THE NARRE WARREN AND 12 UPPER FERNTREE … · 12.1 NarrE WarrEN OvervIew Cause Harkaway:...

12THE NARRE WARREN AND UPPER FERNTREE GULLY FIRES

Volume I: The Fires and the Fire-Related Deaths

182

THE NarrE WarrEN aNd UppEr FErNTrEE GUlly FIrES

On 7 February 2009 a number of small fires burned at the rural–urban interface in Melbourne’s south-east; among them were three fires in Narre Warren (one at Harkaway and two at Lynbrook) and one in Upper Ferntree Gully. The fires burned in grass reserves and scrubland, on residential streets, and in homes and gardens.

Each of the fires might have resulted in far greater and more widespread destruction than eventuated. In particular, the Harkaway and Upper Ferntree Gully fires could have caused severe damage, the latter having had the potential to run into the Dandenong Ranges. In total, seven houses were destroyed.

Figures 12.1, 12.2 and 12.3 show the extent of the fires.

Image 12.1

Source: Courtesy of the Herald & Weekly Times.

12

183

The Narre Warren and Upper Ferntree Gully fires

Figure 12.1 The Harkaway fire

Source: Exhibit 994 – Harkaway Fire – Final Fire Perimeter.1

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Figure 12.2 The Lynbrook—Coral Drive fire

Source: Exhibit 994 – Lynbrook Fire – Final Fire Perimeter.2

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Figure 12.3 The Upper Ferntree Gully fire

Source: Exhibit 994 – Upper Ferntree Gully Fire – Final Fire Perimeter.3

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11:32 17:00

Harkaway fire starts

11:41Harkaway fire initially contained

15:42Upper Ferntree Gully fire starts

Air support requested

The Coral Drive fire in Lynbrook ignites

11:37 15:32 15:55 16:05 16:48

First tanker arrives on scene

Harkaway fire re-ignites

Alert message for Upper Ferntree Gully fire issued

16:30Urgent threat message issued for Upper Ferntree Gully fire

An air crane diverted to Harkaway fire

15:33First tanker arrives on scene

Narre Warren and Upper Ferntree Gully

The following time line summarises events associated with the Narre Warren and Upper Ferntree Gully fires. For the most part, the times given are approximate. Further details about the events are provided in the accompanying narrative.

7 February

7 February

187


First appliances arrive on scene at Golf Club Road fire in Lynbrook

17:42Wind change pushes Coral Drive fire towards Langbourne Drive

Upper Ferntree Gully fire contained

Lynbrook fires reported under control

Urgent threat message issued for Harkaway fire

Harkaway fire contained

19:09Upper Ferntree Gully fire reported under control

18:10Mr Glass takes over as Incident Controller for both Lynbrook fires

18:15Control of Harkaway fire transferred to Belgrave ICC

17:10Downgrade message issued for Upper Ferntree Gully fire

17:08 18:00 19:01 20:29 21:40 21:5018:5017:45

17:27Red flag warning issued to firefighters at Upper Ferntree Gully

Wind change pushes Harkaway fire towards Dandenong Ranges

18:44First alert message issued for Harkaway fire

19:15Strike team redeployed from Lynbrook to Harkaway fire

Downgrade message released for Harkaway fire

18:50Harkaway fire crosses Harkaway Road


188

12.1 NarrE WarrEN

OvervIew

Cause Harkaway: accidental.4

Lynbrook: not determined.5

Fatalities No fatalities.6

Houses destroyed Seven houses.7

Overall area burnt Harkaway: 147 hectares.8

Lynbrook: 12 hectares.9

Firefighting resources On 7 February, 294 CFA, 16 MFB and 12 NEO personnel attended the fires. They were supported by 63 CFA appliances, 4 MFB appliances, 7 NEO appliances and 2 aircraft.10

SeqUenCe OF evenTS12.1.1

Preparation

In the lead-up to 7 February, Country Fire Authority brigades in Region 8 attended other incidents, including the Delburn fires, and planning and preparations were advanced in anticipation of fire escaping Bunyip State Park.11 This meant that some brigades were already fatigued before 7 February.

Mr Trevor Owen, Region 8 CFA Operations Manager, prepared level 3 incident control centres at Pakenham and Moorooduc, and incident management teams were in position on the morning of 7 February. At that time Mr Owen supervised the move of MFB appliances to Dandenong, Springvale, Hallam, Frankston and Patterson River; this released CFA resources in those stations to respond to the Bunyip fire. Later in the day some of the MFB crews responded to fires in Narre Warren.12

From 08:00 on 7 February the Regional Emergency Coordination Centre was running at full capacity.13

The Harkaway fire

The fire at Harkaway began at about 11:32 at a home in Garden View Court. It is suspected the fire was caused by someone using an angle grinder: Victoria Police has charged a man with using a power tool in breach of regulations on a total fire ban day.14

The Narre Warren North tanker was the first to arrive at the Harkaway fire, arriving at 11:37. A number of CFA appliances subsequently attended, including brigades from Dandenong and Hallam. The fire was initially managed by the Narre Warren North CFA Brigade at the local level. The Incident Controller was Mr Shaun Trotter, captain of Narre Warren North Brigade. Both the Moorooduc and Belgrave Incident Control Centres monitored the fire during the early part of its run.15

The fire initially ran to the south-east. It was contained at 11:41 and stopped at 12:23. At 15:32, however, the fire re-ignited on the Robinsons Road side of Crawley Road when a resident cut down a smoking branch, causing burning embers to hit dry fuel on the ground. Once re-ignited, the fire ran towards the south-east under the influence of strong north-westerly winds, crossing Robinsons Road. The fire was again attended by local CFA brigades. Shortly after, additional resources were sought, including from Upper Beaconsfield, Berwick and Cranbourne. Crews worked quickly, and at 16:05 air support was requested. Initially, the Regional Emergency Coordination Centre was unable to secure air resources, but at about 17:00 an air crane en route to the Upper Ferntree Gully fire was diverted to assist.16

189


Mr Owen, the RECC Coordinator, feared that the Harkaway fire could have ‘followed a similar path of destruction to that of Ash Wednesday’. He adopted a ‘triage’ approach and focused on developing priorities for the various fires in the area and identifying where the available firefighting resources would best be deployed.17

The usual Municipal Emergency Response Coordinator for the area was on leave, and no formal arrangement had been made for anyone to fill his position during his absence. Sergeant Sheree Moore performed the duties of the MERC on 7 February, although she had neither been formally appointed to that position nor been trained for the role.18

