency Management Commissioner) Craig Lapsley was regularly at my side, offering every assistance possible in conjunction with the Chief Officers of CFA, DSE and Metropolitan Fire Brigade (MFB). Their support was outstanding and the resources provided to support VICSES throughout the state were significant. Craig was a tower of strength and would often spend hours with me each day as we worked to coordinate support from the fire agencies, particularly CFA and DSE, who were

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prepared for the summer fire season but now had limited fire risk to deal with. CFA brigades and dedicated volunteers in many small communities worked beside VICSES volunteers, and in many cases on their own where VICSES had no presence, to conduct rescues, assist in moving furniture, lay sandbags and provide community information. CFA crews, while supporting their local communities, also played a major role in clean-up activities; this became a major role for CFA where they organised crews to travel to several locations around the state, fully self-contained, to work with local communities in assisting property owners to start the initial and heartbreaking task of cleaning mud, slush, and damaged and destroyed possessions from their home. It was ironic that the water used by brigades in the clean-up was in abundant supply, yet 12 months earlier was a precious commodity even for firefighting. I have often heard people say they would rather have their home destroyed by fire than flooded, as with a fire everything is gone but with a flood you are left with an enormous mess to clean and you can still see all of your prized possessions lying there ruined. DSE had a full complement of seasonal firefighters across the state and they too were not busy fighting fires, so they were an excellent resource that was able to support operations on the ground, laying sandbags and working around levees. DSE seasonal firefighters are required to undergo rigorous fitness testing and most of them are young and very fit, so they were a great resource to maintain the pace and stamina required when laying down large areas of sandbags. There were many images of green-clad DSE firefighters working beside CFA in yellow and VICSES in orange with hundreds of community members forming armies to lay sandbags in an effort to hold back water from homes, key access roads and other important community infrastructure. For example, DSE firefighters were at the frontline supporting VICSES and community members in laying sandbags to close gaps in levy systems around townships such as Kerang. MFB provided staff for frontline roles such as flood rescue; I recall some of their members being deployed to rural communities in Victoria and enjoyed hearing some of the stories of their crews’ actions and how grateful communities were to see them in their hour of need. The Australian Defence Force (ADF) was also a valuable source of support during the floods. While some time was taken to establish the requirements of ADF assistance and have this approved, when it arrived it was fully equipped with appropriate equipment and suitable vehicles for the flood environment. The ADF deployed its own command structure, which operated consistently with command and control principles set out in the state arrangements. On the ground VICSES received excellent support from Victoria Police, Parks Victoria, CMAs, Melbourne Water, local government authorities, Office of Water, Ambulance Victoria, the State Aircraft Unit and the Emergency Services

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Telecommunication Authority. Interstate assistance was also provided by the New South Wales, South Australian and Tasmania State Emergency Services. VICSES also received valuable assistance from all levels of government including the Premier and Ministers, Bureau of Meteorology, the Emergency Services Commissioner and the Fire Services Commissioner. The State Emergency Management Team (SEMT), bringing together the emergency response agencies and government departments, was a key group whose members met on a daily basis during the height of the flood crisis. The SEMT was key to ensuring that the broader consequences of the flood were discussed and understood. Although there were some challenging scenarios, the SEMT was able to work through many issues that could not be solved locally and needed the support of the state to get the right people involved, especially those that had the ability to make things happen. At Mildura we had very limited command and control presence and when a large area of irrigated farms were saturated in water that would just not move away, a team of senior personnel from several organisations within the SEMT flew to Mildura to support the locals. There they were able to cut through red tape and secure resources to commence a major pumping operation to move water away from areas deemed to be a priority on the basis of reducing community consequences. It was agreed that a major priority was to regain some road access to allow local producers to move their produce. The scale of the 2011 floods stretched VICSES’s capacity beyond its abilities. In order to support VICSES with incident management staff, VICSES had to register all other agency employees as VICSES volunteers to meet the legislative requirements to allow any CFA or DSE Incident Controllers to assume control of an incident and the Incident Management Team. You can imagine how this made us feel as we worked through the process of sending documentation to every person that was likely to assist us and asking them to sign up as a VICSES volunteer. We didn’t even issue them with orange overalls, although many jokingly requested a pair and many, still to this day, ask me where their overalls are. Fortunately, in 2013 the VICSES legislation was changed to allow the Chief Officer Operations to appoint members of other organisations to command and control roles in support of emergencies for which VICSES is the control agency. This is a far more satisfactory arrangement and it seems surreal that we had to work through such a convoluted and difficult process at a time when we were really ‘up against it’. I am grateful for the support and cooperation provided by CFA Chief Officer Euan Ferguson, DSE Chief Fire Officer Ewan Waller and MFB Chief Fire Officer Shane Wright, who were very supportive throughout the whole flood emergency. Communication between control centres and support agencies tended to be paper-based or, if electronic, via in-house email systems to personal accounts

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rather than function-based accounts. Communication between Control Centres and VICSES units frequently failed. VICSES attempted to use its internal information communications technology (ICT) systems, but once staff moved to an Incident Control facility their ICT connectivity failed and they were unable to access the support information, policy, other documents and general information held on VICSES internal systems. Without access to VICSES ICT, staff were forced to use their host agency’s ICT, which had functionality and interoperability restrictions. Communication from unit to Divisional Command and to ICC and state tiers of command and control had to occur using two or three different agency systems and applications. This became a major impediment when requesting resources. The VICSES operational information management system (OIMS) was not compatible with CFA and DSE operational response systems. OIMS was a relatively recent addition to VICSES’s ICT and sufficient for normal operations, but it became clear it had serious shortcomings during the major floods. At the time of the floods there was no single multi-agency incident management ICT platform available for agencies to use, and information within the VICSES OIMS platform was not accessible in multiple locations to multiple agencies to support multiagency operations and effort. I resigned myself to the fact that we would just have to make do with the systems we had and work around obstacles during the floods in the hope of the subsequent learning, demonstrating the real need to invest in better systems. Thankfully, I can say we are in a much better position today and one of the key actions in the Emergency Management Strategic Action Plan for the newly formed Emergency Management Victoria (EMV) is to implement the first stage of a common operating system.

Community information and warnings A lot of work was undertaken to build the profile of VICSES once it was created as a statutory authority. The aim was to ensure that the hard work undertaken by volunteers was given a higher level of visibility in the community and that the VICSES brand was recognised as a professional and reliable service. Volunteers were provided with training and empowered to act and talk to the media at the local level. This created an opportunity in many instances to provide timely information backed up by local knowledge about a current situation or event. Following Black Saturday, we were keenly aware of our obligation to ensure community members had timely, relevant and accurate information on which to base their decisions. VICSES, with the support of the other agencies, worked hard to try and maintain situational awareness and service the needs of multiple communities that were seeking information about the floods. At the local level, VICSES set up and arranged community meetings where we endeavoured to provide information about the flood situation, answer questions

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about the availability of sandbags and give the community members advice on what they should do to prepare their property. In some circumstances people were advised to evacuate their properties. What we did not do well, in some instances, was to have a local trusted face standing in front of the community. In some cases we missed the opportunity to gather information from the community that might have assisted our decisionmaking. At the time of the 2011 floods, VICSES only had three Community Education Coordinators on staff so, where possible, trained CFA and DSE members were enlisted to assist VICSES. It was evident that communities that were well prepared were better able to put in place mitigation strategies to minimise property damage. During September 2010 this was the case for the communities of Benalla and Shepparton. In January 2011, the communities of Horsham and Warracknabeal had in place flood plans that were underpinned by good intelligence and community awareness via VICSES FloodSafe programs. In the immediate lead-up to the flood event, feedback to VICSES personnel indicated that the communication of information to the public was much better than anything we had previously achieved. A key feature in managing the 2011 floods was the availability of technology to communicate with communities and, for the first time, external websites and social media such as Facebook and Twitter were used. There was a strong, proactive media campaign providing advice to the community about preparations for the flood and information was provided through the Flood and Storm Info Line: 1300 VICSES (1300 842 737). Regular flood bulletins were issued to communities, community newsletters were translated into several languages, extensive local doorknocking was undertaken and variable message signs were used on major roads. The Flood and Storm Information Line took 16 800 calls until 24 February 2011. In excess of 100 community meetings were held, attracting more than 15 000 people. For the first time some of these meetings were broadcast live, over radio stations that covered the target area as well as being uploaded to the VICSES website. Daily media conferences were conducted on radio and television at state and local levels and advertisements were taken out in major city and local newspapers, including some in New South Wales. The Emergency Management Joint Public Information Committee (EMJPIC) was utilised to ensure all government agencies were delivering the same messages, and regular briefings were arranged for media partners and emergency broadcasters. The emergency broadcasters did their part, working cooperatively with VICSES and other emergency services to ensure that communities had information available around the clock. As the flood situation worsened in January, then-Premier Ted Baillieu and Minister for Police and Emergency Services Peter Ryan kept in close contact with

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the SCC and were briefed on the situation regularly. Daily afternoon media conferences were conducted to keep the public informed about what was happening and what we expected to happen. Both the Premier and the Minister were incredibly supportive, taking the time to be briefed, to understand the situation and then to deliver those important safety messages to the community. The Premier was particularly good at asking the detailed and often difficult-toanswer questions. I knew he wanted to make sure he really did understand the situation to ensure government was providing the right support to the community. The Victorian Bushfires Royal Commission had identified the importance of providing warnings and information to the community, so it was a clear expectation of mine that Incident Controllers would be proactive on that front. Arrangements had been made to issue emergency warnings via the Emergency Alert (EA) system to landlines and mobiles. This was done fairly successfully during the floods, delivering 76 campaigns with voice messages to 61 200 landlines and short message service (SMS) messages to 80 600 mobile telephones. It is fair to say that we were still feeling our way with the EA system and we certainly did not have a strong understanding of community expectations around the use of EA. Operational volunteers and other agency personnel were at times critical when they were not informed of EA messages before they were sent to the public, as this left them unable to respond to community questions asked immediately afterwards. On many occasions responding personnel became aware of the alert over their personal mobile telephones. The use of EA messaging for non-emergency information, such as notification of community meetings, was a subject of debate within VICSES and partner agencies. Many believed the use of EA for routine messaging such as this would devalue its emergency status. Feedback was also provided about community expectations of receiving EAs. Indications were that some community members regarded EAs as the primary authoritative information and warning source to be noted and acted on ahead, in preference to other forms of communication. There was a reported incident in a country town where a policeman was doorknocking residents to inform them to prepare to be evacuated, only to be told they would wait until they received an EA.

Flood intelligence In August 2010 Victoria experienced significant riverine flooding and flash flooding, following the first prolonged, heavy rainfall for many years. During that flood, VICSES was able to engage flood experts to support incident management teams, following the establishment of arrangements initiated by VICSES Director of Emergency Management Planning Andrew Gissing. Andrew, who had a wealth of flood knowledge on flood management, joined VICSES in early 2009 after a successful period with New South Wales SES where he had

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gained a lot of valuable experience heading up the flood planning capability under the guidance of Steve Opper. For the first time VICSES was able to contract expert knowledge into the incident planning area to support prediction on likely flood impacts. Experience proved, however, that there was also a need to validate the predictions with local knowledge. Several areas were hit hard by flash flooding; this is always difficult to predict, as it occurs with little warning and causes rapid and often short-lived inundation and damage. Flash flooding occurred in many relatively new housing developments where residents were caught unaware that they were living in an area that could be subject to flooding after a period of intense, heavy rainfall. Many of these housing developments were in the growth corridors around Melbourne, so while many regional and rural communities were undergoing an agonising wait for riverine flood waters to make their way down the river system, others had no time to contemplate what was happening to them. A major challenge during the flood response came in obtaining accurate information about the flood conditions. While we had access to flood consultants from both the private and public sectors, we did not really have access to enough experts to cover all of the requirements for state and ICC needs. We also had very limited flood mapping data apart from access to some 1:100 year flood extents. In many instances this historical flood data was exceeded by the behaviour of the 2011 record floods, so it would have let us down anyway. The 2012 parliamentary inquiry into flood mitigation infrastructure in Victoria by the Environment and Natural Resources Committee (ENRC) (Parliament of Victoria 2012) stated that, in relation to flood monitoring infrastructure, the effectiveness of flood warnings is reduced if there are insufficient river and rain gauges or if they cannot be monitored during a flood. In several instances there were insufficient gauges and, on a couple of occasions, flood monitoring gauges were washed away. The ENRC recommended improvements to the flood gauge network, including cost-sharing arrangements and that the knowledge of local people, including flood wardens, be better utilised to read river gauges and predict flood heights and impacts.

Flood levees During the course of the floods there were many challenging moments when individuals threatened to tear open levees to try to get the water away from their properties. There were many instances where levees were constructed by individuals to protect their properties without regard for the potential impacts on other properties in the area. There were also occasions when Incident Controllers contemplated the opening of levees to divert the flow of water to areas where the community impact would be minimal compared with the alternative.

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In one instance the Incident Controller was trying to breach a levee to help divert the flow of water into lower value grazing land, away from more valuable horticultural land, which may have sustained long-term impacts. The property owner was not happy to have the levee breached so the police were enlisted to try to get the landowner to change his mind. At one stage there were lengthy discussions late into the night to look at options to deal with the situation, including using other agency legislation. Fortunately, the next morning another visit to the property by local police in a helicopter managed to convince the owner to change his mind and approval was given to breach the levee. There were many situations where tense, lengthy negotiations were led by Incident Controllers to get landowners to cooperate for the greater good of the broader community. In most instances, commonsense prevailed, but it was unfortunate that valuable time and scarce energy was taken up arguing and negotiating with people when we could ill afford to divert resources to this task. The ENRC inquiry noted that when floods are slowly approaching, individuals in communities often become anxious about prevention or mitigation arrangements. During the January and February 2011 floods some individuals put in place mitigation strategies that were designed to meet local needs but which could have had unfortunate consequences for other communities. Under the pressure of imminent flooding, individuals also built or breached levees without consideration of planning regulations and without consideration of the effect their actions would have on other individuals or communities. Such unplanned action had the potential to negate mitigation strategies already initiated or cause unnecessary flooding to other individuals and communities. Where such action was taken, as it was on several occasions, the Flood Incident Controller had no legislative authority to make directions to ensure the safety of individuals or prevent unnecessary inundation in other areas. Additionally, there was no power for VICSES members to enter private property to take action to prevent damage or assist in flood response, causing significant frustration. I am pleased to say that in August 2015 the State Government introduced a bill to State Parliament that proposes to give VICSES and Incident Controllers the power to enter property and construct, alter or remove a levee in emergency situations without the consent of landowners. The application of these proposed new powers will require careful guidance and planning by Incident Management Teams. The maintenance and ownership of levees has been largely unaddressed since the early part of the last century. In a 2013 presentation to the Floodplain Management Conference, Mike Edwards from the DSE gave an overview of the parliamentary inquiry into flood mitigation infrastructure in Victoria by the ENRC (Edwards 2013). Mike highlighted that there are an estimated 4000 km of urban and rural levees in Victoria, about 98 of which are rural levees. Approximately 80% of these have been privately constructed, to protect either individual properties or several farms. The remaining rural levees were

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constructed with some government involvement, mostly 60 to 100 years ago. The rural levees are located on both private and public land and are often on the natural river bank, which severely confines the passage of floodwaters and increases the likelihood of failure. The report also noted that these rural levees have not been regularly maintained, although some have been repaired after major floods. Several urban levees were constructed before 1980 and the standards and management obligations for these older levees are unknown. Other urban levees were built by local government authorities after 1980, to reasonable standards, often as approved schemes under the Water Act 1989. The cost of design and construction was substantially subsidised by state and federal governments in return for the local government agency agreeing to manage the levee. Prior to the 2011 floods there was an identified lack of direction on roles and responsibilities for the management of levees. The following issues were noted in the ENRC report: • Where a levee system straddles public and private land it is difficult to create a consistent and equitable system for managing the levee. • Many rural levees were partially funded by or constructed by authorities or agencies that no longer exist. • There are situations in which landowners are legally prevented from entering public land on which a levee is situated, in order to repair it. • There are also situations in which emergency management agencies have been impeded when entering private land to repair or cut a levee to alleviate flooding. This proved to be a source of distraction on more than one occasion during the floods. I quickly learnt that the community does not understand that even if a levee is well maintained it can still fail. I was disappointed by the low level of community members (as low as 10%) who elected to evacuate their properties when we advised them to do so. Many in the community seemed content to stay in their homes and accept the risk of a levee overtopping or failure, even though such an occurrence had the potential to flood their homes or leave them isolated, without access to essential services. Over time, we will need to work with local communities in high flood risk areas and educate them about the limitations and vulnerabilities associated with levees, as well as weighing up their options, which may include the risk of isolation and loss of essential services if they choose to remain at their properties. This needs to be given the same priority as our efforts in the development of evacuation plans. The lack of guidance on managing levees, before, during and after a flood event extended to an absence of published criteria for assessing the ongoing viability of ad hoc temporary levees constructed immediately before a flood.

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The 2012 report by the ENRC review into flood mitigation infrastructure in Victoria made 20 recommendations in relation to levees, including: • Consider using temporary levees as an alternative to permanent structures and consider sharing temporary levees across different areas. • Develop guidelines for the management of levees in emergencies, including criteria for assessing the ongoing viability of ad hoc levees constructed shortly before a flood. • Examine more effective means for local government to remove illegal levees.

Flood evacuation The subject of evacuation has generated much debate in the fire and flood response professions and at times in the past there has been some reluctance to use the ‘E word’, with ‘relocation’ being the preferred term. In fire situations, previous policy focused on ‘stay or go’ messaging. In more recent years the term ‘shelter in place or shelter at home’ has become a popular way to provide guidance to the community during emergencies, although community understanding of what this means may not be widespread. Only in the last couple of years in Victoria has greater attention been placed on the development of robust evacuation plans that consider modelling for warning and movement of the community. Exercises have even been held in some communities based on fire scenarios. Evacuation is an important strategy to protect communities during floods; however, it requires careful and effective planning, including modelling the evacuation time frames. The evacuation process requires effective consideration and management of the decision, warning, withdrawal and return phases. During the 2011 floods, several communities were asked to evacuate. In some instances this was done with limited planning time; however, with the support and assistance of Victoria Police, where residents chose to evacuate, this was done safely and without incident. New South Wales SES also assisted with evacuation planning for towns in the Swan Hill area. Effective evacuation requires solid, integrated planning and community engagement, well in advance of any emergency.

VICSES profile and community expectations Building the VICSES community profile following the creation of VICSES as a statutory authority was seen as a means of supporting community engagement initiatives. Unfortunately, during the 2011 floods, many local communities did not see VICSES volunteers, as they were prevented from travelling to neighbouring communities because of floodwaters. Unlike fire situations, flooding can severely restrict the movement of response agencies for long periods of time and this is not well understood or accepted by the community. Unlike VICSES, CFA brigades have a large footprint across the state with over 1200 brigades (and 59 000

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volunteers) scattered throughout most small communities and settlements. VICSES has a presence which is based on 143 units with 5000 volunteers in metropolitan Melbourne, outer suburban municipalities, regional centres and small townships from where it is able to service outlying communities for the majority of requests for assistance. These units are also supported by 10 regional units and a State Support Unit who assist staff with operational readiness and command and control activities. It is fair to say the community would have had some significant expectations of VICSES and our ability to respond to flood emergencies by 2011, given the positive effect of profile building. The community had an expectation VICSES had a capacity to respond to and deal with the significant flooding that affected over 35 municipalities and 140 townships across many communities throughout Victoria. In many locations VICSES units did the best they could to assist the community with sandbagging and conducting flood rescues where boats were able to operate safely and effectively. CFA brigades in many areas also assisted with sandbagging and conducting rescues in their high clearance fire trucks. There were some communities where VICSES was not able to provide early warning and this was particularly difficult for local VICSES units who incurred the ire of locals who blamed them for failing to warn them of the approaching floodwaters and for not doing enough to protect their properties from floodwaters. This has taken a heavy toll on many VICSES volunteers who have had to work hard in several communities to win back community confidence. It seems very unfair that community volunteers can be given such a hard time by others in the community when they work so hard all year round to protect their neighbours and answer their calls for help. It is especially hard when friends and acquaintances are involved. In true volunteer spirit, however, many units have been very proactive in establishing and supporting community engagement programs to assist communities to understand their flood risk and to educate them about the things they can do to minimise losses during flood events In 2014 I had the opportunity to listen to Lyn Symons from the Carisbrook Flood Recovery Group. Lyn reflected on the initial community reactions and associated emotion that occurred after a large number of properties were flooded in Carisbrook. The VICSES members who were based in the neighbouring town of Maryborough bore the brunt of some community anger at the time of the floods. Similar community sentiment was directed towards the local VICSES unit at Rochester, which was also severely affected during the floods. Over the past five years, however, a lot of work has been done involving VICSES and others to support the flood recovery group. Lyn Symons is a great example of a local community leader who has emerged in a time of crisis to support her community to recover. She talked about how the community now has a better understanding of VICSES’s capability and what we will not be able to

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manage. Local flood planning will now ensure that other local agencies such as CFA have clearly defined roles and accountabilities, and that education programs are delivered to the community based on needs identified by community leaders from the flood recovery group.

Property protection and community expectations The allocation of sandbags became an issue in most areas where flooding occurred. Sandbags were at times difficult to source because of floods occurring simultaneously in other parts of Victoria and Australia, but supply was maintained overall. At the time of the 2011 floods VICSES had policies and procedures for filling and placing sandbags, but did not have policies and procedures for the distribution of sandbags. VICSES’s policy provided some guidance for properties under threat; however, whether or not a property was under threat was a subjective judgement for residents and business owners. For some community members the acquisition of sandbags provided psychological support even though the available flood intelligence indicated their properties would not be flooded. The desire to acquire sandbags often overrode reason, and at times community members became verbally aggressive towards VICSES members and council staff assisting in the distribution of sandbags. The unnecessary use of sandbags caused problems when people who needed sandbags later into the event were having their access to sandbags correctly monitored and limited, while they could see properties on high ground well outside any flood prediction areas securely sandbagged. Additionally, some community members sourced their sandbags from private enterprises, further adding to the frustration of community members in real need of them. VICSES members noted that the method of construction of some sandbag barriers by community members provided limited or no protection from rising waters. VICSES has since produced a flyer and YouTube clip to show individuals how to correctly erect sandbag barriers if they are unable to access VICSES assistance. VICSES developed a policy for the provision and distribution of sandbags after the 2011 floods. Unfortunately several local government councils were unhappy with the policy and the accountabilities it assigned to them. They were also not happy with the limited consultation undertaken so we had to backtrack and make sure we engaged more widely. In 2014 we worked with the Municipal Association of Victoria and local councils to develop some guidelines we are all comfortable with. Over time, these principles will be incorporated into local flood planning.

Community impacts and recovery As a result of the 2011 floods, many people had their belongings ruined and, in some cases, their homes were damaged almost beyond repair. Many livelihoods were badly disrupted and will take years to recover. In some communities, the loss

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of key community facilities such as the local hospital had a big impact with some elderly residents having to move away to other towns, causing stress and dislocation. For some, the suffering still continues with post-traumatic stress and just trying to cope with daily life. Some communities with the support of state and local government have rallied well, with local flood action groups forming to work with government agencies on recovery programs and to develop flood mitigation strategies for their local communities. Natural community leaders have emerged and worked positively to represent their communities. This has required strength of character and the ability to separate emotional responses from the rational arguments and assessments that need to be made in support of affirmative action to address flood risk and to identify mitigation options. While engineering solutions will always be a popular and natural choice for people to make, it is extremely important that the emergency management sector and the broader areas of government are able to develop, support and contribute to the community resilience through effective engagement and the delivery of education programs, preparation of local flood guides and personal emergency plans.

Lessons learnt The Victorian Floods Review The key lessons learnt from the Victorian floods in 2011 were essentially captured amongst the 90 recommendations made by Mr Neil Comrie AO, APM in the report of the Victorian Floods Review 2010–11 (VFR). The terms of reference were broadly to review the adequacy of flood information from predictions through to warnings and the actions of emergency services and government throughout the event. The VFR made recommendations within key themes as follows: • • • • • • • •

the adequacy of flood predictions and modelling the timeliness and effectiveness of warnings and public information emergency services command and control arrangements the adequacy of evacuations of people most at risk, including those in health and aged care facilities the adequacy of clean-up and recovery arrangements the adequacy of service delivery by federal, state and local governments the adequacy of funding provided by state and federal governments for emergency grants community resilience. My assessment of the key lessons learnt from the 2011 floods were:

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• No single agency has the capability and capacity to sustain a response to manage large-scale emergencies on its own. • Communities who are given good information can make informed decisions about their safety and welfare, but success is improved if they have been provided with underpinning knowledge and education. • More investment in community engagement was required. • The arrangements for collecting reliable flood intelligence across the state were inadequate: ➤ in some places due to lack of flood monitoring infrastructure ➤ due to lack of processes and skills to capture and communicate various sources of information. • There was an opportunity to improve the effective integration of flood specialists into the Incident Management Teams. • The process for dissemination of flood warnings and community information needed improvement, including increased focus on the use of social media. • An all hazards, all agencies approach to incident management was required, including the development of multi-agency Incident Management Teams. • There was an opportunity to improve the effectiveness of emergency management teams. • Changes and improvements to the state coordination arrangements were required. • There was a need to clarify the arrangements and responsibilities for water rescue. • There was an opportunity to improve the evacuation planning and execution process with a focus on vulnerable people. • Improvements were required to the impact assessment process, and clarification of accountabilities for community clean-up and recovery were required. Many lessons were learnt from the 2011 floods and the VFR captured many of these. The Victorian Government subsequently looked at recommendations from the VFR and the Bushfires Royal Commission to chart the course for a major reform of the Victorian emergency management arrangements. In contrast to aspects of the Royal Commission into the 2009 bushfires, the VFR focused on looking at the systems and processes in play leading up to and during the floods; this proved to be a very effective way to identify critical shortcomings and opportunities for improvement. Importantly, the review looked at the emergency management arrangements and not just the performance of individuals and agencies. In the end, the review led to wide-ranging recommendations about improvements required for flood warning and mitigation and for the incident management arrangements to ensure that the collective

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resources of emergency management organisations across the state could be effectively employed to assist the community to prepare for, respond to and recover from emergencies.

Progress since the 2011 floods Community engagement and resilience Since the floods, the State Government has provided funding to VICSES for the employment of community engagement coordinators who have started working with councils and community groups to establish education programs. They are working to change the community’s behaviour towards flood and get their acceptance in understanding their own flood risk and taking personal responsibility for planning and preventative actions to minimise the impact of flood on their families and properties. VICSES was also funded by government to support the development of flood emergency plans and local flood guides. Funding was also provided to employ Operations Managers in the regions, but before this initiative VICSES had very limited capacity to work with councils and develop Municipal Flood Emergency Plans (MFEPs). For many years CFA legislation has required local councils to develop a municipal fire prevention plan, but there is no such legislation to require councils to prepare an MFEP. VICSES has strong support from councils to develop MFEPs and good progress has been made. Numerous communities now have their own local flood guide, which contains valuable information on flood history for the area and guidance on what can be done to prepare for floods and how to minimise property damage. Flood planning and intelligence VICSES is in the process of producing MFEPs in 74 municipalities and has delivered local flood guides to 50 communities in high flood risk locations. These resources will be refined and their number added to as they are included in operational procedures, addressing issues such as each agency’s responsibilities. For example, in many locations CFA brigades will provide the first local response to floods as VICSES units will be cut off by floodwaters and not able to access these locations. In surge events such as the 2011 floods, no single agency has the capacity and capability to deal with the demands placed upon it. VICSES has led the development of municipal flood emergency plans across the state, working closely with local government, DELWP, CMAs and other key stakeholders. Local flood guides now form a solid basis to underpin the ongoing improvement to flood intelligence cards for high risk locations. DELWP is also leading the development of the Flood Zoom platform that will provide access to historical flood data with the added benefit of real-time modelling to support intelligence and decision-making.

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The Bureau of Meteorology has also commenced a program to upgrade and expand the flood gauging network on some of Victoria’s river systems; this will improve the early warning capability for authorities to prepare more timely and accurate flood warnings for the community. VICSES continues to work closely with the Bureau of Meteorology to develop weekly briefing products and other tools to support our flood readiness planning. The presence of a severe weather forecaster at the SCC for severe weather events is of particular value. Emergency management arrangements The Bushfires Royal Commission, the VFR and the subsequent white paper on emergency management reforms in Victoria have resulted in the most significant change to the emergency management arrangements in over 30 years. EMV has been formed to oversee the state’s emergency management arrangements. Emergency, fire, relief and recovery agencies have all been brought together under one umbrella for emergency management. This will promote and support end-to-end delivery of services to the community, including resilience building, holistic planning, greater use of scarce resources and more effective preparedness, response and recovery. Our ability to think ahead and more broadly has been enhanced with the development and establishment of a Strategic Risk and Consequence Unit at the SCC. This unit brings together representatives from a range of agencies to develop seasonal outlooks and plans. It operates, before, during and after emergencies, to provide the Emergency Management Commissioner and Incident Controllers with advice to support strategic thinking and a more holistic approach to managing the consequences of events that have impacts on the community. I am confident the structural arrangements now in place, bringing VICSES together with the fire, relief and recovery agencies under the EMV umbrella, will strengthen our capability and ensure that we continue to develop common systems to support a unified and well-coordinated approach to emergencies that will continue to challenge us into the future.

Leadership reflections It is natural for any leader to reflect on their own performance and that of the team that they lead. I have reflected on what was done during the floods of 2011, knowing that it resulted in significant consequences, affecting the lives of many people. I am awe of the magnificent job done by hundreds of people during the flood response and supporting communities in recovery. It is particularly pleasing to see the way in which most people and organisations have positively embraced the need to change the way we do things.

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I have certainly learnt that it can be tough during periods when the community is being badly affected and there is a need to meet diverse and significant expectations; however, having faith in oneself and embracing the support offered by others goes a long way to navigating through some stressful and tiring situations. Recently I had the opportunity to attend a leadership program delivered by General (Ret) George W. Casey, Jr., former Chief of the United States Army. I attended with several senior leaders from the emergency management sector. I learnt that is important to be clear about what you are trying to manage and fix and that it is difficult to work in a volatile, uncertain, complex and ambiguous environment. The 2011 floods were somewhat like that, but the leadership program reminded me to have a Red Team, who are your group of critical friends that will be prepared to challenge you and make you feel uncomfortable, just to make sure that you think about all of the bad things that might happen. VICSES is a relatively small organisation by comparison with the other emergency services in Victoria, so it was important to be inclusive and make a commitment to work collaboratively with the other agencies, in particular CFA, DSE and MFB. This commitment and leadership needed to be demonstrated from the senior leaders and I feel that we did this well, although there were no doubt missed opportunities, some of which were related to the emergency management arrangements and a lack of maturity in our overall capability as a sector. Our relationship with the relief and recovery agencies grew enormously, and the willingness of many government agencies to come to the table at the SEMT level supported more holistic decision-making and collaboration. Communication is very important and I learnt that communicating from the political level through to the people on the ground requires different approaches for a variety of audiences. To do this well, the support and advice of others is critical in order to test assumptions and consider issues from a range of perspectives before communicating. Fire Services Commissioner Craig Lapsley was incredibly helpful in this area, having a strong knowledge of the emergency services sector and a wealth of experience in his former role as Director of Emergency Management at the Department of Human Services, who managed significant and complex recovery issues following the Black Saturday fires. The communities made it known whenever they were not happy about aspects of the response, such as the lack of VICSES presence, even though the fire agencies were present, or the support being provided from government. Every day there was a need to focus on community feedback and key messages to build and maintain community confidence. Regular and sometimes daily press conferences involving the Premier or Minister, along with other key agencies representatives, required careful preparation and coordination. So often in emergency management we continue to contemplate potential problems in a frame of reference that we are used to, rather than thinking about

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some of the worst possible things that could happen and how we might respond to those challenges. The 2011 floods broke several records and affected many communities that did not expect to be flooded based on historical records. Perhaps we should have been thinking beyond our normal boundaries more often. While riverine flooding is known to move slowly, allowing time to plan ahead, there are many other issues that need to be contemplated and some that may not be obvious until a crisis or problem arises. Staying ahead of the game is extremely important so scanning the horizon to identify emerging issues and risks is essential. There were times when this was done well during the floods and instances where this did not happen, largely due to lack of command and control presence and poor communication between all levels of the control structure. It was also important to remain agile, as situations would arise where the existing arrangements were inadequate or did not cater for the circumstances. The situation of residual floodwater around Mildura, cited earlier, is a good example of where minds came together collectively to develop a workable solution to deal with a complex problem that needed a flexible solution at the time. As a leader, success can only be achieved by working collaboratively and making sure that you encourage and support a strong team environment. When things aren’t going so well it is even more important to be supportive of your team. Being open and honest with people and maintaining a good sense of humour is something that I have always endeavoured to do and for me that certainly helped during the floods. In the lead-up to the VFR I was a bit apprehensive, particularly reflecting on how things had gone during the floods and the level of community criticism levelled at VICSES in some parts of the state. There were times when I felt we were unfairly criticised; however, I am grateful that the review took the opportunity to look at the emergency management arrangements more broadly and, while identifying opportunities for improvement inside VICSES, it was clear that our ability to manage floods of the scale we had experienced, and indeed any other large-scale emergency, would require better arrangements across the whole of government. It is abundantly clear to me that all agencies across the whole of government need to work as one for us to be successful in our efforts to keep the community safe, as we are faced with the impacts of climate change and what is certainly emerging as more frequent and severe natural hazard emergencies affecting the community. It is very satisfying to see the enormous improvement in the capability of VICSES and the emergency management sector generally in Victoria as we continue to shape the most significant change the sector has undergone in almost 30 years. For me the floods provided a steep learning curve and, although there were many challenges, frustrations and stressful periods during the event, the most

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gratifying aspect was the great amount of support offered and provided by many individuals and organisations.

Conclusion The 2011 Victorian floods were a difficult and taxing period for the community, emergency services and government agencies. The consequences are still being felt in some communities; however, the lessons learnt and subsequent actions to address opportunities for improvement have been a very positive step forward. The past two years have seen significant improvements in the arrangements to harness the collective capabilities of the community and government agencies, and this capability will continue to grow and improve over the next 10 years as we adapt to the ongoing environmental changes around us.