As the afternoon unfolded Sergeant Moore established roadblocks in the Narre Warren area to control the flow of traffic near the fires. She did this without the benefit of information from the ICC. Later in the day she was able to speak to the Deputy Incident Controller, but her experience was not satisfactory and in her opinion the police had not received adequate information. The lack of information from the ICC made it difficult to situate roadblocks safely—both for residents of the area and for police staffing the roadblocks. From 16:00 Victoria Police set up roadblocks as full road closures; these roadblocks had to be moved a number of times during the ensuing hour because of the speed of the fire.19

The south-westerly wind change arrived at 17:45 and pushed the fire towards the Dandenong Ranges.20

At about 18:15 the fire was formally escalated to the control of the Belgrave ICC. Mr Colin Brown, a CFA operations officer, became the Incident Controller.21

Initially, warnings for the Harkaway fire were handled by the Regional Emergency Coordination Centre. The first warning issued was an alert message at 18:44; it referred to a fire burning in a north-easterly direction between King Road, A’Beckett Road, Harkaway Road and Narre Warren North Road. Mr Brown stated that at the time the alert message was sent the fire was already ‘burning out to the Harkaway Road area’. The alert warning was thus too late and of little use to residents.22

The fire crossed Harkaway Road at 18:50 and burnt the area between Helleur and King Roads.23

At 20:29 the Belgrave ICC released an urgent threat message for Harkaway, Narre Warren North and Beaconsfield Upper. Mr Brown explained that the message was issued ‘because of the wind change that had come through and was driving the fire in a north-easterly direction and threatening those areas at that stage’. But the wind change had occurred two hours before, and Mr Brown was unable to explain why the message was not issued earlier.24

Subsequently, at 21:40, a downgrade message was released for the Harkaway fire.25

By 21:50 the fire was contained.26

An alert message was issued at 23:11, saying fire activity was continuing. At 01:25 on 8 February a downgrade message was authorised: it advised that the communities of Harkaway, Narre Warren North and Beaconsfield Upper no longer needed to be on alert.27

Overall, the Harkaway fire burnt 147 hectares and destroyed and damaged a number of homes, sheds, garages and outbuildings.28

The Lynbrook fires

The Coral Drive fire in Lynbrook started at 16:48 in a grassy area along Coral Drive in Narre Warren South. The grassy area appears to have acted as a corridor, assisting the fire’s spread to the boundaries of properties on Langbourne Drive. The cause of the fire has not been determined. Having initially run along the grassy reserve beside Coral Drive, it then headed north-east and crossed Ormond Road.29

At about 16:52 Mr Arthur Haynes, a CFA operations officer from the Moorooduc ICC attended the Narre Warren North CFA Control Centre to help the local Incident Controller, Mr Trotter. At 17:40 Mr Haynes became the Incident Controller for the Coral Drive fire and appointed Mr Trotter as his operations officer. Together they divided the fire into sectors and deployed resources accordingly. The strategy was to contain the fire and stop its spread into the Dandenong Ranges.30


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Mr David Beards, captain of the Narre Warren Brigade, arrived at the Coral Drive fire at 16:55, some seven minutes after ignition. At 17:10 he was advised that a strike team was on its way but that no further resources were immediately available. Subsequently, a number of appliances attended the fire, among them MFB crews and appliances that were covering CFA stations in Dandenong, Hallam and Pakenham.31

Another fire, at Golf Club Road in Lynbrook, was first reported at 17:08, when a member of the public telephoned the Cranbourne fire station. The fire’s point of origin was in grassland on the western side of the South Gippsland Highway, about 300 metres north of Golf Club Road. The cause of the fire has not been determined.32

At 17:08 appliances, including MFB resources, started arriving at the fire. A strike team arrived at 17:30, and from 17:40 onwards a number of additional appliances attended.33

Shortly after the fire started it crossed the South Gippsland Highway and entered grassland, threatening a landscaping business where quantities of LPG, petrol, diesel and other chemicals were stored, and damaging a shed.34

After the wind changed from south to south-westerly at 17:42, the Coral Drive fire headed to Langbourne Drive and into the transmission line reserve. It then spotted back onto the other side of Ormond Road. With the assistance of firefighting crews, residents of Langbourne Drive tried to defend their properties with buckets and wheelie bins full of water. A number of houses were destroyed. Those burnt on Langbourne Drive were relatively new houses built on suburban-sized blocks and positioned very close together. The land was mainly flat, and there was limited vegetation along the roads.35

Mr Beards stated that one of the features of the Coral Drive fire was ‘that the residents banded together to help protect their properties … with buckets, hoses, anything that could carry water to assist in the fire fight’. One house that had a swimming pool was able to be saved because of the availability of water from the pool.36

The two Lynbrook fires were initially managed separately. At 18:10, however, Mr Ian Glass, a fire officer with the Cranbourne Brigade, took over the role of Incident Controller for both fires. By 19:01 both fires were reported as being under control. At about 19:15 the strike team was redeployed to the Harkaway fire.37

At some time between 19:00 and 19:30 Sergeant Moore received a phone call from Senior Sergeant Hengel (the officer normally assigned to be the Municipal Emergency Response Coordinator), who told her she should activate the Municipal Emergency Control Centre. Shortly thereafter the MECC was opened in Vesper Drive, Casey.38

Sergeant Moore agreed that, considering the impact of the Coral Drive fire on the houses on Langbourne Drive, it would have been prudent to establish the MECC earlier, when the damage occurred. She also acknowledged that more formal arrangements about who would fill the role in the absence of the usual MERC would have been helpful. The Commission was advised that since 7 February steps have been taken to improve the relevant police service areas’ preparedness for fire.39

No formal warnings appear to have been issued for the Lynbrook fires, which burnt 12 hectares and destroyed homes.40

COnCLUSIOnS12.1.2

Residents of Narre Warren and police in the Casey Police Service Area were surprised by the outbreak of fire in an urban area. In its subsequent research into the three fires, the Bushfire Cooperative Research Centre found that very few residents expected to be affected by bushfire.41

The initial attack efforts devoted to each of the fires were successful, and the cooperative arrangements between the MFB and the CFA worked well. Effective managing, resourcing and firefighting on the ground—noting the limited availability of resources in the region from 14:30—averted possible widespread damage to the Dandenong Ranges.42

The Commission considers that some of the delays and confusion in communications relating to this fire, and the lack of information flowing to Victoria Police, might have been avoided by earlier escalation of incident management to the Belgrave ICC.