Acknowledgements I wish to thank Andrew Gissing from Risk Frontiers (former Director of Emergency Management Planning and Communications at VICSES) and Stefan Delatovic, Manager Emergency Management Communications at VICSES for their assistance.

References Comrie N (2011) Review of the 2010–11 Flood Warnings and Response. Victorian Government, Melbourne. Edwards M (2013) Resolving Problems with Flood Mitigation Infrastructure – Responding to Community Needs. Department of Sustainability and Environment, Melbourne, Victoria. Esplin B (2009) Review of the Gippsland Floods June/July 2007. Office of the Emergency Services Commissioner, Unpublished. Parliament of Victoria (2012) Inquiry into flood mitigation infrastructure in Victoria. Parliamentary paper No. 169. Environment and Natural Resources Committee, Parliament of Victoria, Melbourne.

9 Thinking differently, leading differently: lessons from the Canberra fires, 2003 Mark Crosweller AFSM Director General, Emergency Management Australia

Introduction 18 January 2003 is a date that will forever be etched in the memory of many Australians as one of the worst bushfire disasters in our more recent history, resulting in the deaths of four people, the destruction of 488 homes and economic costs worth hundreds of millions of dollars. The day will certainly remain with me for the rest of my life, not only for the events that I experienced on the day but what they taught me to prepare for more than 10 years since. But the Canberra bushfires were not unique. The truth is Australia has experienced severe to catastrophic natural disaster events for many millennia as recorded in our Indigenous history. Ironically they have become commonplace not only in our history, but in our music, art, literature and poetry. It is fair to say that

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there is hardly a long-term resident in Australia that does not have a story about a bushfire, flood, storm or cyclone. That has certainly been my experience over the past 30 years when listening to many communities tell their stories. The following reflections are a selection of thoughts and experiences I have gained over the past 30 years. I focus mainly on the Canberra firestorm of 2003 as an example of various issues the fire and emergency services industry and society in general have had to face, not only over the past 10 years but arguably since European settlement. Further, since fires are such common events in our landscape, this is at least a small contribution to the debate about how we might break the cycle of seeing our efforts as ‘failures’ and to cease pointing the ‘finger of blame’.

The years leading up We had only just emerged from a busy fire season in 2001–02 in New South Wales when we came to realise, around May 2002, that a potentially strong El Niño was forming. My recollection is of sitting down in August 2002 with the then Commissioner of the NSW Rural Fire Service and others in the Commissioner’s office at Rosehill in Sydney’s west to discuss the potential for the upcoming fire season, talking through all of the possible scenarios, which left us all with a mixture of feelings, none of which brought any sense of joy or relief. The fire season unfolded early and as intensely as predicted, and NSW moved into coordinated firefighting operations in September; these continued right up until a few days before Christmas Eve when a brief respite in the weather brought cooler and moister conditions. But the brief respite was exactly that – brief. By early January 2003, the hot, dry windy weather re-emerged and by 8 January both NSW and Victoria experienced literally hundreds of dry lightning strikes across the Great Dividing Range, starting many new fires, some of which were easily contained and, as history would later prove, some that were not, with devastating consequences.

18 January 2003 By Wednesday, 15 January 2003, the Operations section in NSW had serious concerns about the potential for all fires burning in the Brindabella Ranges to run into the suburbs of Canberra. The testimony of former Commissioner Phil Koperberg and others, as evidenced in the coronial inquiry report, The Canberra Firestorm – Inquests and Inquiry into Four Deaths and Four Fires between 8 and 18 January 2003, explains in detail the differing points of view leading up to that fateful day. It is safe to say that the concern and debate were not so much about whether the fires would run, but rather the extent to which they would affect the Canberra community and how much resource would be required to minimise such an impact. On the morning of Saturday 18 January 2003 at around 8.30 a.m., I responded to Canberra at the request of the Commissioner to assess the deteriorating situation

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and to ascertain whether I could influence the Australian Capital Territory authorities to deploy additional NSW resources into the ACT. The gravity of the situation was not lost on me and that sick feeling in the pit of my stomach arose as a reminder of its seriousness and the responsibility I was about to take on. As I approached Canberra, I witnessed the largest plume of smoke that I had seen in my then 20 years as a firefighter. It was beginning to form what we now understand and describe as a pyrocumulonimbus cloud above the fireground. The temperature was in the high 30s (°C), the winds strengthening from the north-west and relative humidity almost non-existent. I made my way into the then Emergency Services Bureau building in Curtin, Canberra and met up with NSW Rural Fire Service colleagues who introduced me to a senior officer. Our conversation was to become pivotal to a profound learning that I only came to fully appreciate many years later during a conversation with the then Chief Minister of the ACT Government upon my appointment as Commissioner of the ACT Emergency Services Agency (ESA). The Officer was a little surprised to see me as I had not been invited by the ACT, nor were they aware of my pending arrival, but nevertheless he walked me into the Incident Room and commenced a briefing. I noticed a map on the wall of the Incident Room and my first observation was that there was no fire plot showing the current or potential location of the fire. This was not necessarily unusual at that time as situational awareness was manually collated and often became out of date before you could put pen to paper. The industry was to learn bitter lessons about this shortcoming not only in 2003, but again in Victoria in 2009. After the Officer finished his brief I asked how long the western interface of Canberra was (roughly from Gungahlin to Tuggeranong) to which he replied ‘25 to 30 km’, and also how many fire appliances he had to protect the urban interface, to which he replied ‘nine stations managed by the ACT Fire Brigade who are available to respond to any structure fires that may occur’. When I asked what more resources were available, the Officer felt confronted and pointed out that, unlike in Sydney, there was no ridge top development but rather the suburbs were downhill from the fire, implying that the downward slope would slow up the spread of the fire. At this point, the tone for the rest of the conversation had been set. Despite the Officer advising that the degree of downhill slope was 2 to 5°, I knew full well that the fire would not respond to this amount of slope as one might normally expect; however, the Officer assured me that they had enough resources and did not require any more support from NSW. After he walked out of the room I stepped into the corridor, stopped and went as white as a ghost. A cold shiver ran through my body and I started sweating at the same time as well as feeling like I needed to throw up! Why? Because I doubted myself. I stood there and asked myself, ‘After 20 years of doing this, have I misread it all?’ The mental process was agonising and any sense of what I thought was

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confidence, knowledge, experience, whatever you want to call it, disappeared. I felt gutted. But then a very quiet but wise voice inside me made me realise that my assessment was correct! The experience was profound. Any sense of doubt disappeared but so did any sense of righteousness as I came to realise that, there I was, with no resources, no powers or authority, and no support from the jurisdiction in charge to do anything, yet I was faced with an unfolding situation of enormous magnitude. But while I did not have resources, powers, authority or support, what I did have was choice. I could choose to do nothing based on my ‘rational’ predicament, which would be entirely defendable in court, or I could do something which could land me in court! I chose the latter. Ethically, professionally and morally I couldn’t do nothing, despite all of the reasoning to the contrary. I stepped outside just as the smoke plume blocked out the sun across the entire region, turning day into night. I knew I needed to get to the local NSW Rural Fire Service Control Centre in Queanbeyan to release resources into Canberra but I had no idea how to get there. And as so often happens in life the right person turns up at the right time. One of my staff, who knew exactly how to get to Queanbeyan, walked around the corner. I rang the Sydney office, appraised Operations there of my thoughts and requested immediate resources as the incident was about to unfold in a spectacular way. Arriving at the Queanbeyan Fire Control Centre shortly thereafter, I raced in and asked to speak to the local Superintendent, who came out of the operations room looking somewhat preoccupied; I then requested he release his resources into Canberra. The Superintendent was under enormous pressure and was concerned that the fires would run through Canberra and out the other side and affect the NSW villages of Michelago and surrounding areas, which he had direct responsibility for protecting. I argued with him and said that we would worry about that when, and if, it happened but for now we needed to get whatever we had into Canberra. It was at this point that I experienced, for the second time in my life, a former Regimental Sergeant Major yelling at me at close range with the resultant effect of me being scared out of my skin: another defining moment of character building! For only the second time in my then 20-year career I exercised my seniority and directed the Superintendent to release his resources into Canberra and to his absolute credit he complied. Over the course of the next 24 hours I went directly to the urban–rural interface to witness firsthand what total devastation the fire had caused. The scene before me was unprecedented in my experience. I rang the then Commissioner and reported to him that, in my view, there must have been hundreds dead as the amount of property on fire, including houses, shops, service stations and other buildings, was at the time immeasurable.

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The rest of that week was spent securing the fireground and reassuring the community that there were now sufficient resources in town to deal with any further outbreak of fire. I spent much of my time speaking with survivors, listening to their stories and reassuring them that their actions were truly heroic and beneficial to many others around them. I came across three teenagers who were distraught and upset at not being able to save more homes. Between them, they had saved over 10 homes in the hours that followed the main fire front by putting out spot fires on structures and burning embers around their neighbour’s houses. They had worked throughout the night and were at the point of exhaustion when I came across them. After hearing their story I realised they needed validation that they had done as much as they could given the circumstances. I was able to offer them some relief and I suspect that the simple act of listening to them and validating their actions saved them 10 years of counselling! This experience, and many more like it in the aftermath of that fire, planted within me the importance of connection with the community both in the face of and in the aftermath of adversity. I came to realise that it was important to be connected to these people and to share in their grief and pain rather than distance ourselves. We had the ability to use our own experiences as firefighters to validate their actions. Most of them thought on some level that they had failed to do enough, that they should have done more, that somehow they had let others down. Over time I was to observe that this was a reaction not only from the community, but also from the firefighters and emergency workers themselves. History now records the full extent of the damage and impact. It also records the evidence given in numerous public inquiries where a mountain of testimony was presented from many people from different professional and personal perspectives. Following on from my personal experiences before, during and after the 2003 Canberra bushfires, including during my appointment as Commissioner of the ACT ESA as well as on other significant natural disaster events I also attended such as the 2009 Victorian bushfires, I came to realise three key points. First, we needed to change the way we were thinking about severe to catastrophic disasters; second, we needed to change the way we were thinking about risk; and, third, we needed to change the way we were leading the response to disasters.

Lessons learnt Changing the way we think about severe to catastrophic disasters The futility of blame The aftermath of the Canberra bushfires demonstrated our collective lack of appreciation of how catastrophic a fire could be, and what followed immediately is

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what follows after every other major natural disaster – the inevitable list of public inquiries. In the ACT this included a government review, a coronial inquiry and Supreme Court action. Despite how they might be viewed, inquiries are beneficial. There is clearly an expectation by the community that the causes of death and the fires need to be established, areas need to be identified for improvement, people and organisations need to be held to account, and lessons need to be learnt in order to minimise the effects of similar disasters into the future. Many people are aggrieved following a natural disaster and public inquiries are a way of assisting some to express their views and disappointments. Inquiries also highlight systemic failures, personal and professional limitations of individuals, limitations in public policy and planning, and underlying cultural tensions within and between organisations, both government and non-government, to name but a few issues. Public inquiries also tend to happen soon after the disaster, often driven by a broad community desire to get to the bottom of the perceived failures as soon as possible. They are also driven by a desire to put the disaster behind us as soon as we possibly can. But this need for expediency is often a limiting factor to establishing some of the more critical lessons that we need to learn, particularly when science is involved. While most inquiries often start out with the overarching premise of finding out what happened followed by identifying areas for learning and improvement, inevitably the evidence, the findings and the recommendations provide the basis for laying the blame on someone for letting things happen. While the inquiry itself may not initially seek to do that, the interpretation of the evidence, the adversarial nature of the arguments put before the inquiries, the cross-examination that follows and the commentary espoused in the media open up the opportunity for some people within emergency services, government or the community to point fingers of blame. But the question has to be asked, ‘Is blame useful?’ The veil of silence The potential for blame always invites defensiveness and what I found disturbing following the Canberra bushfires (and this happens after every major natural disaster) was what I call the ‘veil of silence’ that pervaded the industry. Many people principally driven by the fear of being blamed, along with all of its resultant effects, automatically assumed, and I am advised that some were directly counselled, not to speak publicly or privately about their experiences, observations, opinions or their learning, but to await the opportunity to give their evidence under legal guidance and then to further await the outcomes of the inquiries. However, in that intervening period, the absence of such dialogue more broadly unfortunately leads some in the industry and the wider community to make wildly false assumptions about what happened. It is often these wild assumptions that

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establish a ‘false truth’ and the basis for blame. Silence also perpetuates a level of ignorance about the facts of the event, often with devastating consequences. Suffice it to say, the emergency services and government’s inability to sufficiently warn people and communicate effectively during the 2003 Canberra bushfires was to play out again in 2009 in Victoria. Very little had been learnt or acted upon in those six years because, in my view, some people placed so much attention upon ‘who was to blame’ that any chance of learning critical lessons was drowned out by the arguments and counterarguments posed by both sides. Many people stayed right away from the debate and, subsequently, history would show that what was not learnt from the Canberra experience, particularly regarding warnings and communication, would need to be learnt even more bitterly from the Victorian experience. The propensity to blame by some people soon pervaded the emergency services, governments and the community, and the resultant experiences left many people bitter, defeated, angry and, some, outraged. While the reactions to the ‘blame game’ were perhaps understandable, they were clearly not useful. Blame will always overshadow any possibility of true learning as, in essence, it perpetuates the acts of censuring, holding responsible and making negative statements about an individual or group that their action or actions are socially or morally irresponsible. As a result, people get defensive, close down, become detached and distant, and avoid admitting any deep sense of contemplation and reflection that would otherwise lead to important and salient lessons – lessons that could fundamentally alter the outcomes of the next major disaster for the better. But on what basis do we judge others to be socially or morally irresponsible (or both)? If we had supreme knowledge of all of the complexities that natural disasters produce, both ahead of time and during their course, let alone the infinite complexities of the human psyche and how it prepares for, responds to and recovers from them, then perhaps, just perhaps, we might permit ourselves the higher moral ground and then cast our judgements. To think this was even possible demonstrates a level of both arrogance and ignorance, but it is these traits that unfortunately perpetuate blame. More specifically, did anyone, 10 days before, on 8 January 2003, genuinely foresee with acute accuracy the events of 18 January 2003, when the fires first started? I think not. Following the inquiries, I have heard many stories and spoken to many people about their recollection of events before and on that day, and clearly some people had justifiably grave concerns about its potential to cause significant death and destruction, but no one could have foreseen the range of terrain and weather interactions that combined to produce violent pyroconvection (resulting in a pyrocumulonimbus cloud that turned the ACT from day to night at 3.30 in

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the afternoon) and the ensuing fire behaviour (heavily influenced by dry air some kilometres above the ground), which included eruptive fire behaviour and fire channelling (which produced fire spread across slope as well as downwind), or the manifestation of a Fujita Level 2 tornado producing wind speeds in excess of 250 km/h propelling the fire and travelling through the populated suburbs of Chapman, Fisher and Kambah! They could not have foreseen it because these effects were not known until several years following the Canberra bushfires when science was allowed to come to the fore and explain what actually happened. In the absence of this knowledge, many people made an assumption that the Canberra bushfires were no more than another significant bushfire on a bad day. As highlighted by Rick McRae in his address at the 2011 Australasian Fire and Emergency Service Authorities Council Conference in Sydney (McRae 2011): This was largely premised on the fact that we had been conditioned to understand that, simply put, if you knew the terrain, the fuel and the surface weather, then the fire’s resulting behaviour could be reliably determined and occasionally we would encounter the odd circumstances in which the fires did unexpected things. That is to say, those events such as the Canberra fires were predictable, but from time to time there would be something erratic or unpredictable as well. For many years this approach had served us well and the same assumptions were made of these fires. The inquiries were certainly premised on this basis as was the view of the industry more broadly. Turning the finger of blame upon itself To put it bluntly, a lot of what we assume to be truth arises from a gross ignorance about the true complexity of events of this nature, not only in terms of fire science, but also in terms of the thought processes that were going on inside the minds of those called to lead and manage, to respond and suppress, and to confront and survive. Not long after I took up the appointment of Commissioner of the ACT ESA I was asked to brief the ACT Government on the remainder of the then current fire season. At the conclusion of the brief, the then Chief Minister relayed a story to me that has resonated every day since. It was the conversation that he had with the very same senior officer whom I had encountered on 18 January 2003. In summary, he said that the Officer in Charge had come to him a few months after the fires and told him that the fire went beyond his knowledge and anything that he had learnt throughout his firefighting career, beyond his skills and anything that he had acquired over that period, beyond his experience and

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anything that he had ever been through, and – this is what really got to him – it went beyond his imagination! He just couldn’t imagine the fire ever doing what it did. He knew it would run and run hard, but he never thought it would breach the boundaries of the forested areas and run so deep into the suburbs. What the Officer in Charge could never have possibly known or understood was the complexity that the fireground produced on that day. Did this make him faultless? No. None of us who hold positions of accountability ever have that privilege. In fact, I would argue that no one involved with the fire can ever claim that privilege. But what the Officer in Charge could claim is the same limitation that we all face every day in our lives: the events that go beyond our knowledge, skills, experience and imagination. Prior to and following the Canberra bushfires, the emergency management industry had let people down. And for that we must be held to account and learn from the experience. Neither not fully understanding the complex fire science that manifested that day nor accepting the limitations of knowledge, skills, experience and imagination excuses us from accountability. But it does turn the finger of blame upon itself. In my 30 years in emergency services and emergency management, most of the people that I have come across have always been driven by the primary motivation of doing the very best they could within the constraints of their internal and external resources. They were all limited to various degrees by their knowledge, skills, experience, imaginations and other mental factors as well as the limitations of the financial, physical and non-physical resources available to them at any given point in time. They all had much more to learn, acquire, experience and imagine, but what they did not need was a finger of blame pointing at them. There will always be differences between any two given people for any given event or circumstance in life; there will always be someone who can claim to know, acquire, experience and imagine more than another, but no one can ever know, acquire, experience or imagine it all (although some may think they can!). In my view, here lies one of the root causes of the problem that perpetuates a cycle of perceived failure and blame – arrogance and ignorance. Exploring the limiting effects of these traits on our individual and collective ability to prepare for, respond to and recover from disasters is not a moral judgement. We all have these traits and we all suffer from their limitations. My reflections on these experiences has taught me how unhelpful they really are and how much they prevent us from genuinely seeing a different perspective and finding a better solution, not to mention the damage they can cause to professional and personal relationships. But if we are able to shift our thinking in the way we prepare for, respond to and recover from disasters in order to change the outcome for the better, we must set aside any sense of arrogance and dispel as much ignorance as possible.

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The science that emerged from the Canberra bushfires clearly showed us collectively how ignorant we were of so many factors that were to have a significant effect on the fireground and subsequently the community on 18 January 2003. While the science certainly did not answer all of the questions, it did leave us wanting in the absence of its appreciation and understanding. Also, as discussed below, our capacity to constantly forecast or predict severe to catastrophic events, and then fail to act accordingly, epitomises our internal limitations of arrogance and ignorance and perpetuates the cycle of perceived failure and blame. Seeing the future and not acting on it In evidence tendered to the coronial inquiry in 2003 (Doogan 2006), a report written by Mr HR McBeth (McBeth 1994) was tabled, after he was asked to review hazard reduction processes in the ACT in 1994. In his report, Mr McBeth made the following observations: The ‘Bush Capital’ Canberra populace as a whole migrated to the Capital with its industry or enterprise base being predominantly Government Administration and Ancillary Services. The vast majority of these people came from other urban communities with no tradition, experience or understanding of living in the bush or with successive bushfires … Although major fire events swept across the ACT ‘Bush Capital’ in 1936 and again in 1952, Canberrans have not been subjected to the ravages and trauma of events like Hobart 1967, Ash Wednesday 1981 in South Australia; the deaths and mutilation of firefighters in the Royal National Park, Sydney 1983 or the 1983 Bushfire Disasters in Victoria and South Australia. Culturally, socially, politically and departmentally the ACT community is and has been lulled into a sense of false security with regard to the ravages of bushfire. He went on to say that: … it is inevitable that significant loss of assets will accrue together with loss of life during the next single, multiple or configuration fire event. The urban rural interface will obviously bear the brunt of such losses. He stresses that a set of climatic conditions will eventuate producing ‘fire weather’ conditions of such an intensity that such losses will occur: It is not if such a disaster will occur, but when. Further on in his report he cited a document written by Mr Phil Cheney who observed:

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The fundamental basis for disaster management, which includes bushfires in Australia, is to carry out an analysis of the worst case scenario. Our knowledge of worst case fire behaviour and fire weather is adequate to realistically put a worst case scenario to the people of the ACT and perhaps to estimate a frequency of occurrence and to estimate the damage which is done … My estimate is that a 1–50 year conflagration fire will burn a total of 60,000 hectares in 1 day and severely damage suburban dwellings where they are adjacent to forests, hill parks and nature reserves. Under this scenario the firefighting resources of the ACT will be totally overwhelmed. They will not have enough tankers or pumpers to attend every house threatened, and by and large destruction will be limited only by the action residents themselves take both before the fire occurs to reduce fuels around their homes and, during the fire to suppress embers and spot fires starting in their gardens and dwellings. (Cited in McBeth 1994) According to the evidence, the observations made by Mr McBeth and Mr Cheney were not disputed by the heads of the emergency services at the time of the report. History would show that, despite both predictions, according to the evidence too little was done by the government, the emergency services and the broader community in preparation for such an event and it was only after the tragic outcomes of 18 January 2003 that major reforms were put in place, according to some, to ensure that such an event could never happen in the ACT again (a promise that is impossible to keep). The predictions made by Mr McBeth and Mr Cheney would be of little surprise to fire and emergency services, and in themselves are not revelations. It would also be quite feasible to extend the thinking to any other area of Australia vulnerable to severe to catastrophic bushfire such as the Blue Mountains in NSW, the Dandenong Ranges in Victoria, and the Adelaide Hills or Mount Lofty Ranges in South Australia. There are also many other areas in Australia where these predictions would be equally applicable to other natural hazard types. What is more concerning, however, and which goes to the heart of the issue of resistance, is that the major reforms to prepare for, respond to and recover from such an event were all implemented after the event, not before it, despite general agreement that the scenarios were both realistic and probable.

Changing the way we think about residual risk Prior to the Canberra bushfires, and even today, we identify hazards, contemplate both their likelihood and consequences, and then decide how best to allocate limited and competing resources. This process is influenced by our ability to reasonably prevent, mitigate or ameliorate their effects – economically, socially, politically, technologically, legally and environmentally. It is eminently sensible to balance what is reasonably likely to occur, how much we are prepared to invest – money, time, resources and effort – and what level of

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residual consequence we are prepared to accept, provided that residual risks are properly understood. However, we tend to avoid any serious contemplation that severe to catastrophic events will actually occur, given their rarity. We also tend to develop false optimism; that is, if we implement all of the identified risk treatments for a particular hazard we will be okay. This is a reasonable assumption for low risk events, but for the more severe to catastrophic events, this is rarely true. Further, by focusing most on risk treatment and the resultant benefits, we often do not sufficiently acknowledge residual risk, and it is the residual risk resulting from a severe to catastrophic event that causes the greatest consequence to society. Severe to catastrophic disasters are generally viewed as the least likely but most consequential. This establishes a paradox and, at the same time, highlights a fundamental flaw in the way we have been thinking about risk; that is, ‘least likely’ implies not needing to spend too much time thinking about the problem, whereas ‘most consequential’ implies the exact opposite. However, we must remember that frequency has no bearing on the intensity of an event or its potential consequences. When an event occurs, its potential impact on society will manifest in both immediate and downstream consequences. The aforementioned evidence highlighted exactly this problem. While it is reasonable to limit investment in mitigation to the more likely events, these are also less consequential and if we do not turn our minds to understanding the full potential consequences of a severe to catastrophic event then we will be found wanting. The inevitability of natural disasters The Canberra bushfires highlighted the inevitability of severe to catastrophic natural disasters and our inability to truly come to terms with their presence across the Australian landscape. The Brindabella Ranges, for instance, have been sending fire, ignited by natural causes (lightning), to the NSW coast for tens if not hundreds of thousands of years, while it was only 100 years ago that we decided, again in ignorance of the full potential of the hazard, to locate a city at their foothills. The idea of inevitability was well and truly reinforced when visiting Marysville and Kinglake, some days after the tragic fires in Victoria of 7 February 2009. I stood in the middle of Marysville, surveyed the damage and total destruction of the township knowing how many people had perished, and asked myself, ‘How did we not see this coming?’ After I had driven through the remnants of a tall timbered forest accessed by a single road in and out of a township located close to the top of a ridge, scattered amongst a sea of trees embedded in a landscape that had been drought stressed for 10 years, and that had experienced fire weather conditions that went off any recognised scale of measurement, its vulnerability became so obvious yet appeared to be so ignored. I am not suggesting that nothing was done before the event, but I am suggesting that as a society we had not done enough.

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The reality is that severe to catastrophic natural disasters are inevitable in Australia. The only variables are ‘where’ and ‘when’, and on days when the landscape and atmospheric conditions fully manifest, it will not be a matter of ‘when’, just ‘where’. If we explore this notion a little further we come to find that whenever the right atmospheric and landscape conditions prevail: • a severe to catastrophic bushfire will go wherever it wants and burn for as long as it wants while there is sufficient fuel in its path • a cyclone will go wherever it wants, will generate wind as strong as it wants, and dump as much water as it wants for as long as it wants • a severe thunderstorm will form wherever it wants, will go wherever it wants, drop as much water as its wants, in a concentrated area of its choosing, and produce winds as strong as it wants. It is hard for us to hear and accept their inevitability because, in my view, as a nation we do not want them, but unfortunately we do not have that choice. Any community in Australia will have a natural hazard profile evidenced by history, observation and science – data telling us that a range of events has occurred, observing that they are happening now, as well as telling us that they will occur again. All natural disaster events are a result of immense climatic or geological energies involving earth, wind, fire and water. We have absolute control over none of these, but all of them are produced from highly complex natural systems and interactions between the climate, its resultant weather, the landscape, the manner in which we use the land, and the minds that we bring to these events before, during and after. While the frequencies and intensities of these events vary considerably, all events are part of a continuum within our environment. Predicting when they will reach a maximum potential remains an unknown, but averages of 50, 100 or even 10 000 years are frequently proffered. Nonetheless, at some point in the future when the right causes and conditions arise, major events will manifest and, when they do, we will have no choice but to confront them. Antecedent conditions leading up to these events (for natural hazards excluding earthquakes) are generally overt; there is little surprise in their arrival, but considerable complexity in their effects. Climate outlooks, weather forecasts, landscape conditions, land use and presenting conditions all narrate to us what is broadly about to happen. How this information translates into impact and consequence (immediate and downstream) minutiae is hard to foresee, but not impossible. Basically, these events are inevitable (with varying frequencies and intensities over time and varying impacts), beyond our ability to choose them, reasonably foreseeable in broad terms, infinitely complex and unpredictable in specific terms

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and, while we are unable to choose them, we do get choice in how we prepare for, respond to and recover from them. Shifting our thinking to accept inevitability simplifies our approach to the problem. We no longer need to weigh up whether or not we think a severe to catastrophic event will happen. We accept that it will at a time not of our choosing, and we avail ourselves the opportunity to rethink how we will prepare well before they occur. We have the opportunity to look at the whole problem ... not just the more likely problem. Then, methodically, we may work through how to find appropriate solutions. We must open a philosophical doorway to rationally and reasonably consider what an event might look like, and to properly consider not only what we might do when it occurs, but what we might do differently or, perhaps more importantly, we might choose to do nothing at all. If society as a whole truly accepted the inevitability of the event then we could have invested our resources more wisely in anticipation of it occurring and therefore could have better prepared ourselves mentally and physically for its eventuality. But, more importantly, by accepting that we do not get to choose these events, we would not have been so emotionally distressed by their impacts, which would have undoubtedly been less if we had prepared our minds for the events and initially invested in all or many of those initiatives that were put in place afterwards. We would have also recovered quicker, at least, emotionally. Shifting from blame to learning and improving The consequences of society resisting the inevitability of severe to catastrophic events such as those as we have seen play out in the last 12 years exposes at best a degree of naivety, and at worst a degree of arrogance and ignorance, of their full potential to adversely affect us; this subsequently limits our collective ability to effectively prepare for, respond to and recover from them. Furthermore, our resistance also limits our ability to fully learn from the experiences and to use our imaginations, creativity and innovation in preparation for the next inevitable event; and sadly, as mentioned earlier, it establishes the basis for a blame culture and perpetuates the cycle of perceived failure. As a community we do not like disruption and we want things to return to normal as soon as possible. The reality is that it is simply not possible to return to normal. Natural disasters, particularly the more severe ones, are transformational. Things change forever and it is not possible to go back to how things were. People, environments, economies and landscapes change. Often the greatest psychological impact on people is their resistance to this fact. They struggle for long periods, sometimes years, wishing for things to be other than the way they are. But if we help them understand inevitability and acceptance in a sensible and

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responsible manner, we may be able to alleviate some of the mental anguish that these transformational events cause. Acceptance does not mean that we have to like what happens, that we do not care about the impact, that we are not emotionally and physically affected, or that we are powerless to change the outcome. But it does mean that we fully accept that disasters will happen, thereby giving ourselves the power to individually and collectively choose how we will prepare for, respond to and recover from them. It is through both this acceptance and the power of choice that we will definitely change the outcomes for the betterment of all.

Changing the way we lead severe to catastrophic disasters After reflecting upon the realisation that severe to catastrophic disaster events were inevitable and that by coming to accept them there was an opportunity to shift from blaming to learning, improving and maturing, I came to realise that there were attributes of leadership within the emergency management sector that were not sufficiently understood nor expressed, and that could also contribute towards this shift. These attributes could be better described as ‘ethical premises’ – not viewed as moral judgements, but instead viewed as virtue, and virtue as excellence. Trust My personal experience on 18 January 2003 taught me to trust myself and over the years I came to realise how critically important trust is to all emergency managers and leaders. Despite the odds, the unfolding adversity, and what was presented before me that appeared to be defeating and the situation hopeless, I needed to trust what my intuition was telling me, to check that my deepest motivation had integrity and was ethical, and to have the confidence to act on it. Through reflection and contemplation I realised that the ability to trust myself in such a dire circumstance had always resided within me but, unless I went looking for it, it was never going to surface and I would have missed the opportunity to take away something positive from a situation that looked to be anything but. This lesson was to play out time and time again in the following years. There is no doubt that as emergency services, and more broadly as a community, we had much to learn from the Canberra bushfires. It would be easy to lay the responsibility for their outcome on the local jurisdictions and their leaders but in reality they were, to a greater or lesser degree, a reflection of where the broader industry was at the time. As an industry, we were not good at warnings, situational awareness, interjurisdictional relationships or planning for events of such magnitude. We were not well connected to our communities or to our executive governments. Our internal relationship between services was not as good as it could have been. Our knowledge of fire behaviour in such circumstances was lacking. As a broader

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community, we had also grown apathetic to the full potential of the magnitude of a bushfire that ranges, like the Brindabellas, were capable of producing. But, perhaps more fundamentally, as emergency services we had lost the trust and confidence of the people we were there to protect. They had put their trust in us, they had listened to our commentary and opinions, and they had taken our advice. Somewhere along the line, we got it wrong. Many people have heard me say over the years that ‘I am not interested in blame, but I am interested in accountability’, and to this day I stand by that statement. From time to time, I have been misquoted or misunderstood as purporting to interpret the futility of blame as a means of abrogating responsibility for those who were accountable, but nothing could be further from the truth. We are accountable. We seek accountability and we ask the community to trust us. Every police, fire and emergency service member in Australia, as in most other countries in the world, wears a uniform with a badge on each shoulder. When I ask members of the police, fire and emergency services what the badge symbolises, the usual response is a reflection of the culture of their organisation, a branding element that defines and distinguishes not only what they do, but also why they are different to other services and what it means to them personally. While these responses are not wrong, they miss the point as they tend to focus the intent towards the industry; as hard as it is to hear, we can be somewhat selfserving. I would strongly argue that if you put on a uniform with a badge on each shoulder that represents a police, fire and emergency service organisation in Australia, you are asking someone to trust you, both personally and organisationally. Uniforms are a strong symbol in any country. However, the meaning attached to the symbology varies across the world. In some countries if I were to put on a uniform and walk into a community, people would hand over money to avoid trouble and stay on side with the authorities. In other words, the uniform there is a symbol of corruption. If I were to go to another corner of the world and put on a uniform and walk into a community, the women and children would run for their lives and the men would take up arms. In other words, the uniform there is a symbol of death and destruction. However, in this country when we put on a uniform, we have the great privilege of assuming an automatic level of trust between those that we aim to serve and ourselves. This privilege extends both directly and indirectly. Even those within our services who do not wear a uniform are still trusted by the community by direct association with the uniform that represents their service. I have also often been asked what defines a successful operation. My answer is, ‘Maintain the trust and confidence of the community we serve before, during and after the adversity of disaster (and that includes natural and man-made disasters)’. While it sounds simple, the challenge is significant.