A delay of about two hours in issuing warning messages for any fire is not acceptable. It is unlikely, however, that the delay caused any major detriment to residents, who were apparently alerted to the fires by smoke or information received from friends, family and neighbours.43

191


12.2 UppEr FErNTrEE GUlly

OvervIew

Cause Unknown.44

Fatalities No fatalities.45

Houses destroyed No houses destroyed.46

Overall area burnt 4 hectares.47

SeqUenCe OF evenTS12.2.1

The Upper Ferntree Gully fire started at about 15:42, near the Burwood Highway and Quarry Road. It was difficult for firefighters to gain access to the fire because there was a railway line nearby. The cause of the fire is not known.48

The fire initially spread south-east through scrubland between the Burwood Highway and Quarry Road. It was spotting in various places along the edge of the Burwood Highway.49

From 15:42 onwards a number of brigades were dispatched to the fire. Mr Todd Small, the Ferntree Gully CFA captain, attended the scene and at 15:47 asked for five tankers and then a further three. He established an operations point behind 1140 Burwood Highway at about 16:00.50

Prompt warnings were issued for the fire. An alert message for Ferntree Gully and Upper Ferntree Gully was authorised at 15:55. At 16:30 an urgent threat message was sent to the integrated Emergency Coordination Centre for the residents of Quarry Road and the communities of Upper Ferntree Gully, Ferntree Gully and Tremont. The message was downgraded at 17:10.51

Mr Colin Brown, CFA Incident Controller at the Belgrave ICC, was informed at 16:37 that the State Duty Officer was sending an air crane to the fire. The air support was diverted, however, to protect assets at Harkaway. At 17:04 a Helitack on its way to Moorabbin for refuelling made a number of rapid drops on the fire, obtaining water from a nearby disused quarry. The Helitack’s assistance was vital. Mr Brown explained that when the aircraft arrived the fire had begun to spread to the northern side of Quarry Road and was heading towards residential properties.52 The Helitack made a single drop and caught the fire right on the cusp of a wind change from the south-west:

By pulling that fire up they prevented the fire possibly spreading … into the Tremont – Ferny Creek area. We estimate probably within 10 to 15 minutes … [it] would have been impacting on those houses up there and this would have been a significant event.53

At 17:14 Mr Brown received advice that the wind change had reached Moorabbin airport, and a red flag warning was issued by radio to all vehicles in the area at 17:27.54

After the south-west wind change the fire spread between homes on the northern side of Quarry Road and headed towards Ferntree Gully National Park. At this time there were wind gusts of up to 90 kilometres an hour.55

By 17:30 there were eight tankers, three slip-ons and three pumpers on the ground. The Helitack was still working over the fire as it burned towards Lady’s Walk and the Boulevard.56

The fire was contained by 18:00, and by 19:09 it was declared under control. Four hectares were burnt, but no houses were lost.57

COnCLUSIOnS12.2.2

The Commission notes the opportune arrival of the Helitack and commends the efforts of firefighters. This averted possible widespread damage to the Ferny Creek area and the Dandenong Ranges which posed a very significant potential threat to human life.


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1 Exhibit 994 – Harkaway Fire – Final Fire Perimeter (CFA.600.006.0002)

2 Exhibit 994 – Lynbrook Fire – Final Fire Perimeter (CFA.600.006.0001)

3 Exhibit 994 – Upper Ferntree Gully Fire – Final Fire Perimeter (CFA.600.006.0003)

4 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [22]–[23], [37]–[38], Annexure 9 (WIT.3004.029.0171) at 0171; Brown T13050:16–T13050:24; Exhibit 608 – Statement of Moore, Annexure 4 (WIT.3010.007.0274) at 0274

5 Exhibit 602 – CFA Incident Report (CFA.001.025.0223); Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [14]–[15], Annexure 3 (WIT.3004.029.0074); Exhibit 606 – Statement of Booth, Annexure 1 (WIT.3004.029.0006) at 0011–0012; Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0092; Exhibit 602 – Victoria Police Incident Fact Sheet (CORR.0910.0033)

6 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0110, 0114

7 Exhibit 980 – Correspondence – Houses Destroyed – Breakdown by Fire (CORR.1003.0048_R) at 0048_R

8 Exhibit 786 – Statement of Clow (WIT.3004.034.0004) [19.4]


10 Exhibit 939 – Details Regarding Emergency Response (CFA.600.005.0195) at 0195, 0198; Exhibit 939 – MFB Response (MFB.001.001.0040) at 0040; Exhibit 939 – Day by Day Breakdown – Narre Warren (DSE.HDD.0048.0545_20); Exhibit 939 – Aircraft Data 0809 (DSE. HDD.0048.0544_20) at 0544_25

11 Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [33], [39]

12 Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [21]–[25], [66]–[67], [123], [134]; Brown T13052:27–T13053:7

13 Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [115]

14 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [22]–[23], [37]–[38], Annexure 9 (WIT.3004.029.0171) at 0171; Brown T13050:16–T13050:24; Exhibit 608 – Statement of Moore, Annexure 4 (WIT.3010.007.0274) at 0274

15 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [39]–[45], [55]; Brown T13053:8–T13053:28

16 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [46]–[47], [49]–[53], [64]; Brown T13051:8–T13051:23; Graystone T6034:3–T6034:16, T6073:9–T6073:17

17 Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [150], [156], [161]; Owen T12936:11–T12936:16

18 Exhibit 608 – Statement of Moore (WIT.3010.007.0206) [23]; Moore T13079:16–T13079:27

19 Exhibit 608 – Statement of Moore (WIT.3010.007.0206) [36]–[40]; Moore T13081:14–T13081:28, T13082:7–T13084:12, T13085:16–T13085:30

20 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [71]; Brown T13054:8–T13054:24


22 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [75], Annexure 11 (WIT.3004.029.0204); Brown T13056:28–T13056:31, T13057:4–T13057:7

23 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [66], [77]–[79], [97], Annexure 4 (WIT.3004.029.0142_R) at 0142_R; Brown T13051:29–T13051:31

24 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [90], Annexure 13 (WIT.3004.029.0209); Brown T13057:22–T13057:31, T13058:3–T13058:10

25 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [95], [99], [107], Annexure 14 (WIT.3004.029.0212), Annexure 15 (WIT.3004.029.0215), Annexure 19 (WIT.3004.029.0239)

26 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [66], [77]–[79], [97], Annexure 4 (WIT.3004.029.0142_R) at 0142_R; Brown T13051:29–T13051:31

27 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [95], [99], [107], Annexure 14 (WIT.3004.029.0212), Annexure 15 (WIT.3004.029.0215), Annexure 19 (WIT.3004.029.0239)

28 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [23], Annexure 3 (WIT.3004.029.0140) at 0140, Annexure 4 (WIT.3004.029.0142_R) at 0142_R; Exhibit 606 – Statement of Booth, Annexure 1 (WIT.3004.029.0006) at 0010–0011, 0016–0026; Exhibit 786 – Statement of Clow (WIT.3004.034.0004) [19.4]

29 Exhibit 602 – CFA Incident Report (CFA.001.025.0223); Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [14]–[16], Annexure 3 (WIT.3004.029.0074); Exhibit 606 – Statement of Booth, Annexure 1 (WIT.3004.029.0006) at 0011–0012; Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0092

30 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [55], [57]–[58], [63]