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Generally, we are very quick to place the burden of trust onto someone else but in reality it has to start with self. If you do not trust yourself and you do not have a personal and informed view of what trust looks like for you, then you will struggle to honour the code of a uniform. It is often said that trust is hard to win and easy to lose; this is very true. Trust is an attribute that underpins every relationship you will ever have in your life, whether personal or professional. If you do not value it, understand it, commit to it and improve upon it, then your relationships and your leadership will suffer. Trust is hard work. It forces us to maintain our integrity at all times. It insists that our words and our actions always align. It demands that we have sufficient humility to acknowledge when we are wrong or when we have wronged others, and to forgive ourselves or seek the forgiveness of others. It requires us to exercise the courage to speak to the truth of a matter regardless of the personal cost to our egos. It expects us to derive our thoughts, words and actions from a motivation for the benefit of others and insists that our agenda is clear, unambiguous and open for all to see. It accepts nothing less than exemplary behaviour towards others. It also expects us to constantly improve upon our knowledge, skills and experience of not only our professional expertise, but also of our sense of self and our ability to be a well-balanced, compassionate human being. It will hold us to account for our past, present and future results. It will insist that we utilise to the fullest and constantly improve upon all of the talents that are an inherent part of our true nature. Trust accepts nothing less. If we are serious about honouring the code of our uniforms, then we should accept nothing less of ourselves because that is what the community that we serve expects of us. The breach of trust between the emergency services, wider government and the residents cut deeply into the ACT community then, and the resulting loss of confidence and its effects still resonate today, more than 10 years after the event. A slow rebuilding of that trust is occurring and much has been done to re-establish it through post-fire reform initiatives arising principally from the various inquiries but, in reality, it will not be completely re-established until there is proof that the emergency services, wider government and the residents collectively do much better in preparing for, responding to and recovering from the next catastrophic bushfire, which itself is inevitable. Perhaps the greatest compliment I have ever been given in my 30 years of experience, and said to me in various ways more than once, was when a member of the community who had never met me but had often seen me on TV or heard me on the radio said, ‘Mark, every time I hear you speak, I feel safe.’ That one comment made every minute of my 30 years of learning and experiences (many of them hard and painful) worthwhile. When I asked her what she meant by that, she said, ‘You explain things to us. You treat us as equals, you are never patronising or

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condescending, and you take responsibility not only for yourself, but for your organisation. We trust you.’ Unity Severe to catastrophic natural disaster events are inevitable, immeasurably complex in their science (causes), behaviour (what they do) and impacts (who and what they effect and how). Accepting that we do not get to choose them, and understanding that we do have the individual and collective power and responsibility to choose how we prepare for, respond to and recover from them leads us to a natural conclusion that we need to come together as a society to deal with their effects. This may sound obvious, and on the surface one could argue that every state and territory in Australia, along with their respective local governments, private and not-for-profit sectors and broader communities, already have governance and other arrangements in place to create this environment. But are we truly unified? Do we truly accept inevitability and have we properly worked through all of the issues and come to an agreed position from the highest levels of government to the ‘end of the fire hose’ about how we will prepare for, respond to and recover from the effects of the severe to catastrophic events of the hazards relevant to our communities? Some say ‘yes’, but most say ‘no’. As emergency services leaders we are entrusted by our communities and governments to lead and manage through most of the worst natural and humanmade disasters that Australia has and will experience. The pressure on Commissioners, Chief Officers and other senior officers is significant and increasing every year. The expectations placed upon our leadership and advice to the community and government is higher than it has ever been and is increasing. These expectations demand that we bring together every aspect of government, the private and notfor-profit sectors and the wider community to prepare for, respond to and recover from major disasters. Historically, however, our ability to properly unify has been less than optimal and this has had a negative effect on our ability to lead and manage as well as maintain the trust and confidence of the public. Seeing ourselves as separate First, emergency services have not always seen themselves as part of government but rather as some form of independent entities, either formally as independent statutory authorities or informally as uniformed services. To be fair, sometimes government has not seen emergency services as part of them either. Approximately 10 to 15 years ago, most fire and emergency services agencies were either statutory authorities, or their Commissioners and Chief Officers were also Chief Executive Officers reporting directly to Ministers.

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Fast forward to 2015 and we find that, out of more than 30 fire and emergency service agencies in Australia, only the NSW and Western Australian agencies report directly to a Minister. The remainder report through much larger government bureaucracies and tend to find themselves in the middle to upper level management, and while we may have been integrated structurally, we are yet to sufficiently integrate culturally, although we are making inroads. The limitation of seeing ourselves as separate, or being seen as separate, is significant. While no one would argue against the fact that we are specialised in our level of capability and expertise to manage disaster events, there is a fine line between ‘specialised’ and ‘special and different’. We can and do bring a level of knowledge, skills, experience and expertise during these events and it is heavily relied on. But when we take those qualities and then seek to differentiate ourselves to the point of being special and different to others, through a subtle but pervasive arrogance within our cultures, we prevent ourselves from fully developing the level of unity that a severe to catastrophic disaster will demand of us – effectively setting ourselves up for a fall. Needing to save the day For many years we have also positioned ourselves as being able to save the day, largely because in most circumstances we can. Most incidents that we are called to attend and manage are within the capability of our external resources, which usually accord with our individual or collective, knowledge, skills, experience and imagination. It could be argued that we have almost become victims of our own success. We have been very successful in keeping the community safe in most circumstances; we have promoted this fact through our performance reporting and the community has believed us, particularly as the alternative is unacceptable to us all. Our point of limitation However, as we know, severe to catastrophic disasters highlight the fact that our external resources, such as fire trucks, flood boats, helicopters, and frontline personnel, are severely limited in their effectiveness by the scale and intensity of these events, and our own internal resources are severely tested as these events take us all beyond our individual and collective knowledge, skills, experience and imaginations. In other words, they take us beyond our ‘point of limitation’. Not understanding our limits often positions us for a fall as we have a propensity to set expectations that, either consciously or unconsciously, we are unable to meet. Often a breach of trust will result when someone sets an expectation and then does not deliver on it. It goes to the heart of integrity, making sure that we do what we say we are going to do. When we are unable to do what we promised or committed to, a breach of trust occurs and the relationship between ourselves and those we are called to serve and protect suffers.

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Being successful for most of the incidents that we attend and manage does not automatically translate to being successful in the face of catastrophe. The rules change. Nature exhibits such force and complexity that our point of limitation is soon exposed for all to see, and if we do not see it beforehand, nor understand it and admit to our own limitation and vulnerability, then the moment of humiliation soon arrives and, with it, the cycle of blame and failure. Recognising the need for unity I would argue that our propensity to see ourselves as separate from government, inadvertently promoting ourselves as being able to save the day, and not understanding our point of limitation have been three of our biggest constraints and the principle causes for the public criticisms levelled at us from successive inquiries, particularly since 2003. All three constraints have been underpinned by a subtle, and sometimes not so subtle, level of pervading arrogance and ignorance that have displayed themselves individually and collectively across the industry and more broadly across parts of government and the community. This is not a moral judgement but rather an identification of a constraint that we all suffer from and need to move past. In accepting the inevitability of these events and the adversity that they cause, it is critical that as emergency services leaders we utilise not only all of the collective physical resources, knowledge, skills, experience and imagination of emergency services, government, not-for-profit and private sectors and the wider community, but that we also foster within that realm a culture of creativity and innovation before, during and after the inevitable events to help solve the immeasurable complexity of problems that natural disasters present. We must properly unify and change the way we think about disasters. We must take a much broader view of the problem and the solutions, and be significantly more inclusive of others, underpinned by an acceptance of the inevitability of disasters and our lack of ability to choose them. Humility Having the capacity to accept inevitability; our individual and collective limitations in dealing with outcomes externally and internally; and the need to unify in the face of such adversity and to surrender our arrogance and ignorance requires all of us to exercise humility before, during and after a disaster. True humility is releasing the need to have to win – to have the last word, and to have to always have our insecurities reinforced with endless support and acknowledgement. Humility is the ability to help someone who has aggrieved us, to say we are sorry, and not wait years for the other person to apologise before we speak to them. Humility allows us to surrender our own fixed view of the world and presents the opportunity to expand our thinking, and genuinely hear the contributions and

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suggestions made by others, as well as grant ourselves and each other permission to say, ‘We do not know but we will find out.’ It assists us in using our collective imagination to bring to mind things that are not present to our senses, creativity to develop original ideas that have value, and innovation to put new ideas into practice. It opens up the capacity for receiving knowledge from others and helps dispel our ignorance. If I reflect back on the catastrophic events over the past 10 years, particularly the Canberra and Victorian bushfires, and ask myself, ‘Were we collectively and individually exhibiting sufficient humility?’, the answer would have to be ‘no’. The Hon. Bernard Teague AO, who led the Royal Commission into the Black Saturday bushfires in Victoria stated in his keynote address at the 2013 Australasian Fire and Emergency Service Authorities Council Conference in Melbourne: ‘[A]s an industry we had lost sight of the primacy of life’ (Teague 2013). Somewhere along the way we had forgotten that our overriding mission was to maintain the trust and confidence of the public and to always put them before us. Ever so subtly we had allowed our arrogance and ignorance to pervade our organisations and the consequences were significant. I had witnessed firsthand the humiliation felt by those who led and managed the Canberra bushfires and only six years later I was to witness the same devastating effects again in Victoria. Many good men and women, all primarily motivated to do the very best they could within their internal and external limitations, were reduced to tears, unable to walk down their local street for fear of being judged or worse, utterly deflated, depressed and fatigued, not just for a few days, but for months and, for some, years. Compassion Over the past 30 years, having personally experienced the physical, emotional and psychological impacts of severe to catastrophic natural disaster events as well as witnessing these impacts on those who directly lost loved ones or property; those indirectly impacted; those called to respond, lead and manage; those called upon to report; and those who bore witness either firsthand or through the many forms of media that exist within society, I came to understand that there was not a person anywhere who was not in some way affected by these events. Most if not all of the people that I have had the privilege to work for, work with or serve were all primarily motivated to do the very best they could within the limits of their internal and external resources while facing adversity. When I genuinely came to understand that, I understood the futility of blame, and if the finger of blame was to be turned upon itself, there needed to be something more beneficial that could replace it. That is when I came to understand the opportunity for compassion. Throughout my career I have witnessed and experienced suffering. Having attended many emergency incidents where someone had arisen that morning with a rightful and reasonable expectation of coming home that night to their loved ones, but did not due to a set of unforeseen and tragic circumstances that would

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see them pass away, helped to teach me the value of life and, perhaps more importantly, its uncertainty and unpredictability. Having personally suffered the effects of post-traumatic stress disorder (PTSD) following the 1994 bushfires, and its painful and long-term consequences on my personal life, helped me understand the suffering that so many police, fire and emergency services personnel and many others have experienced during their salaried or volunteer careers simply by fulfilling their commitments to others or protecting their own families and livelihoods. Having comforted residents who had lost their homes and a lifetime of possessions, with their memories and the clothes they were wearing the only evidence left of their former lives, and having experienced substantial loss in my own life, helped teach me how painful loss could be and how impermanent everything was that existed outside of ourselves. In all of those circumstances, was blame ever useful? Simply put, no. But all of these experiences taught me many things, including the power of compassion – the capacity to put myself genuinely in the shoes of the other person, to understand their emotional pain and trauma, and the inner strength to be with them and to offer whatever words of comfort they needed to hear, or to do whatever was needed at the time. In short, they taught me the capacity to rise above my own internal suffering, genuinely put someone else’s needs before my own, and do everything I could do to take away their suffering. I have said numerous times that all natural disasters present the opportunity for people to show a level of compassion towards each other that everyday life does not normally allow. I have had the privilege many times in my career of witnessing numerous acts of extraordinary compassion firsthand, seeing both volunteer and salaried firefighters continue to fight fires and save lives and property while learning that their own properties had been destroyed; neighbours lending a hand to others despite their own substantial property losses; and the ‘mud army’ in Queensland mobilising to provide significant assistance to those who had lost property as a result of extensive flooding, to name a few examples. Such acts of compassion have, for the most part, galvanised the community, forged new relationships (or repaired previously dysfunctional ones) and eased the emotional burden of those who suffered loss. The absence of compassion, however, did the exact opposite. As emergency services, we have sometimes mistaken compassion for weakness. We have tended to remain clinical and objective in our comments and observations about the impacts of disasters. We have also from time to time held the high moral ground of saying, or at least implying, ‘We told you so’ where once again arrogance and ignorance pervaded. While remaining clinical and objective has its place in operational management, especially when there is a need to focus on the task at hand and attempt to deal with the myriad complexities of the unfolding situation, it is not

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helpful to maintain that approach once the full extent of the impact emerges and people’s emotional reactions begin to surface. The effect of remaining clinical and objective and being perceived to take the high moral ground negates our ability to connect with the very people that we have committed to serve. It also has the effect of negating our ability to show our own vulnerability. As I mentioned earlier, if we have a point of limitation, then we must have vulnerability, and it is our vulnerability that helps establish connection between us and the people we serve. It shows that we are human. Just like those we are committed to protecting, we have our limits and we are not unaffected by the emotional impacts that disasters impose. But to admit vulnerability also requires humility. Unless we give something of ourselves, if we do not reveal our humanness, if we cannot ‘let people in’ then we cannot establish a relationship with them, and a relationship is what most people that we aim to protect want in leadership. They want to know the real you – not the image, not the perception, and not the spin. Displaying uncontrolled emotions during an operation is not helpful and does tend to imply weakness or lack of competence; however, showing genuine emotion through reflection and contemplation of the impacts that disasters have on us and our fellow human beings is not weakness but strength. It takes great inner strength to first acknowledge and then control and express one’s own emotions while being able to relate to the emotional distress of another human being and, second, to put aside one’s needs in order to assist someone else. But the rewards are significant. I genuinely believe that the power of connection, the ability to relate, the capacity to be there for someone else, the humility to admit mistakes and to show vulnerability, and the grace to acknowledge, without judgement, the emotional reactions of all of those affected provides the basis for our compassion, which in turn assists to protect us from the alternative pathway of blaming each other and the spiralling effects that it causes. It also provides us, at least in part, with the opportunity to maintain the trust and confidence of those we serve in the face of overwhelming adversity. Of course, our competencies, leadership ability, capacity to communicate effectively and our ability to efficiently and effectively manage are also on display and are equally important in maintaining trust and confidence. For many years, in order to define success, we have resorted to a rational approach to the outcomes of disasters. We have tried to either define success or defend criticism by quoting statistics on relative low levels of losses or significant deployment of resources, or listing the many activities undertaken before and during the event, for instance. However, these have generally had little effect on how people have felt about the disaster. Why? In my view, natural disasters are more a matter of the ‘heart’ than the ‘head’. The rational view of the world is important, but so is the emotional view.

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Astute leaders understand this. They have both the intellectual and the emotional intelligence to display confidence and competence as well as making a personal connection with those they have been called upon to lead, irrespective of the circumstances. You will never be remembered for all of the statistics you quote, but you will always be remembered for your capacity to show genuine compassion towards others even in the face of the most dire of circumstances. In fact, I would argue that if ‘securing and maintaining the trust and confidence of our communities’ is the greatest success measure of a disaster, then ‘removing, reducing or minimising the suffering of our communities through compassionate motivation’ has to be our greatest mission. Forgiveness In the cold, hard light of day when the disaster has abated and we have a chance to reflect on the event, most of us will experience to a greater or lesser degree feelings of regret, remorse, anger and frustration. Some of these will be directed towards ourselves, and some towards others. However, understanding that we could not choose the event, that its severity went beyond our internal and external resources and knowing that we were motivated to do the best we could within these constraints gives us the opportunity to reflect upon the experience and, in time, come to realise not only how much more we individually and collectively need to learn, but, perhaps more importantly, that blame is futile. Unfortunately what I have both witnessed and experienced over the past 30 years leads me to believe that, out of all of the lessons natural disasters provide, forgiveness is the most important one, but it is also the one least learnt. I have lost count of the number of people within our industry who still hold a grievance over something that happened many years earlier, usually, although not always, resulting from an operational experience. When I took up the position of Commissioner of the ACT ESA it became very apparent very early on that while the majority of people had gained some level of perspective on the events leading up to and on 18 January 2003 and had resolved their differences, others had been deeply hurt and aggrieved by what happened. While I had great empathy for how they may have felt immediately after the event, I had much less empathy for their bitterness that still pervaded over seven years later. To not forgive leads us to a mind that becomes flooded with anxieties, burdens us with a sense of injustice, or perhaps even worse, fills us with bitterness and hatred. Unfortunately these emotions can persist and pervade for many years and, if left unmanaged, become toxic. We do not have to stop and reflect for too long to see that we carry many burdens through our lack of forgiveness almost on a daily basis. Irrespective of how we may justify them, we are the ones that experience the effects of such negative feelings and they are never pleasant. They also have a

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negative effect on our health, relationships, leadership abilities, career progression and organisational cultures. In short, by thinking, speaking and acting through such feelings, we bring harm to others and, in so doing, perpetuate the very cycle of suffering that we are so desperate to release ourselves from. We should certainly not acquiesce to the destructive behaviours that some people exhibit, and it is indeed true that negative behaviours often become the cause for actions that bring such people to account, but if we understand that the aggrieving behaviour is separate from the person who is behaving in such a way, and if we further understand that such behaviour is motivated from a mind of unconscious suffering, then such realisations give us a powerful choice – the choice to be righteous and seek vengeance, or the choice to forgive. Guilt, or a lack of self-forgiveness, also plays a central role in our propensity for harsh self-criticism and once again arises from our egos. Put simply, if we were to free ourselves of guilt we would not attack ourselves internally (for those things we did or did not think, say or do) or others externally (for those things we perceived others did or did not think, say or do to us). Guilt, more often than not, leads to feelings of condemnation and often forms the basis for our anger and aggression towards ourselves or others. I have seen many people over the course of my career sit with guilt for far too long and watched them suffer unnecessarily. How many of us have a propensity to take on ‘too much responsibility’ and then be burdened with its weight. Forgiving ourselves is as important as forgiving others. Having enough humility to accept that we make mistakes and from them we have the opportunity to learn and grow is a sign of a good leader. Not having sufficient humility and maintaining a fixed and righteous view of the world maintains our arrogance and ignorance. The choice is simple. The truth is that forgiveness is a gift that you grant yourself. It is not just to do with the person you are forgiving. By granting forgiveness through compassion we initiate an act of transformation in which we release ourselves from the negativity and toxicity that otherwise arise from holding onto the thought, through a mind of anger, that we have been unjustifiably aggrieved and that only righteousness and vengeance will suffice in seeking what our egos would interpret as entitled justice and fairness. When we truly understand this lesson, forgiveness becomes a daily ritual that contributes significantly to clearing our minds of those past traumas and unfinished business, and in turn opens up space within us to deal with those challenges that ultimately we will be called to face as leaders in our chosen field. Ask yourself a simple question: ‘Can I afford to carry with me any emotional stress caused from lack of forgiveness into the next operation that I will need to lead and manage?’ If you are in a position of leadership and you are called upon to lead and manage, you will either inevitably come across the very people that caused

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you grief and you have not yet forgiven, or you will come across the very people that you have aggrieved and have not yet sought forgiveness from. Either way you have taken on a whole load of trouble before you even begin to deal with all of the complexities that the natural disaster you are about to confront will throw at you. Remember that you do not get to choose the event, but you do get to choose how you prepare for, respond to and recover from it. The reality is we all make mess. We all aggrieve other people, sometimes consciously, often unconsciously, and other people aggrieve us. No one can ever hold the mantle of perfection and claim not to have offended anyone. To even contemplate such a thought would be both arrogant and ignorant. Forgiveness requires both humility and compassion: the ability to accept wholeheartedly that we are responsible for aggrieving others, and the compassion to understand that most people aggrieve us as a result of their own internal suffering – suffering that we too can relate to as it is our own internal suffering that drives us to aggrieve others. Following the aftermath of disasters we owe it to ourselves, and to each other, to reflect upon our own perceived limitations and, over time, forgive ourselves for those things that we did or did not think, did or did not say, or did or did not do and, having reached some sense of inner peace about our own perceived limitations, we owe it to others to grant them forgiveness for they have endured the same internal suffering.