31 Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [29]–[30], [34], Annexure 5 (WIT.3004.029.0105) at 0106; Beards T13075:3–T13075:18; Exhibit 576 – Supplementary Statement of Murphy (WIT.3006.001.0263) [12]; Murphy T12588:23–T12589:5

32 Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [45], Annexure 6 (WIT.3004.029.0110) at 0110; Exhibit 608 – Statement of Moore, Annexure 5 (WIT.3010.007.0277) at 0278; Exhibit 602 – Victoria Police Incident Fact Sheet (CORR.0910.0033)

33 Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [45]–[46], [48]–[49], [53]–[64]

34 Exhibit 608 – Statement of Moore, Annexure 5 (WIT.3010.007.0277) at 0277; Exhibit 602 – Victoria Police Incident Fact Sheet (CORR.0910.0033); Beards T13072:29–T13073:18

35 Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0086, 0094–0102; Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [17], [32]; Murphy T12596:18–T12596:28

193


36 Exhibit 605 – Statement of Beards (WIT.3004.029.0056) [38]–[39]; Beards T13069:11–T13069:13, T13069:21–T13069:28; Exhibit 606 – Statement of Booth, Annexure 1 (WIT.3004.029.0006) at 0011, 0016–0026; Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0091

37 Exhibit 604 – Statement of Brown (WIT.3004.029.0056) [55], [58], [66]–[68], Annexure 1 (WIT.3004.029.0006) at 0011, 0016–0026; Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [66]; Beards T13069:11–T13069:13

38 Exhibit 608 – Statement of Moore (WIT.3010.007.0206) [52]–[55]; Moore T13084:13–T13084:21

39 Exhibit 608 – Statement of Moore (WIT.3010.007.0206) [48], [76], [88]; Moore T13086:11–T13086:18, T13085:4–T13085:11

40 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [23], Annexure 3 (WIT.3004.029.0140) at 0140, Annexure 4 (WIT.3004.029.0142_R) at 0142_R; Exhibit 606 – Statement of Booth, Annexure 1 (WIT.3004.029.0006) at 0010–0011, 0016–0026; Exhibit 786 – Statement of Clow (WIT.3004.034.0004) [19.7]

41 Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0090

42 Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [144], [147]

43 Exhibit 602 – Bushfire CRC Supplementary Report (CRC.301.001.0001) at 0090–0091

44 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [25], [114], Annexure 5 (WIT.3004.029.0144), Annexure 22 (WIT.3004.029.0248) at 0248; Brown T13061:27–T13061:28

45 Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0112

46 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [28]


48 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [25], [114], Annexure 5 (WIT.3004.029.0144), Annexure 22 (WIT.3004.029.0248) at 0248; Brown T13061:27–T13061:28


50 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [115]–[121], [124]

51 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [125], Annexure 23 (WIT.3004.029.0255), Annexure 24 (WIT.3004.029.0258) at 0258, Annexure 27 (WIT.3004.029.0274)

52 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [64], [74], [77], [127], [130]; Brown T13062:1–T13062:17, T13063:18–T13063:25

53 Brown T13062:11–T13062:17

54 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [133], Annexure 6 (WIT.3004.029.0146_R) at 0146_R; Brown T13063:29–T13064:2


56 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [136]–[137]

57 Exhibit 604 – Statement of Brown (WIT.3004.029.0112) [28], [138], [144], Annexure 29 (WIT.3004.029.0278)


194



13THE BENDIGO FIRE


196

The City of Greater Bendigo is about 150 kilometres north-west of Melbourne. The city itself, centrally located in the municipality, is one of Victoria’s main regional centres.

The Bendigo fire started shortly after 16:00 on 7 February 2009 in Maiden Gully, 8 kilometres north-west of the central business district. It burned through gently rolling country bordering the city’s western suburbs, where there are numerous former gold diggings that are now public open space interspersed between suburban blocks. The fire burned for six hours in the late afternoon and evening, running for about 5.5 kilometres to the south-east before the wind changed at about 18:45 and pushed the flames to the north-east, further into suburban Bendigo. About half of the area burnt was public land. One fatality occurred, a number of people were injured, and 58 houses were destroyed. Figure 13.1 shows the extent of the fire.

Overview

Maximum temperature The maximum temperature recorded was 45.4°C at Bendigo automatic weather station.1

Minimum relative humidity The minimum relative humidity recorded was 6 per cent at Bendigo AWS at 13:16.2

Wind The maximum winds recorded before the wind change were north-westerly at 41 kilometres an hour at 17:01.3

The wind change was recorded by the Bendigo AWS at 18:45 at 35 kilometres an hour.4

The maximum winds recorded after the wind change were south-westerly at 35 kilometres an hour at 18:45.5

Fire danger index The maximum Grassland Fire Danger Index was 129 at Bendigo AWS at 13:31.6

Cause Suspicious.7

Fatalities One fatality.8

Casualties Forty-one casualties.9

Houses destroyed Fifty-eight houses.10

Overall area burnt 341 hectares.11

Firefighting resources On 7 February, 152 CFA and 111 NEO personnel attended the fire. They were supported by 30 CFA appliances, 31 NEO appliances and 3 aircraft.12

13 THe BendigO Fire

197

The Bendigo fire

Figure 13.1 The Bendigo fire

Source: Exhibit 994 – Maiden Gully Fire – Fire Spread Map.13

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198

Bendigo

The following time line summarises events associated with the Bendigo fire. For the most part, the times given are approximate. Further details about the events are provided in the accompanying narrative.

7 February – 9 February

16:20 16:30 16:50 17:00

16:20Fire starts in Maiden Gully

Residents try, without success, to call 000

16:30Eaglehawk CFA Brigade notified of fire

16:50Police arrive, start directing traffic and evacuations and establish roadblocks

17:00Eaglehawk Leisure Centre opened as emergency relief centre

18:00Spot fire in Lilac Street extinguished by residents

Embers extinguished several kilometres south of fire

16:40First CFA tanker arrives on scene

Eaglehawk CFA captain assumes role of Incident Controller at fire ground

17:14Fire sectorised

17:30Fire jumps Maiden Gully Road

18:04Information officer arrives at Adam Street ICC17:17

Awareness message posted to CFA website

16:45Adam Street ICC Incident Controller appointed

18:047 February

199

The Bendigo fire

18:42ABC Bendigo begins regular fire-related broadcasts

19:10Operations officer sent from Redesdale; establishes operations point at fire ground

21:30Endorsed level 3 Incident Controller takes control of the IMT

18:45Wind change extends fire to north-east

18:30Adam Street ICC makes first contact with the fire ground

Endorsed level 3 Incident Controller arrives at Adam Street ICC to assist

MECC becomes fully operational

Information officer tries to distribute first urgent threat message

19:00Team arrives from Epsom ICC; Deputy Incident Controller appointed

21:00Operations officer arrives at Adam Street ICC; briefs the IMT

21:52Fire declared contained

03:00Fire declared safe

18:30 18:45 19:00 9 February


200

13.1 Sequence OF evenTS

PreParaTiOn13.1.1

Bendigo is in the same CFA region as Redesdale, so preparations for Bendigo were the same as those for Redesdale (see Chapter 11). On 6 February Mr John Deering, Operations Manager of CFA Region 14, and Department of Sustainability and Environment acting Area Land and Fire Manager, Mr Andrew Matthews, set up a joint level 3 incident management team at the Epsom Incident Control Centre, for a ‘hot start’ the following day. Many of the IMT members selected for the hot start were at the ICC on 6 February and used that day to test and confirm ground observer arrangements and begin fire behaviour prediction work. Those present also participated in a practice scenario involving a multi-agency response to a level 3 fire.14

A fully staffed IMT was at the Epsom ICC on the morning of 7 February. Mr Deering was there from 08:30 and shared the leadership role with Mr James Dalton, DSE Assistant Manager, Fire and Emergency Management. Both men were accredited level 3 Incident Controllers.15

What was not contemplated in the detailed preparations at the Epsom ICC was the possibility that a second level 3 fire would demand further incident management resources. The possibility became reality, and the Epsom IMT felt unable to manage two complex fires that were about 40 kilometres apart.16

The Municipal Emergency Resource Officer had confirmed on 6 February the availability of council staff for emergency response and recovery and placed the council’s seven water tankers and six graders on standby.17

Table 13.1 summarises the state of preparedness for the Bendigo fire.

Table 13.1 The Bendigo fire – iMT preparedness

Pre-designated level 3 iCC No18

Pre-formed iMT at iCC No19

Pre-identified level 3 iC No20

Pre-identified iMT members No21

Time fire started Approximately 16:2022

Full iMT in place by Approximately 21:3023

Safety adviser appointed No24

7 FeBruary13.1.2

Origin and cause

Ms Kirsty Tinker-Casson of Bracewell Street, Maiden Gully, was home alone on the afternoon of 7 February when at about 16:20 she noticed flames coming from the edge of the creek near her home. She tried to ring 000, without success at first; by the time she did get through, the fire was racing alongside the creek.25

Police investigations determined the cause of the Bendigo fire to be suspicious. In order not to prejudice criminal investigations and proceedings, limited evidence was presented to the Commission concerning the cause of the fire.26

Fire run, response and management

Mr Eric Smith, captain of the Eaglehawk CFA brigade, was at the Eaglehawk fire station on 7 February when, at about 16:30, two private cars arrived and the drivers told him there was a fire in Bracewell Street that was ‘going pretty well’. The Eaglehawk pumper turned out immediately, and Mr Smith notified VicFire of the fire. As the Eaglehawk pumper travelled towards the fire Mr Smith could see the growing smoke column and made a series of requests for tankers to be dispatched.27

201

The Bendigo fire

The fire initially travelled south-east and quickly built into a ferocious fire, crowning in trees less than 20 metres from the area of its origin.28

Mr Smith and the Eaglehawk pumper arrived on the scene at about 16:40 and were soon joined by the Bendigo tanker. Together they were able to extinguish the edge of the fire near the point of origin, protecting nearby houses. As other tankers arrived Mr Smith directed them to work along both flanks of the fire, concentrating on the eastern edge.29

At about 16:45 the Adam Street ICC was assigned to manage the Bendigo fire. This facility was a level 2 CFA incident control centre; it had been staffed in preparation for the day as a group coordination centre. It became the ICC for the Bendigo fire because by this time the Epsom ICC was already fully engaged responding to the Redesdale fire (see Chapter 11), which had begun more than an hour before the Bendigo fire. The Redesdale Incident Controller did not think his team had the capacity to manage a second complex fire at the same time.30

CFA Group Officer Mr Peter Rogasch had been at Adam Street since morning and assumed the role of Incident Controller. Although he was an experienced firefighter, at the time he had no qualifications or experience as a level 3 Incident Controller.31

From the beginning, the Adam Street ICC was hampered in its efforts by poor radio and telephone communications. Repeated attempts to use the telephones, both landline and mobile, met with little success. In addition, the ICC had no access to the CFA’s Incident Management System from either of its two computers.32

The first alert for the Bendigo fire, in the form of an unofficial verbal awareness message, was broadcast on ABC Bendigo at 16:52; this was done from the information unit at the Epsom ICC because there was no information officer at the Adam Street ICC during the initial stages of the fire. The first official fire information release was broadcast on ABC Bendigo at 17:10, informing listeners of a fire near Bracewell Street, Eaglehawk. An urgent threat message, also prepared by the Epsom ICC, was posted to the CFA website.33

At about 17:00 Senior Sergeant Grant Morris, the Municipal Emergency Response Coordinator, asked Mr Alexanda Malone, the Municipal Emergency Resource Officer for Greater Bendigo Council, to open an emergency relief centre for residents evacuating from Bracewell Street: the Eaglehawk Leisure Centre was opened.34

As first officer on the scene, Mr Smith had assumed the role of Incident Controller and had established a control point at Bracewell Street. He was unaware of the Adam Street ICC until much later in the day. At about 17:14 he made contact with Mr Greg Stead on Bendigo Pumper 1, and together they divided the fire ground into two sectors. Mr Smith continued as sector commander of the north and Mr Stead became sector commander of the south.35

Within 35 to 40 minutes of being reported the fire was approaching Maiden Gully Road, near Bonazza Road. Despite appliances having responded to the southern end of the fire, it crossed Maiden Gully Road near Albert Street at about 17:30 and was so intense it melted the asphalt. By this time there were already three spot fires about 2 kilometres to the south-east of the main fire.36

Mr Peter Beaton, a communications officer employed by DSE at its Epsom office, was rostered to work as an information officer at the Epsom ICC from 17:00 on 7 February. Not long after 17:30 he was directed to go to the Adam Street ICC to fill the position of information officer.37

The fire continued with high intensity, crowning in small patches of forest on both sides of Albert Street. The fire’s initial south-eastern run was halted at an area of forested Crown land known as the Dai Gum San diggings, where a fuel-reduction burn had been conducted the previous spring. This restricted the width of the firefront moving into suburban Bendigo by about 40 per cent and, the Commission was advised, limited the fire’s impact at that time.38

DSE slip-on units arrived near Victoria Hill diggings, where they directly attacked the fire. A DSE crew arrived with a bobcat, and staff were directed to cut firebreaks in grassland at the intersection of Marong Road (the Calder Highway) and Eaglehawk Road. The strategy was to contain the fire at Upper California Gully Road and to extinguish any spot fires that started to the east of that line. Consistent with this, resources were directed to work in the Upper California Gully Road – Eaglehawk Road – Victoria Street area, extinguishing any spot fires and cutting breaks along the northern flank of the fire.39


202

The fire continued to crown, causing spotting that carried it over some areas of low fuel and into grasslands and backyards in the areas of Daniel Street, Walker Street and Cunneen Street. At about 17:30 a resident lost his life after being overcome by flames outside his home in Daniel Street.40 The circumstances surrounding his death are considered in Chapter 19.