Summary My experience of 18 January 2003 in itself was relatively insignificant compared to what many others experienced. What that experience did, however, was trigger within me a long period of reflection and contemplation, reading and studying, talking and listening, all with the expressed purpose of trying to understand what it was that we were not seeing as emergency services, governments and communities. Why was it that we constantly ended up in the negative and destructive cycle of blame that, to varying degrees, had perpetuated since the 1939 Black Friday bushfires in Victoria and caused so many people, who were primarily motivated to do the best they could within the limits of their external and internal resources and in the face of great adversity, great suffering? I have come to realise that if we change the way we view severe to catastrophic natural disaster events and how we lead them, we can start to shift the cycle of blame to a more beneficial experience that will significantly improve our collective knowledge, skills, experience and imagination and enhance the effectiveness of our actions before, during and after these events, all with the primary purpose of reducing the suffering experienced by ourselves and others. It is important to understand that natural disasters do not punish, nor do they discriminate. They are natural processes that wield enormous physical power and

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they are an essential element in the Earth’s survivability. It is only our constant resistance to their presence and effects and our lack of appropriate action, both mentally and physically, that causes most of our grief, perpetuates the cycle of blame and causes us to see our efforts as inevitable failures. We will always experience some level of loss and impact following a natural disaster, and our emotional responses to those losses and impacts should always be honoured. But when we make a decision, both individually and collectively, to generally change the way we think about them, we will definitely alter their outcomes for the better so that every experience, no matter how hard it may be at the time, will add to the richness of our lives and help us discover who we really are, what we are really capable of, and what it is that we still need to learn. We need to accept that severe to catastrophic natural disaster events are inevitable (with varying frequencies and intensities over time and varying impacts), reasonably foreseeable in broad terms, infinitely complex and unpredictable in specific terms and, while we are unable to choose them, by accepting them we get the choice in how we prepare for, respond to and recover from them by undertaking imaginative, creative and innovative actions to reduce their effects and the suffering they cause. We need to change the way we think about risk, first by better understanding residual risk and the potential for the consequences within that residual to fully manifest when an event occurs. Second, by understanding that rarity does not reduce consequence we need to turn our minds more comprehensively to the full potential of the effects that those hazards within our communities are capable of producing through to the level of severe to catastrophic, remembering that, as rare as they might be, they are at some point inevitable at a time not of our choosing. We need to lead our organisations, governments and communities differently. We need to establish an ethical premise that forms the basis of how we think about natural disasters; where we derive our motivation to prepare for, respond to and recover from them; and on what basis we establish our priorities and make our decisions to reduce their impacts and consequences and deal with their effects. Finally, we need to recognise that the greatest measure of success for these events will always be securing and maintaining the trust and confidence of our communities. The greatest mission will always be removing, reducing and minimising the suffering of our communities through compassionate motivation and action. We should always commit to both – before, during and after.

References Doogan M (2006) The Canberra Firestorm: Inquests and Inquiry into Four Deaths and Four Fires between 8 and 18 January 2003. Volume 1. ACT Coroner’s Court, Canberra, ACT.

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McBeth HR (1994) The Fire Hazard Reduction Practices of the ACT Government. ACT Parks and Conservation Service, Canberra, ACT, p. 2. McRae R (2011) Learning, Improving and Blaming. 2011 AFAC and Bushfire CRC Conference. 29 August – 1 September 2011, Sydney. Teague B (2013) Speech given at 2013 AFAC and Bushfire CRC Conference. 2–5 ­September 2013, Melbourne, Unpublished.

10 Bushfire around Linton township, Victoria Greg Leach Incident Controller, Country Fire Authority (Now Deputy Chief Officer, Metropolitan Fire and Emergency Services Board)

Introduction The Linton fire occurred on 2 December 1998 in forest to the north of the small township of Linton which is about 30 km south-west of Ballarat in Western Victoria. The fire started around 1 p.m. and by early evening had burned through private and state forest to the outskirts of the Linton township. At around 8.40 p.m. that evening while firefighters were working to secure the fire perimeter with a mineral earth break, a south-west wind change arrived on the fireground and affected the eastern flank, burning over and entrapping two Country Fire Authority (CFA) tankers and resulting in the deaths of five volunteer firefighters from the Geelong West Fire Brigade. My account of that afternoon was during my tenure as Operations Manager for CFA Region 15, and I was made the Incident Controller for the Linton fire.

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The Linton fire On 1 December the weather forecast for the next day came off the facsimile machine at the Country Fire Authority Regional Office in Ballarat at around 5 p.m. While the summer fire danger period was still two weeks away from being gazetted, the forecast demanded a second look. The temperature for the Ballarat area for the next day, Wednesday, 2 December 1998, was for temperature of around 29°C, relative humidity of 17% and winds from the north-north-west at 45 km/h gusting to 55 km/h. The upper winds at 1000 m were forecast for north-north-west at 80 km/h. Victoria had experienced over two years of drought conditions. We weren’t to know that it would be the beginning of a decade of drought that would devastate the landscape to an extent previously unknown during European settlement. The official records showed below-average rainfall for the Central Highlands area of Victoria for the period between October 1996 and December 1998; this was attributed to the influence of an El Nĩno event, which had affected Victoria during the winter of 1997 and the 1997–98 fire season. As the Operations Manager in charge of CFA Region 15 I spoke with the other operational staff about our preparedness for this high fire danger day so early in the season. We initiated our usual notification and operational preparedness processes with the nine fire brigade groups and the 73 fire brigades within the region, as well as liaising with the local senior operational fire management staff of the Department of Natural Resources and Environment (NRE), the land management agency responsible for fire management on crown land and state forest in Victoria. Over the preceding years, since the introduction of the Australasian Inter-service Incident Management System™ (AIIMS) in the late 1980s, CFA and NRE had increasingly worked together collaboratively in preparing for, responding to and managing fires in Victoria. In Ballarat, the local CFA and NRE officers were proud of our progress on the level of inter-agency cooperation and interoperability that had been developed between all the emergency service organisations. This level of inter-agency cooperation had been honed over recent years through the management of several significant bushfires in the area, including a 10 000 ha fire in the Enfield Forest in February 1995, known as the ‘Berringa fire’; the ‘Creswick fire’ in the Creswick State Forest in January 1997; and the ‘Spring Hill/Trentham fire’ in March 1998. The experience and learnings from these fires had assisted in building relationships and enhancing response capabilities between the two fire agencies. On the morning of Wednesday, 2 December when I arrived at the regional office, the 6.30 a.m. forecast from the Bureau of Meteorology confirmed that the weather estimates for the day were unchanged. After conferring with the Operations Officers, I satisfied myself that the readiness arrangements were in place in accordance with our operational procedures. The region had a Duty

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Officer system in place and Kevin Brown was the designated Duty Officer for the day. I had a pre-existing engagement that day, and so I travelled to the CFA training college known as ‘Fiskville’ about 30 km east of Ballarat to participate in a strategic working group established by the CFA Chief Officer. This working group, known as the Major Incident Planning Group, was working on a revised doctrine for the way in which CFA undertook planning for major operational incidents, and I was keen to participate. At around 1.30 p.m. that afternoon I was contacted by Duty Officer Kevin Brown, who advised me that there were currently three fires burning in the Ballarat area. Kevin advised that the status of two of the fires was ‘contained’ but that one fire, burning in the Linton area, was continuing to build and was a concern. Linton is a small former gold mining town that was first settled around 1840 and is about 30 km south-west of Ballarat on the Glenelg Highway. Linton had a population of around 350 people at the time of the Linton fire. The town is nestled in a valley, surrounded to the north by the Linton State Forest, which consisted predominantly of mixed stringybark/peppermint eucalypt forest. Linton was also abutted to the east by several commercial softwood radiata pine plantations, and to the south was open farming land. The remnants of the gold mining era can still be seen in the alluvial gold diggings around the area, and these old diggings in the Linton State Forest were to have a significant impact on firefighting strategy on 2 December. Kevin and I determined that he would remain at the CFA Region 15 Emergency Operations Centre and coordinate the response of CFA brigades to the Linton fire while I would return to Ballarat and attend at the State Government Offices, known locally as the ‘Glasshouse’, to establish a joint-agency CFA–NRE Incident Management Team (IMT). The Glasshouse is occupied by several state government agencies, including NRE, and it was the agreed joint-agency Incident Control Centre for Ballarat. I arrived at the Glasshouse around 2 p.m. and met John Sanders, the senior NRE Fire Management Officer for the Midlands district. John updated me on the current status of the Linton fire and we established a joint-agency IMT by appointing available CFA and NRE staff to key IMT positions. We discussed the fire, its location and, given the north-north-westerly winds, the fire’s probable path of spread from its point of origin in private (freehold) land through the Linton State Forest and back out into freehold land where our estimation of likely fire spread had the fire affecting the north side of the Linton township. Given the threat to private assets we agreed that I would assume the role of Incident Controller, with Brad Mahoney from NRE as the Deputy Incident Controller. The Linton fire originated on private freehold land in long-unburnt open eucalypt forest about 1.5 km north of the Pittong–Snake Valley Road and about 6 km north of the Linton township. The cause of the fire was later attributed to a

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local landowner burning off on Monday, 30 November and Tuesday, 1 December to reduce the fuel load before summer. While evidence was led at the coronial inquest that although the landowner made significant attempts to extinguish and black out the fires, the wind direction and strength on Wednesday, 2 December fanned ‘hot spots’ embedded deep in the heavy vegetation. The fire was reported by a local CFA brigade member at about 1.03 p.m. Local CFA brigade resources from the Snake Valley Fire Brigade arrived on scene at 1.22 p.m. after having difficulty locating the fire in the densely forested area. This early in the fire season the NRE fire-spotting towers were not staffed so no support in locating the seat of the fire through the dense tree canopy was available to local crews or the IMT. NRE first-attack crews and a D4 dozer from the Beaufort NRE depot arrived around 2 p.m. By this time it was clear to those in fireground command roles that the first attack had failed and that an indirect strategy was required. The D4 dozer made its way to the point of origin and began tracking in a southerly direction down the eastern flank of the fire to construct a control line close to the fire edge. During the debriefs conducted after the fire, first responders that made the initial attack spoke of limited access and intense fire behaviour with short distance spotting hampering efforts to control the fire. By this time, the IMT was just being established at the Glasshouse in Ballarat. At the same time that Kevin Brown had notified me about the fire, he had also contacted another Region 15 Officer, Neville Britton, and they agreed that Neville would travel to Linton and establish a Forward Operations Point. Neville met NRE Forest Officer Bob Graham at Linton, and Neville and Bob established the Forward Operations Point at around the same time that the IMT was getting established in Ballarat. At that time, while it was the practice to pre-plan the availability of key personnel for IMT roles, the pre-planned operational arrangements for that day did not have an IMT in situ, but to respond as required. As Incident Controller, I did reflect on the day that it was reassuring to have experienced staff available from both CFA and NRE for key IMT and Forward Operations Point roles, and I took some comfort that the work that had gone into developing local inter-agency relationships, the recent large fire experience in the district and the level of preparedness between the agencies would underpin the management efforts of the Linton fire. I recall one of the early telephone hook-ups between Neville and Bob at the Forward Operations Point at Linton and John Sanders, Brad Mahoney and myself at the IMT in Ballarat where, as we analysed and discussed the intelligence that was being received via radio from the fireground, it was evident that this fire was not going to be contained during the first attack and that it was going to escalate and needed to be managed as a significant fire. One of the constant challenges for an Incident Controller is to ensure that the incident management structure is matched to the demands of a particular incident.

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It is not about trying to fit an incident into an AIIMS structure, but about applying the principles of AIIMS to get an operational management structure that works. In this case, while the pure AIIMS operational structure did not include a ‘Forward Operations Point’ per se, it was discussed on the teleconference, and I agreed to it. Because of the 30 km distance from Linton to Ballarat and the vagaries of VHF radio transmission between the IMT and the fireground due to distance and terrain, I felt that having a Forward Operations Point staffed by senior fire officers would provide better communication between the IMT and fireground commanders, and place a senior command presence closer to the incident. I was also briefed at that time that a staging area was being established at Linton. For several years the Ballarat City Fire Brigade had taken upon itself to develop expertise in staging area management, and on the day they deployed career and volunteer firefighters along with a specialist vehicle to the Linton Recreation Reserve to establish the staging area and coordinate the arrival of firefighting resources and ready them for deployment onto the fireground. While local firefighting resources had responded direct to the fireground during initial attack, once the staging area was established resources were deployed to and from the fireground via the staging area at Linton. When I assumed the Incident Controller role at 2 p.m., I wasn’t aware of events that were unfolding on the fireground on a road known as the Pittong–Snake Valley Road. From the time the fire was first reported at 1.03 p.m. to around 2.30 p.m., the fire had progressed south through private property and was approaching the Pittong–Snake Valley Road. The road runs roughly east–west and cut across the path of the approaching fire. By this time, around 10–12 CFA tankers had arrived at the fire and assembled on the road. It was here at around 2.45 p.m. that an attempt was made to stop the fire crossing the road and entering the Linton State Forest. The fire had been backing down a gentle slope before reaching a gully on the north side of the road. Crews reported that once the fire reached the upslope it increased in intensity and ran towards the road on a front of about 200 m. It was at this point that the first significant entrapment event occurred at this fire. As the fire increased in intensity on the run up the slope towards the road, the amount of embers intensified and the fire began to spot over the tankers assembled on the road (the embers are carried in the air ahead of the main fire and start new spot fires that then coalesce into a new, large fire). The crew of the Snake Valley Fire Brigade ‘A’ tanker (a brigade-owned tanker) observed a spot fire burning south of the Pittong–Snake Valley Road some distance in from the road. The crew left the other assembled tankers on the road, and drove into the forest and upslope towards the spot fire with the intention of extinguishing it. As they attempted to extinguish this spot fire, crew members reported that it seemed to be raining embers with new spot fires breaking out all around them. Visibility quickly deteriorated due to smoke as the main fire accelerated upslope from the Pittong–Snake Valley Road

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and engulfed them. The crew took shelter in the cabin and on the rear of the tanker. The driver attempted to drive out of the fire area, but due to the reduced visibility (down to only several metres), became disoriented and drove the tanker south, unknowingly following the progression of the main fire front. The crew endured minutes of extreme radiated heat before reaching an area of green vegetation. One crew member suffered burns to the face and hands and required attention by an ambulance crew. The tanker incurred heat damage to external panel work, but after being checked by CFA mechanical staff rejoined the firefight with a fresh crew later in the day. I recall being briefed on the day about this incident in the early stages of establishing the IMT, but the information received at the IMT was minimal and it downplayed the significance of the burn-over. The seriousness of the incident wasn’t fully appreciated until the post-fire review process. As the fire was continuing to run through the State Forest towards Linton, the IMT efforts returned to focusing on developing and implementing a control strategy, and consideration of the Snake Valley ‘A’ tanker burn-over was postponed as an issue for post-incident follow-up. The Snake Valley ‘A’ tanker incident highlights the very real intelligence and control gap risks associated with transitioning control from a Type 1 (field-based control) to a Type 2 or 3 incident control structure, and the learnings from this in modern incident management practice of having pre-planned and pre-positioned IMTs in place on high fire danger days based on fire danger rating ‘triggers’ cannot be understated. I recall thinking, as I analysed a map of the Linton area early in the afternoon, about the challenges that I confronted in managing a fire on the border between two fire brigade groups, from different CFA regions, that operated on different radio communications channels. I initiated discussions with key IMT functional officers in the IMT and the Field Operations Point about the management structure for the fire, sectorisation, and the use of the default Region 15 Incident Communications Plan to ensure that the resources on the fire were united under a common operating structure. What became clear in the intense post-incident analysis that occurred after the Linton fire was that the incident management arrangements and Incident Communications Plan were not adequately documented or communicated to those that needed to know. And so it was that, at this first critical stage of the firefight at Pittong–Snake Valley Road, knowledge of the joint-agency IMT structure had not yet penetrated to the fireground. In fact, some brigades and key fireground command personnel from the neighbouring Region 16 (where the fire had started) were not aware of the formation of the IMT in Ballarat or the overall control arrangements until well into the firefight, or indeed until after the fire. One of the key reasons why accurate information about the Snake Valley ‘A’ tanker burn-over incident did not reach the IMT in a timely manner was because

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the Region 16 resources were not adequately integrated into the incident management structure. By 3 p.m. the fire was progressing south and moving out of private property into the Linton State Forest, which is public land under the management of NRE. A management plan for the forest had been developed by NRE and at the IMT John Sanders, Brad Mahoney and I reviewed a map outlining the mosaic of prescribed fuel reduction burns undertaken over preceding years, and considered what impact the reduced fuel conditions due to the previous fuel reduction burns would have on fire spread and behaviour. Fuel load was calculated as high to very high and the forest type ranged from messmate and peppermint forest to stringybark. Forest fuel loads varied due to the undulating topography and the history of prescribed burns. Forest fuel loads were estimated at 10 to 12 tonnes per hectare of surface fuels, with moderate to high elevated fuels and high to very high bark fuels. As the fire progressed south of Pittong–Snake Valley Road into the State Forest the sector commanders were initiating firefighting tactics and deploying firefighting tankers at their disposal in direct response to fire spread and behaviour. There was an attempt to backburn on the eastern flank along a gravel road that ran south from the Pittong–Snake Valley Road to halt the spread of the fire and secure the eastern flank. This backburn was held along the south-west road, known as Madden Flat Road, for about 500 m until the deteriorating weather conditions and increasing fire behaviour saw the fire spread over Madden Flat Road. The outcome of this backburn resulted in the widening of the fire front by about 500 m. As this backburn was attempted along Madden Flat Road, further south in the Linton State Forest a strike team of tankers had assembled on an east–west track known as Possum Gully Road ahead of the approaching fire front. This road, running roughly parallel to the Pittong–Snake Valley Road to the north, was determined by the sector commander to be the last remaining geographical feature between the fire and Linton township that could be utilised as a fire control line. The strike team commenced a backburn along the eastern flank of the fire along a bush track that was the extension of Madden Flat Road south of Possum Gully Road. What they didn’t realise at the time was that the earlier backburn to their north had already escaped and was burning south, placing them within a direct line of the approaching fire front. As the strike team began their backburn along the edge of the bush track heading south off Possum Gully Road at around 3.30 p.m., crew members felt the wind begin to pick up. It was at this time that they observed the fire approaching from the north and spot fires began to ignite around them. The Sector Commander, who was commanding the strike team from his own CFA radioequipped utility, had taken the lead down the bush track, followed by two tankers. As the fire intensity increased, the Sector Commander tried to turn his vehicle around to head back to the relative safety of Possum Gully Road, when the front wheel of his utility went down an old mine shaft and the vehicle became immobile.

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After sheltering in the ute for a brief time, the Sector Commander left the utility and ran for the nearest tanker. The crew and the Sector Commander took refuge in the tanker while the fire burnt over them. This was the second burn-over incident at this fire, and again only minimal information was provided from the fireground to the Forward Operations Point or the IMT about the nature or the seriousness of the incident. Meanwhile, back in Ballarat the local Victoria Police Superintendent Lindsay Florence had arrived at the Incident Control Centre and established himself in a conference room adjoining the IMT. One of the strengths arising from the interagency relationships that had developed in Ballarat over preceding years was the support of Victoria Police, who had overall coordination responsibility under the Victorian emergency management arrangements. On the day of the Linton fire Lindsay assembled representatives from State Government agencies and utilities in what would today be known as an Emergency Management Team. This practice in Ballarat had emerged based on experience from previous fires in the district, and having these support agency and utility representatives in close proximity to the IMT where I could brief them regularly on the current situation, and in return receive advice on assets at risk and key consequence issues, was invaluable. I also ensured that the IMT disseminated information to the community via local media outlets. Again, based on experience from recent previous fires, arrangements had been made with local radio stations in Ballarat to broadcast updates for the community on the latest fire situation. This was done several times during the main run of the fire in the afternoon, and I was also interviewed by a local television network for a story that aired that evening on the local news service. Unbeknown to me at the time, this footage of my comments about the timing of the wind change that was to affect the fire that evening would become a key piece of evidence and discussion at the coronial inquest in relation to my knowledge, and the knowledge within the IMT, as to the timing of the passage of the wind change. At 4.00 p.m. I chaired an IMT planning meeting. The meeting followed the usual format of a briefing from the Planning Officer, followed by the Operations Unit overviewing the current situation; then Logistics; then the Victoria Police Regional Coordinator Lindsay Florence updating us on coordination and support agency issues. Following the functional briefings a review of the incident strategy in light of this latest information was undertaken and tasks were delegated to various officers before the meeting was concluded. I was always conscious as an Incident Controller that the fire does not stop simply because the IMT is holding a planning meeting, and other IMT staff need access to, and direction from, the key functional officers. Prior to the Planning Meeting, Operations Manager Euan Ferguson had arrived at the IMT at the request of CFA headquarters. Euan had been deployed to undertake a real-time audit role, but on arrival and discussion

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with me it was agreed that he would assist the Planning Unit, with a specific focus on documenting the Incident Action Plan (IAP) arising from the 4.30 p.m. planning meeting. The subsequent IAP that was developed by Euan and signed by me as Incident Controller contained information on the predicted timing of the wind change, and would become a key focus of the coronial inquest. It would be some three years later that I was robustly cross-examined about the contents of the IAP that I had signed and authorised, and it certainly highlighted in stark contrast the legal accountability and responsibility that rests with an Incident Controller when signing a document of this nature. I am sure that Incident Controllers today are more acutely aware of their personal and positional accountability as a result of the legal scrutiny applied to the Linton fire IAP. At around 4.30 p.m., just as the planning meeting was concluding, reports were received of spot fires occurring around Linton township. Available tankers that had assembled at the Linton Recreation Reserve were dispatched and these spot fires were successfully extinguished. Earlier, at 3.07 p.m., a request was made to CFA Region 7 Geelong from the IMT to supply a strike team for night shift at the Linton Fire. The Geelong strike team was made up of five tankers and a strike team leader command vehicle. The strike team members assembled at Fyansford on the outskirts of Geelong, and made their way to Linton, arriving at the Linton staging area at about 5.40 p.m. On arrival at Linton, the Geelong strike team was given the task at the staging area to travel to the Linton Cemetery on the north-east outskirts of the town and meet up with a local officer, who would provide them with deployment instructions. On arrival at the cemetery they received further directions and were deployed north along the Snake Valley–Linton Road with instructions to then proceed west into the Linton State Forest via Possum Gully Road to reach the eastern flank of the fire. On reaching the intersection of Possum Gully Road and Homestead Track in the Linton State Forest around 7.15 p.m., the Geelong strike team met up with a composite strike team of tankers from the local Ballarat and Creswick area. This strike team was under the command of a local Sector Commander, the same officer who had lost his utility in a burn-over earlier in the afternoon. The Sector Commander briefed the Geelong strike team members and tasked them to follow a Komatsu D155 bulldozer that was constructing a mineral earth control line along the eastern edge of the fire. The bulldozer was working south and had just crossed Possum Gully Road at this time. Up to this point, a composite Ballarat/Creswick Group strike team had been following the bulldozer and burning out unburnt fuel up to the control line edge. On reaching Possum Gully Road, this strike team were tasked to remain on the control line north of Possum Gully Road to continue patrolling and burning out, and the Geelong strike team was tasked to follow the bulldozer south of Possum Gully Road.

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At this time, fire behaviour along the eastern flank was reported as being relatively quiet, with flame heights up to half a metre and winds very light from the north. The Geelong strike team followed the Komatsu D155 along the freshly constructed control line. The strike team crews were busy carrying out burning out and mopping up activities as they progressed along the control line which was being constructed within a few metres of the fire edge. At around 7.50 p.m., a CFA air observer, who had been released from the fire and was returning to his home base, reported to the Forward Operations Point at Linton via radio that the wind change was now at Wickliffe, a small settlement about 80 km west of Linton. The air observer reported, ‘South-west 35 kph, no rain’. This message was logged at the mobile communications vehicle that had been deployed to Linton to assist with communications. This information was then re-broadcast as a general message over the three radio channels being used as sector channels at the fire. Although the communications operator asked for acknowledgements, there were few. At 7.53 p.m., the Bureau of Meteorology issued a second spot weather forecast for the Linton fire, including details of a major wind change. The message read: ‘South-west change due around 2300 hours Wednesday 02 December 1998. Gusts to 60 kph possible in west south west winds.’ This spot weather forecast was sent from the IMT to the Forward Operations Point by facsimile for dissemination to the fireground. At 8.30 p.m., the air observer further advised the Fire Brigade Group Headquarters at Linton that he had experienced the wind change at Skipton, 20 km west of Linton, while he was flying home. From 7.30 through to 8.30 p.m., the Geelong strike team had been travelling along the control line conducting burning out and mopping up activities. Because of this work all of the tankers had used some of their water supply. The Geelong City tanker was at the head of the strike team on the control line behind the dozer; Geelong West tanker was second, followed by Corio, Highton and Lara tankers, which were working further behind at various intervals. Earlier in the evening at around 6 p.m., the main fire front had burnt out of the Linton State Forest and encroached on the northern edge of the Linton township. The change in fuel type as the fire emerged into private property resulted in reduced fire behaviour. The fire was able to be contained with minimal impact on private assets. The halting of the head fire also led to a change of tactics, with the Forward Operations Point recommending to me a change in strategy to deploy dozers at the south end of the fire and progress north up the eastern and western flanks to meet up with the dozers tracking south down both flanks from the point of origin. By this time there were five bulldozers deployed to the Linton fire: three large dozers, similar to the Komatsu D155 that the Geelong strike team was following, and two smaller NRE dozers, known as ‘first attack dozers’. While the

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strategy of starting dozers at the head of the fire and working back towards the point of origin was unconventional, after considering the potential risks the strategy was adopted due to the halting of the head fire, the approaching wind change, and the need to secure a control line on the eastern flank in particular before the arrival of the wind change, still anticipated at 11 p.m. At about 8.30 p.m., there was still a section of fire edge on the eastern flank to be tracked. A conversation between the south dozer supervisor and the Geelong strike team leader resulted in a change of tactic for the Komatsu D155 and Geelong strike team to move away from tracking the fire edge, which was currently burning through an old gold mining gully, and construct the control line along an old bush track to speed up the rate of fireline construction. The Komatsu D155 dozer operator moved the control line away from the burning edge. The control line crossed Sludge Gully and moved along the bush track known as Homestead Track. There was now unburnt fuel on both sides of the dozer. The fire edge was between 30 and 90 m to the west of the dozer and Geelong strike team, and at this time was reported to be still burning quietly in Sludge Gully. About this time, there was a discussion amongst the Geelong strike team about refilling the Geelong City and Geelong West tankers with water. A decision was made for the two tankers to move past the Komatsu dozer and head south along Homestead Track to find a water fill point. As these two tankers moved past the dozer and along Homestead Track they were now surrounded by unburnt forest fuel. At around 8.40 p.m., I was in the Incident Control Centre in close proximity to the Operations Unit. There was the usual hum of radio traffic on the various radio channels, as there had been all afternoon. At this time there was some increased radio traffic and Brad Mahoney, who at this time was the Operations Officer, alerted myself and Deputy Incident Controller John Sanders that a tanker had been ‘lost’. IMT members gravitated to the Operations area and listened to the radio traffic as everyone tried to make sense of what was happening out on the fireground. At 8.45 p.m. on Wednesday 2 December 1998 in the Linton State Forest, on the extension of Homestead Track, the south-west wind change arrived at the eastern flank of the Linton Fire. Just before the wind change, the Geelong City and Geelong West tankers had stopped on the track about 30 m in front of the dozer. Members of the two crews were conferring when they saw the fire approaching. Intense heat hit the two tankers. Crew members on the Geelong City tanker reported experiencing two ‘waves’ of fire, later identified to be a crown fire followed by a surface fire. The driver of the Geelong City tanker transmitted a ‘mayday’ call on the radio. The Geelong City crew initiated survival procedures. They used fog sprays and woollen blankets to protect themselves from the radiant and convected heat. The Geelong City tanker and crew survived the passage of the fire. The Geelong West tanker was destroyed and the five members of the crew perished.

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A concerted response to the ‘mayday’ call commenced. The entrapment was reported to the Forward Operations Point. Back in the IMT, I was contacted by Neville Britton, who confirmed that two tankers had been entrapped, that one tanker had been destroyed and that the crew had been lost. The enormity of what had just occurred was felt by all in the IMT. There was silence as people absorbed the news. Somewhere in the silent Control Centre, I could hear people begin to cry. In the minutes following the Geelong West tanker entrapment at 8.40 p.m. it was difficult to gain a clear understanding at the IMT via the radio communication as to the circumstances on the fireground. It transpired that when the south-west wind change arrived at the fireground the fire on the eastern flank had moved quickly and intensely in a north-east direction, entrapping the Geelong City and Geelong West tankers and continued through a 400 m gap in the mineral earth control line that the two dozers had been working hard to close up before the wind change. Two strike teams from the Ballarat and Creswick Fire Brigade Groups immediately set to work to control this breakaway, while the Forward Operations Point tried to clarify the circumstances of what had happened on the extension of Homestead Track. Radio traffic was congested, and this was compounded by poor radio coverage in the forest area. In the IMT, it was quiet, as IMT members stopped where they were and hung off every word from the radio as the enormity of what had taken place in the Linton State Forest sank in. As the IMT responded to this tragic turn of events, I met with Superintendent Lindsay Florence, Deputy Incident Controller Jon Sanders and Planning Officer Euan Ferguson to revise the incident strategy. We determined that the entrapment would be managed as an incident within an incident, with the entrapment incident being managed by Victoria Police (Superintendent Florence) and the ongoing fire incident being managed by the joint-agency IMT. The complexity of the incident increased significantly due to the multiple considerations of the entrapment site; the welfare of the remaining crew members; the welfare of other responders; notifications to the State Coroner; notifications to senior CFA personnel, including the CFA Chairman, Chief Officer and Area Manager of the Geelong Area; the need to maintain an information lock-down as best as possible until families had been notified; and the need to manage the subsequent media interest in the incident. By 9.30 p.m., the breakaway on the eastern flank was contained. Burning out of unburnt fuel within the breakaway area and securing the perimeter in depth then commenced. By 10.10 p.m., Victoria Police had secured the scene of the entrapment. The remaining members of the Geelong strike team returned to Linton and received counselling at the Forward Operations Point before they returned to Geelong on a bus. Chief Officer Trevor Roche attended the Incident Control Centre that night and I briefed Trevor on the circumstances, and Trevor briefed other senior CFA

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personnel including Chairman Len Foster and the CFA Executive. Trevor and Superintendent Lindsay Florence conducted a media briefing in the early hours of Thursday morning to an assembled media contingent. The eastern flank of the fire was declared contained at 12.15 a.m., and the whole fire was contained at 1.20 a.m. at an area of about 660 ha. The State Coroner attended the scene at around 4 a.m. on the morning of Thursday 3 December and initiated an investigation, which was to be conducted by the Victoria Police Arson Squad and the Victorian Workcover Authority (now WorkSafe Victoria). At 3.30 a.m. I went home for a few hours’ fitful sleep before returning to the Incident Control Centre the next morning at 8 a.m. for the beginning of what would be a three-year journey of detailed forensic analysis of the Linton Fire.