Crowning continued to carry the fire into the Watkins Street and Happy Valley Road areas, and spot fires were occurring several kilometres downwind. Among the spot fires was one near the intersection of Lily Street and Chum Street, which threatened Fortuna Villa (a heritage-listed 19th century villa estate) and St John of God Hospital. This fire was brought under control within about 15 minutes.41

As the fire progressed further south-east it burned through an area that had been subject to fuel-reduction burning in 2006. The Commission was advised that the reduced fuel load again diminished the intensity of the fire, even as it travelled uphill.42

Mr Mike Wassing, an endorsed level 3 Incident Controller, was at home on 7 February and, after learning of the Redesdale fire, went to the Bendigo Regional Emergency Coordination Centre to offer his assistance. He arrived at 17:40 and quickly realised that the Adam Street ICC needed more resources. At about 18:00 he telephoned Mr Pat O’Brien, CFA General Manager for the North West Area, and informed him of the Bendigo fire and discussed resources. Mr O’Brien asked Mr Wassing to go to the Adam Street ICC to help Mr Rogasch. Mr Wassing did so, arriving at 18:30.43

Box 13.1 evacuation and roadblocks

Sergeant Craig Gaffee became aware of the fire in the Maiden Gully area at 16:44 and assumed the role of Forward Commander for the fire. From the time he was able to assess the fire as it approached Maiden Gully and Bonazza Roads, one of his priorities was to warn people of the danger and to tell them to either leave or put their fire plan into operation.44

Initially Sergeant Gaffee had three police units available; more units arrived during the afternoon. Traffic management was also a priority, but Sergeant Gaffee tried to keep himself and two other units free of roadblocks so they could warn people being threatened by fire to evacuate if that was their plan. He found that an effective way of gaining attention was to drive along a street using the police vehicle’s siren and public address system to alert residents to the fact that the fire was approaching. Where possible, he and other police also went door to door.45

Evacuation of residents in areas under threat was carried out at Sergeant Gaffee’s initiative in the face of a crisis, not at the request or direction of the CFA as control agency for the fire. During the early hours of the fire he had limited information about the fire’s movement and extent. The knowledge he did have was gained by his own direct observations and those of other police, as relayed through the police communications network, D24.46

With the resources that were available initially, police were able to warn only a limited number of residents.47 It would, however, have been impossible in conditions as extreme as those experienced on 7 February to ensure that all individuals were warned by police.

Sergeant Gaffee’s other priority in responding to the Bendigo fire was traffic management. Starting at 16:50, when he arrived at Bonazza Road, he directed the available police units to establish roadblocks at strategic points in order to restrict traffic from entering the fire area. During the next three hours he monitored the movement of the fire as best he could and deployed units as they became available to crucial intersections, keeping ahead of the fire. He observed that, because of limited resources and poor communication, it was initially difficult to establish enough roadblocks. Additionally, the Bendigo fire was burning in a built-up area, so people were able to avoid roadblocks by taking back roads.48 The Commission commends the efforts of Victoria Police to warn residents and ensure their safety on the roads.

203

The Bendigo fire

At 17:55 Senior Sergeant Morris telephoned Mr Malone to ask him to activate the Municipal Emergency Coordination Centre. Mr Malone called the relevant council staff, two of whom were not able to respond because they were directly involved with the fire themselves. Mr Malone and the council’s Chief Executive Officer, Craig Neiman, opened the MECC at Bendigo Town Hall. It was fully operational by about 18:30.49

In the meantime, Senior Sergeant Morris had been alerted to the fact that the expected wind change would push the fire towards Eaglehawk, placing the emergency relief centre at risk. He asked Mr Malone to relocate the relief centre. Accordingly, the emergency relief centre was moved to the Kangaroo Flat Senior Citizens Centre. People who had gone to the Eaglehawk Leisure Centre were transferred to Kangaroo Flat.50

At about 18:00 residents were extinguishing embers in Breen Street, several kilometres south of the main fire. Another spot fire, in Lilac Street, was discovered by residents and put out at about this time. By 18:30 the fire was 5.5 kilometres long and had almost reached the Calder Highway, between Happy Valley Road and Dare Street. The head of the fire was only 2 kilometres from Bendigo’s central business district, and there was a spot fire three blocks from the Bendigo police station.51

image 13.1



204

Mr Beaton, the information officer from the Epsom ICC, arrived at Adam Street at 18:04. He immediately set about gathering information about the fire, with the intention of issuing an urgent threat message as soon as possible. When he did try to issue the message, however, he encountered a series of technical problems that resulted in many emails not reaching the intended recipients. The problems Mr Beaton experienced with the official channels for issuing warnings might explain why no urgent threat messages for the Bendigo fire appeared on the CFA website between 17:17 and 21:37 and no further urgent threat messages were broadcast on 774 ABC radio until 22:52.52

When Mr Beaton discovered that the urgent threat messages were not being distributed he contacted local radio stations directly, asking them to send out the messages. This was effective: ABC Bendigo broadcast updated fire information at 18:42, 18:58 and 19:17.53

No-one from the Adam Street ICC was able to make contact with Mr Smith on the fire ground until some time between 18:10 and 18:30. Until then, he acted as the Incident Controller with no knowledge that the Adam Street IMT had been established.54

Mr Jeff Wilkie, Assistant Fire Management Officer with DSE, was on standby for air operations at Bendigo airport. The operations officer at the Epsom ICC asked him to help coordinate the DSE resources responding to the Bendigo fire. Mr Wilkie was similarly unaware of the existence of the Adam Street IMT and until 20:20 provided situation reports only to the Epsom ICC.55

The wind, which had been tending from north-west to west, swung to the south-west at about 18:30. After this the fire was pushed initially to the east and then to the north-east. It made major runs into the back areas of homes along Eaglehawk Road and threatened others along Upper California Gully Road. Spot fires occurred on the eastern side of these roads and north of the Eaglehawk rubbish tip. When the fire entered the tip its impact was considerably diminished, although, because of the fire’s intensity, it did spot over the tip.56

After discussion with Mr Deering at about 18:30, Mr Mark Gilmore, an operations manager with the CFA, agreed to leave the Epsom ICC and help the field commanders at the Bendigo fire. He arrived at the head of the fire, near the Calder Highway, as the wind was changing and assumed the role of divisional commander.57

Having spoken with Mr Wassing, Mr O’Brien alerted Mr Russell Manning, DSE District Manager for the Mallee, to the need to send additional resources to the Adam Street ICC to assist with management of the Bendigo fire. After discussion with Mr Deering and other DSE managers, it was decided that Mr Manning would take a number of people with him from the Epsom ICC to help out at Adam Street. They arrived at 19:00, at which point Mr Manning was assigned the role of Deputy Incident Controller.58

Mr Gilmore also had problems with radio communication and was unable to make radio contact with the field commanders. At 18:30, Mr Gilmore left the Adam Street ICC to help field commanders at the fire. Just prior to 19:00, he drove to Bracewell Street in an attempt to locate the control point. At 19:10 he found Mr Smith in Upper California Gully Road, and together they went to the intersection of Eaglehawk Road and Upper California Gully Road, where they established an operations point. At about 19:15 Mr Gilmore held a briefing at the operations point, using the bonnet of his vehicle on which to formulate a strategy for containing and re-sectorising the fire.59

The first official advice to the public about the location of an emergency relief centre came in an urgent threat message issued at 19:00; it identified the Eaglehawk Leisure Centre. Even though that centre had been closed, this advice was repeated until 21:30, when the Kangaroo Flat Senior Citizens Centre was named the emergency relief centre.60

By 19:22 the winds had subsided somewhat and it was possible to use air support. A helicopter was directed to provide fire-bombing support on the running edge of the fire, where there were no tankers. Once ground crews arrived, the fire-bomber moved to the western side of the fire to protect some of the more remote dwellings.61

Back at the Adam Street ICC Mr Wassing’s skill and experience as a level 3 Incident Controller quickly became apparent. At about 19:30 he and Mr Rogasch agreed that Mr Wassing should take over as Incident Controller, although he did not formally assume the role until 21:30. Mr Wassing’s presence, together with the arrival of

205

The Bendigo fire

a number of personnel from the Epsom ICC, and improved information flows from the fire ground, meant the Adam Street IMT became more functional. By the time of the briefing for the night-shift IMT at about 21:30, Mr Wassing was able to concentrate on pressing matters such as liaison with the Municipal Emergency Coordination Centre, traffic management, and safety concerns arising from gas leaks and fallen power lines. The Bendigo fire was by this time largely under control, having been contained in the area of Happy Valley Road and Marong Road (the Calder Highway) by 19:47.62

At about 19:45 Mr Gilmore eventually made contact with the Adam Street ICC when Mr Rogasch telephoned him, telling him that the ICC was operating, that he was the Incident Controller, and that Mr Gilmore should work through him. Mr Rogasch asked Mr Gilmore to come to the ICC to provide a briefing on the status of the fire. Mr Gilmore arrived at the ICC at about 21:00 and shortly afterwards gave a full briefing to the IMT.63

At 20:00 the southerly wind had dropped further, and the fire behaviour moderated. The fire was contained at 21:52 on 7 February and was declared safe at 03:00 on Monday 9 February.64

The fire caused one death, 41 casualties and destroyed 58 houses as it burned along the fringe of Bendigo, covering 341 hectares. A total of 47 tankers responded during the course of the fire.65

The Municipal Emergency Coordination Centre remained operational and staffed until 17:45 on Sunday 8 February. It closed that night but was then open during business hours from Monday 9 February until Monday 16 February. The emergency relief centre at Kangaroo Flat was closed on 9 February, when the Eaglehawk Senior Citizens Centre was opened as a recovery centre. The Red Cross registered 345 people at the Kangaroo Flat emergency relief centre on 7 and 8 February, about 100 of them staying on the Saturday night.66

13.2 cOncluSiOnS

Although planning and pre-positioning of staff at the Epsom ICC were effective, management in CFA Region 2 did not plan adequately for the possibility of more than one major fire in the region. When the second fire did break out on the outskirts of Bendigo, facilities and the personnel available to manage the incident were inadequate. Qualified staff were concentrated at the Epsom ICC and the Adam Street ICC facilities were unsatisfactory. The latter ICC was largely disconnected from the Bendigo fire response, particularly in the crucial hours before and immediately after the wind change.

Despite this, credit is due to the firefighters who responded to the Bendigo fire: they were able to respond operationally to fighting the fire, establish a working incident management structure, and deploy resources effectively. They did this in circumstances in which radio communications were poor, which could explain why many people at the fire ground were unaware of the Adam Street ICC until so late in the day.

The almost total breakdown in radio communication between the fire ground and the Adam Street ICC was an important feature of the Bendigo fire. Mr Gilmore gave evidence of repeated unsuccessful attempts to contact the CFA field commanders using the CFA radio. By all accounts, his radio appeared to be functioning since he was able to talk with other people and could hear radio traffic. Mr Wilkie of DSE experienced similar radio communication problems from the fire ground, which suggests that it was not only the CFA’s radio system that was struggling. Witnesses attributed these problems to a number of causes, among them heat and smoke and the inadequate facilities at the Adam Street ICC.67 Communication issues are discussed in greater detail in Chapter 3 of Volume II.

Additionally, the lack of a pre-positioned information officer and basic computer facilities at the Adam Street ICC impeded the provision of prompt warnings and advice to the public.

There was confusion about the location of the emergency relief centre, and the public received poor advice about suitable venues for people who were evacuating. This confusion might have been avoided had there been better communication between the Adam Street ICC and the Municipal Emergency Coordination Centre—in particular, with earlier attendance by a CFA liaison officer.68


206

An inter-agency initiative that did work well, though, was the allocation of a police member to each of the sector commanders for the Bendigo fire. This was arranged through the MECC during the evening of 7 February. The arrangement proved mutually beneficial: the police were able to help the sector commanders deal with small concerns before they became big problems, and their presence in the sector commanders’ vehicles meant they had access to good information about the fire situation.69

1 Exhibit 22 – Statement of Williams, Annexure 1 (WIT.013.001.0012) at 0101


3 Exhibit 557 – Meteorological Aspects of the Maiden Gully Fire (BOM.901.0096) at 0109




7 Exhibit 214 – Statement of Hollowood (WIT.3010.001.0338) [64]

8 Exhibit 215 – Supplementary statement of Hollowood (WIT.3010.003.0287_R) [19]

9 Exhibit 215 – Supplementary Statement of Hollowood (WIT.3010.003.0287_R) [19]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [42]



12 Exhibit 939 – Details Regarding Emergency Response (CFA.600.005.0195) at 0195, 0198; Exhibit 939 – Day by Day Breakdown – Bendigo (DSE.HDD.0048.0545_17); Exhibit 939 – Aircraft Data 0809 (DSE.HDD.0048.0544_20) at 0544_20