The investigation process and Coronial Inquest It is hoped that this work helps lead to improvements in safety for all of Victoria’s dedicated and community-minded volunteer and fulltime firefighters. (Graeme Johnstone, State Coroner, 11 January 2002) For me and a host of other key personnel involved in the Linton fire, the weeks that followed were a blur of meetings, debriefings and interviews, as the various reviews and investigations got underway. At the same time, the day-to-day running of the region had to continue, as well as dealing with a fire season that got increasingly busy. I was interviewed by members of the Joint CFA/NRE Linton Fire Review team members as they pieced together the circumstances in order to learn and apply any lessons while awaiting the conduct of the coronial inquest. I was also interviewed by the Arson Squad several times and subsequently provided three statements that were tendered to the inquest. In the months following the fire and in the lead-up to the coronial inquest I visited the Linton State Forest on no less than 14 occasions, as I accompanied investigators, fire scientists, lawyers and barristers while they pieced together the circumstances of the fire. As a result of the entrapment and deaths at the Linton fire, State Coroner Graeme Johnstone announced that he would conduct a coronial inquiry. The coronial inquest would become the second longest inquest in Victorian legal history, spanning 106 hearing days and produced in excess of 11 500 pages of transcript. Over 28 000 pages of exhibits and other documents were produced during the running of the Inquest. There were over 1500 pages of submissions and replies by the legal representatives for the nine interested parties represented in the inquest. The first mention hearing for the coronial inquest was held on 16 December 1999, some 12 months after the fire. A further four mention hearings took place between December 1999 and July 2000. The inquest began at the Coroner’s Court,

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Southbank, Victoria on 10 July 2000, and a viewing of the fire area was conducted on 11 July 2000. The hearing of evidence commenced on 17 July 2000 at the Geelong Law Court – Coroners Court to facilitate the hearing of evidence of many of the Geelong witnesses. The inquest commenced at Geelong because the deaths touched the community of Geelong and it was considered that this community should have as much access to the hearing as was reasonably possible. I recall sitting in the rear of the main courtroom in Geelong as the inquest got underway. The courtroom was full to capacity, and there was a strong media contingent that continued to follow the proceedings for the duration. The hearings recommenced in the Melbourne Magistrates’ Court on 24 August 2000. The hearing of evidence continued at that court until the close of all evidence on 5 April 2001. In total there were 99 days of evidence. There were 230 witness statements made by 190 witnesses. Subsequent to this, as a result of an issue that arose during the inquest in relation to Channel 7 News tape that was taken on the day of the fire and tendered to the inquest, an additional 80 statements were taken. As the Incident Controller for the Linton fire, I attended the inquest hearings most days along with the CFA team established to manage CFA’s input to the inquiry, and I had the opportunity to hear much of the evidence that was led. It was compelling to listen as each witness outlined their personnel actions and observations on the day and their subsequent reflections. It was a stark reminder of how the response to a fire is the sum of the efforts of so many people and how, as Incident Controller, you have an enormous responsibility to coordinate the efforts of all these people to achieve the incident objectives and to ensure the safety of responders and the community. As I prepared myself as one of the last witnesses to give evidence to the inquest I re-read my statements that I made to the Arson Squad so many months before. It was a stark realisation for me, as I went over those statements, to compare my level of incident knowledge on the day as Incident Controller with what I knew after listening to 57 days of testimony from so many witnesses. There is so much information and intelligence that is generated at an incident such as a bushfire, and it is incumbent on the IMT to establish a structure that can collect information, analyse and assess it, and then disseminate useful intelligence to underpin informed actions by both responders and the community. After the close of evidence on 5 April 2001, detailed written submissions and replies were received from counsel for all parties. The submissions and replies totalled 1561 pages. With the conclusion of evidence the case was adjourned to the Coroners Court of Victoria, Southbank on 12 June 2001 for the commencement of final oral submissions by counsel. This process occupied seven days and was completed on 21 June 2001.

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The Coroner handed down his findings in a report entitled ‘Report of the Investigation and Inquests into a Wildfire, and the deaths of Five Firefighters at Linton on 2 December 1998’ on 11 January 2002, some 1135 days after the fire. For many of the witnesses it was a long journey. For some, it was the biggest interaction they would have with the legal system in their lives, and many found it a difficult and stressful experience. For many, the handing down of the findings provided some closure on what was a very difficult period. For the families, the inquest provided some answers and, perhaps in some small way, some closure in their quest to understand what happened to their loved ones at Linton on 2 December 1998.

The challenges of managing the Linton fire The coronial inquiry identified numerous systemic issues arising from the management of the Linton fire, and these were categorised in the Coroner’s report as issues pertaining to management systems; supervision and instruction; information transfer; and training and experience. As the forensic investigation unfolded in the Coroners Court of Victoria, and details emerged from witnesses at various levels of the incident management structure, it is sobering as an Incident Controller to reflect on how much information and intelligence was available but never made it through the chain of command to the IMT. It was clear from the evidence that key information and intelligence wasn’t being communicated upward or downward adequately during this fire. It is beholden on members at all levels of an incident structure to communicate up and down the chain of command quickly and accurately. It is also beholden on the Incident Controller and other senior incident management personnel to actively look for disconfirming evidence as to the effectiveness of the incident management arrangements, not just accept confirming evidence that all is well. As the 1960s CFA doctrinal text, Operations: Tactics and Administration in the Field, Volume 1 stated, ‘Communications is the lifeblood of Operations.’ With modern social media, the pressure on incident managers to receive information, analyse it for its intelligence value and disseminate information up and down the chain of command within the incident structure and externally to affected communities is greater than ever. In relation to the management structure for the Linton Fire, in the late 1980s CFA had adopted AIIMS as the management system for fires in country Victoria, and CFA had been progressively training staff and volunteers in the Incident Control System. Since the 1940s, CFA had been structured on a hierarchical brigade/group/region structure. By 1998, the two systems operated in parallel with AIIMS accepted as the operational management system, replacing the group structure, but the group structure was still used for administrative and management purposes. The potential for tension between the new operational

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management systems of AIIMS versus the old hierarchical group system was not well recognised or understood, but it was clear at Linton that fireground commanders and firefighters reverted to their experience and relied on the group system on the fireground because of their familiarity with those historical arrangements and local relationships. Every organisation that covers a large geographic area is confronted with the requirement to establish boundaries for operational and administrative purposes. CFA was no different. These boundaries tended to follow municipal or other arbitrary borders, and tended to result in large tracts of public land straddling group and regional borders. As a state-wide organisation, CFA has over 1200 fire brigades, reporting to 144 fire brigade groups, organised into 20 regions. It was common for fires to burn across operational and administrative boundaries. Such was the case with the Linton fire, which started in CFA Region 16, and quickly burned into Region 15. These boundary issues were also compounded by the fact that each CFA region operated different radio channels, and this reduced effective communications at the Linton fire. The first-arriving brigades operating on the northern sector of the fire were operating on a Region 16 channel, and the brigades in the south operating on Region 15 channels. While the IMT established a communications plan for the incident early in the run of the fire based on preplanned arrangements, it was clear in the post-incident analysis that the communications plan was not properly documented and was never fully implemented. The issue of effective communications is a common theme in many operational debriefs, and the issues identified at Linton reflect the communications challenges that incident managers continue to face. At a macro level the Linton fire also needs to be looked at through the prism of societal change and the impact that this had in 1998 on fire suppression in Victoria. Victoria had been going through a period of difficult economic times, and the State Government had been implementing a raft of macroeconomic reforms. These reforms had seen several State Government enterprises corporatised or privatised, and the numbers of public servants in remaining government departments reduced. These changes had also affected NRE. NRE had undergone several organisational change programs in the decade leading up to Linton, and these had seen changes in the numbers of NRE forest officers and firefighters, with the subsequent loss of experienced foresters. Every action has a reaction, and in this case the reaction was that over the preceding decade or so CFA had assumed a more active role in fighting fire in Victoria’s State Forests in support of NRE. At the same time, CFA was undergoing a generational change, with many of the older volunteer firefighters from farming communities retiring from active duty, and so CFA was experiencing a loss of ‘bush’ skills amongst its volunteer leadership. This loss of ‘bush’ skills and practical experience was an issue that was explored at some length during the inquest in relation to the future training needs of firefighters.

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Lessons learnt There are no new lessons to be learned from a firefighter’s death or injury. The cause of a tragedy is usually an old lesson we have not learned or have forgotten along the way. (Deputy Chief Officer (Retired) Vincent Dunn, NYFD) In the aftermath of the Linton Fire there were numerous debriefs at local fire brigade level, as well as at fire brigade group level, regional level, and interagency level. These debriefs were attended by those personnel involved in the firefight as well as by representatives of the Joint CFA/NRE Linton Fire Operations Review Team, and members of the Victoria Police Arson Squad who were investigating on behalf of the State Coroner. While the coronial inquiry that would follow would examine the firefight and its management in great detail, these local debriefs identified numerous learnings that were applied immediately. These issues included the importance of an incident communications plan that was documented, disseminated and enacted by all resources on the fireground to ensure that all personnel understood the communications arrangements and had access to command and fireground radio channels to send and receive vital information. Another issue identified was the importance of high quality maps and ensuring that all personnel on the fireground, but particularly personnel in command roles, had access to good mapping products that included key topographic features and incident management information. The importance of briefings was highlighted by the events surrounding the Linton fire. The dynamic nature of firefighting operations is such that it is imperative to ensure that all incoming and outgoing resource people are briefed in accordance with a standard briefing format so that they are provided with all critical firefighting and safety information relative to the situation. The rapid escalation of bushfires on days of high fire danger can quickly overwhelm fireground commanders and results in the requirement for the transfer of control from the senior fireground commander to an incident controller at an incident control centre remote from the fireground in the early stages of an incident. This transfer of control must ensure that all information and intelligence are briefed upward to the incoming incident management team, and that a robust system of information and intelligence flow up and down the chain of command is established by the incident management team. The transfer of control must also ensure that all resources deployed to the incident are integrated into the incident management structure as part of the transfer of control. In the nearly two decades since the Linton fire, fire management agencies have largely moved to pre-formed incident management teams on days of high fire danger, reducing the requirement to transfer control.

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While the Linton fire occurred early in the fire season, there was recognition in the post-fire debriefing that fire behaviour was more aggressive than anticipated due to the several years of dry conditions that Victoria had experienced. The learning in that was that firefighters have to observe and read actual fire behaviour and use this information to inform their firefighting strategies and tactics rather than rely on anticipated or expected fire behaviour based on previous experience. These were some of the key lessons identified from the immediate debriefing process in the aftermath of the fire. In response to the fire, a Joint CFA and NRE Team conducted an operations review of the incident. The report of the Operations Review Team was published on 11 March 1999. This report formed the basis of CFA and NRE’s immediate response to identify and address any issues while awaiting the conduct and outcome of the investigation and coronial inquest. The CFA and NRE operations review made 39 recommendations grouped under 11 broad headings with the intention that joint implementation of the recommendations should occur across CFA and NRE. The 11 areas of recommendations included firefighter competencies; fireground contractor management; command structure; information flow; communications; planning; policy; research; equipment; work practices; and near-miss incidents. The coronial inquest into the Linton fire identified the key causative factors that effectively led to the deaths of the volunteer firefighters and the serious risks to the lives of many other firefighters in the Linton Fire to be in the areas of management systems; supervision and instruction; information transfer; and training and experience. The Coroner made 55 recommendations that were wide ranging in nature. Key areas of focus included risk management and hierarchy of controls; the role of the safety function in AIIMS; real-time audit function within AIIMS; Safety Officers; supervision; minimum bushfire competency training; review of standard fire orders and watchouts; information management; weather monitoring; firefighting vehicle and equipment safety enhancements; research; and near-miss reporting. The recommendations from both the CFA and NRE joint report into the Linton Fire and the coronial inquest were monitored closely not only by Victorian fire agencies, but also by rural firefighting and land management agencies across Australia. The subsequent coronial recommendations and the response to these recommendations by CFA and NRE were mirrored by the actions of agencies across Australia. The implementation of these activities to improve the management of bushfires and the safety of firefighters in the rural environment was to become a milestone of generational change and reform. In the context of CFA and NRE it was the biggest cultural and organisational review program since the Ash Wednesday fires in 1983. It has only been eclipsed by the terrible losses of Black Saturday in 2009 and the significant fire services and emergency

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management reform program that is currently underway in Victoria as this book goes to print. The establishment of competency-based training programs for firefighters gained impetus as a result of the Linton fire and was a significant step forward, and while there was concern at the time for what ‘minimum skill’ requirements may mean to recruitment and retention rates of volunteer firefighters, the passage of time over the last 15 years since Linton would suggest that the current generation of firefighters knows nothing different from the requirement to have minimum training and skills to fight fires. In addition, the review of firefighting vehicle design and the implementation of over 100 safety and functional design features has ensured that the next generation of rural firefighting vehicles provides a higher standard of safety and inbuilt protection systems than ever before. The application of AIIMS over the 1990s and the learnings from incidents such as Linton has seen the evolution of how the Incident Control System is applied in practice. Today, the norm on high fire danger days is for pre-planned and preformed IMTs to be in place on the day, ready to respond immediately to an incident. Further, these teams train and exercise together, and operate from strategically located Incident Control Centres supported by the latest technology and communication systems. One of the key learnings to come from the Linton experience is the need to ensure that not only is an IAP and an Incident Communications Plan developed in a timely manner, but also that the plans are effectively communicated to all personnel that are required to understand and implement them. The best Incident Action Plan is useless unless it is explained to the personnel who are to carry out the tasks. The importance of briefing all personnel involved in the execution of the Incident Action Plan cannot be overstated. (CFA Operations Guidelines)

Linton: 15 years on Since the inception of CFA in 1944 there have been several major fires and incidents that have shaped the organisation and the future direction of rural firefighting. Watershed incidents occurred in 1939 (Black Friday), 1969, 1977 (the Western District fires), 1983 (Ash Wednesday), 1998 (Linton) and 2009 (Black Saturday). Each of these events was defining in the way that its learnings shaped the future not only of the fire services but also of Victorian society in the way in which we prepare, respond to and recover from emergencies. While a small fire in the context of area burnt, Linton was significant because it was a transformational event not only for CFA, but also for rural firefighting

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agencies across Australia. Agencies and jurisdictions monitored the coronial inquest closely in regard to the findings and recommendations. Industry bodies such as the Australasian Fire and Emergency Service Authorities Council monitored its progress and outcomes for application across its member agencies. In the aftermath of Linton there was a growing awareness of the impact of human behaviour in firefighting. There was analysis within CFA of the impact of organisational culture in rural firefighting. While it was recognised that the ‘can do’ culture that is so endemic in rural Australians is a desirable trait, it has to be tempered with a ‘safety first’ approach. There was recognition and acceptance that the ‘can do’ attitude can contribute to an overly optimistic assessment of the likelihood of success of a strategy or tactic as opposed to giving due consideration to the consequences of failure. CFA invested heavily in a cultural change program known as ‘Safety First’ in a carefully considered program to change the culture of CFA without losing the positive aspects of a ‘can do’ approach. A key platform of the ‘Safety First’ program was the introduction of the ‘Safe Person’ concept. It was recognised that, within the hierarchy of risk controls when dealing with an emergency incident, one of the key control measures is to ensure that the individual is well prepared to manage the risk. This involves the key platforms of knowledge through education, skills through training, and ability through experience and practical application, supported by appropriate personal protective equipment. This was recognised by this comment in the report of the coronial investigation: It is because the firefighter is brought into close contact with the hazard that proactive safety systems are necessary. The range of incidents in the Linton Fire from the Pittong Road line-up to the Geelong Strike Team entrapments demonstrates the need for additional systems. Essentially, suppression of wildfire is about assessing and managing risk safely. (Graeme Johnstone, State Coroner) One of the advances in contemporary incident management is the enhanced level of operational readiness planning now in place at state, regional and local level. This includes clear fire control objectives established at state level and communicated to preplanned IMTs; pre-planned joint-agency incident communications plans that are developed and agreed upon in advance of an incident; information and intelligence gathering processes; incident prediction modelling; incident mapping capability; and community education and community warnings. All of these advancements have occurred as a result of the application of incremental learnings of our fire services over many years or the applied learnings from transformational change events such as Black Saturday, Linton and Ash Wednesday.

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In the years leading up to Linton, there had been discussion around introducing basic bushfire skills for volunteer firefighters in accordance with nationally agreed training competency framework. This subject had met with some resistance due to the concern about what a compulsory training program might do to volunteer recruitment and retention rates. As a result of the Coroner’s findings into Linton, and following extensive consultation with stakeholders including volunteer firefighters and volunteer fire brigade associations, a competency-based program of basic firefighting known within CFA as ‘Minimum Skills’ training was introduced. This initiative occurred not just in Victoria, but across Australian rural firefighting agencies. To support the ‘Safety First’ approach, and underpinned by the introduction of the competency-based training program, CFA and NRE reviewed operational policies and procedures. Several of these specific procedures related directly to firefighter safety and included, for example, the introduction of a structured briefing process in the SMEACS briefing format (SMEACS being Situation, Mission, Execution, Administration, Command/Communications, and Safety). Along with SMEACS, the firefighter safety prompts of ‘Watchouts’ and the LACES (Lookout, Awareness, Communication, Escape Routes and Safety Refuges) mnemonic were reviewed and re-introduced to firefighters as tools to assist in supporting the ‘Safe Person’ approach. This was based on the risk management principle of a trained, experienced and competent individual forming part of a ‘defences in depth’ model of hierarchical risk controls. Today, the firefighting equipment at the disposal of rural firefighters is significantly advanced from that in place in 1998 when Linton occurred. As a result of extensive equipment research and design programs arising from Linton, significant advancements were made to firefighting tanker design. Programs such as the CFA ‘Tanker of the Future’ initiative were trialled to test new and innovative design features and to re-think the way firefighting is conducted using tankers. Today, the modern tanker has extensive defensive protection systems and safety systems that evolved from the tragedy of Linton. One of the biggest shifts in the response to fire in the natural landscape has been the shift in thinking in regard to community engagement and the way that the wider community is involved in the planning for, and response to, bushfire. Former Victorian Emergency Services Commissioner Bruce Esplin consulted widely with Victorians after emergency incidents in the 2000s and reflected that Victorians ‘want to be active participants, not passive recipients of services.’ The fire services also recognised that they cannot do it alone, and actively engage the community in a collaborative approach to managing fire risk. The deaths of Matthew, Christopher, Stuart, Jason and Garry at Linton on Wednesday 2 December 1998 were a tragedy of the highest order, but their legacy is evident every time a rural firefighter responds to a bushfire aided by the

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management systems, training programs, safety systems and firefighting equipment enhanced by the learnings that came out of the Linton fire. Stay safe. Dedicated to the memory of Matthew Armstrong, Christopher Evans, Stuart Davidson, Jason Thomas and Garry Vredeveldt