13 Exhibit 994 – Maiden Gully Fire – Fire Spread Map (CFA.600.006.0010)

14 Exhibit 452 – Statement of Deering (WIT.3004.019.0192) [25], [29], Annexure 6 (WIT.3004.019.0272) at 0272; Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [21]; Exhibit 466 – Statement of Vearing (WIT.3024.004.0215) [15]; Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [12]

15 Exhibit 452 – Statement of Deering (WIT.3004.019.0192) [5], [32]; Exhibit 466 – Statement of Vearing, Annexure 4 (DSE.HDD.0052.0651) at 0687, 0707

16 Deering T10162:30–T10163:8; Cutting T10323:14–T10323:29

17 Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [52]–[53]

18 Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [12]–[13], [17]; Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [56]; Cutting T10323:30–T10324:12; Rogasch T10245:8–T10245:29, T10247:17–T10247:26

19 Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [18]

20 Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [13], [18]

21 Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [12]–[13], [17]; Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [56]; Cutting T10323:30–T10324:12; Rogasch T10245:8–T10245:29, T10247:17–T10247:26

22 Gilmore T10130:7–T10130:12

23 Exhibit 470 – Statement of Manning (WIT.3024.004.0233) [44]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [26]; Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [74]; Rogasch T10255:4–T10255:22; Gilmore T10307:28–T10308:7

24 Exhibit 548 – Correspondence – Safety Advisors (CORR.0911.0107_R)

25 Exhibit 462 – Statement of Tinker-Casson (SUMM.044.002.3976_R) at 3976_R–3977_R

26 Exhibit 214 – Statement of Hollowood (WIT.3010.001.0338) [64]

27 Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [16]–[18]; Smith T10229:19–T10229:29, T10230:31–T10231:9

28 Gilmore T10130:27–T10131:4

29 Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [19]–[21]; Smith T10232:2–T10232:21

30 Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [56]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [12]–[13], [17]; Deering T10162:30–T10163:8; Cutting T10323:14–T10323:29

31 Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [56]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [2]–[3], [12]–[13], [17], Annexure 1 (WIT.3004.019.0372), Annexure 2 (WIT.3004.019.0375); Rogasch T10244:7–T10244:20, T10245:8–T10245:29, T10247:17–T10247:26; Cutting T10323:30–T10324:12

32 Exhibit 460 – Statement of Cutting (WIT.3004.020.0001) [57]; Rogasch T10248:15–T10248:24, T10249:5–T10249:20

33 Exhibit 469 – Statement of Downes (WIT.3004.020.0314) [28]–[29]; Exhibit 144 – ABC Local Radio – Disc 1 (TEN.052.001.0001); Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0565

34 Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [2], [60]–[62]; Exhibit 464 – Statement of Morris (WIT.3010.007.0298) [2]

35 Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [19], [22]–[23], [27]; Rogasch T10249:28–T10249:30; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [19]–[20]; Smith T10231:16–T10231:17, T10232:31–T10233:16

36 Exhibit 458 – Statement of Gilmore, Annexure 8 (WIT.3004.019.0147) at 0157–0161; Gilmore T10131:29–T10132:12

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The Bendigo fire

37 Exhibit 471 – Statement of Beaton (WIT.3024.004.0190) [14], [20]–[21]

38 Exhibit 458 – Statement of Gilmore, Annexure 8 (WIT.3004.019.0147) at 0163–0166; Gilmore T10132:13–T10133:15

39 Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [70]–[71], [73]; Gilmore T10306:21–T10307:27; Exhibit 462 – Statement of Wilkie (SUMM.044.002.3887) at 3889–3890, 3892

40 Exhibit 34 – Statement of Kane (WIT.017.001.0001_R); Kane T1040:6–T1057:10; Gilmore T10133:31–T10134:5

41 Exhibit 458 – Statement of Gilmore, Annexure 8 (WIT.3004.019.0147) at 0162; Gilmore T10134:6–T10134:9, T10134:17–T10135:7

42 Gilmore T10135:17–T10136:10

43 Exhibit 472 – Statement of Wassing (WIT.3004.020.0150) [1]–[6], [9]–[14]

44 Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [19]–[21]; Gaffee T10337:17–T10338:10

45 Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [28], [32], [38], [48], [65]; Gaffee T10336:9–T10336:17, T10338:20–T10338:27, T10340:18–T10340:29, T10346:29–T10347:7

46 Gaffee T10345:27–T10346:3

47 Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [65]; Gaffee T10346:17–T10347:28

48 Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [11], [13], [19]–[21], [65]; Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [38]; Smith T10238:30–T10239:16; Gaffee T10337:17–T10338:10, T10345:27–T10346:3, T10348:31–T10349:20

49 Exhibit 464 – Statement of Morris (WIT.3010.007.0298) [27]; Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [63]

50 Exhibit 464 – Statement of Morris (WIT.3010.007.0298) [28]–[29]; Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [64]; Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [56]

51 Gilmore T10136:11–T10136:13, T10137:12–T10137:20, T10140:1–T10140:12

52 Exhibit 471 – Statement of Beaton (WIT.3024.004.0190) [22]–[28], [31]–[34], Annexure 2 (DSE.HDD.0012.1659); Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0565–0629; Exhibit 7 – Transcript – 774 ABC Radio (SUMM.001.002.0001) at 0535

53 Exhibit 471 – Statement of Beaton (WIT.3024.004.0190) [31], [33], [36]–[37]; Exhibit 144 – ABC Local Radio – Disc 1 (TEN.052.001.0001)

54 Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [19]–[20]; Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [23], [27]; Smith T10233:11–T10233:16; Rogasch T10249:5–T10249:30

55 Exhibit 462 – Statement of Wilkie (SUMM.044.002.3887) at 3887, 3892

56 Gilmore T10140:1–T10140:12, T10140:20–T10141:15, T10141:25–T10141:31

57 Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [5], [6], [13], [60]–[64]; Gilmore T10278:6–T10280:1, T10280:29–T10283:4, T10284:3–T10284:17

58 Exhibit 471 – Statement of Beaton (WIT.3024.004.0190) [21]–[22]; Exhibit 470 – Statement of Manning (WIT.3024.004.0233) [23], [41]–[44]; Exhibit 472 – Statement of Wassing (WIT.3004.020.0150) [13]

59 Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [60]–[68], [70]–[71], [82]–[83], Annexure 3 (WIT.3004.019.0043); Gilmore T10301:17–T10306:20

60 Exhibit 471 – Statement of Beaton, Annexure 3 (DSE.HDD.0012.1660), Annexure 4 (DSE.HDD.0012.1661), Annexure 5 (DSE.HDD.0012.1662), Annexure 6 (DSE.HDD.0012.1663)

61 Exhibit 463 – Statement of Jarvis (VPO.001.012.0032) at 0034

62 Exhibit 472 – Statement of Wassing (WIT.3004.020.0150) [17]–[33]; Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [79], [93]–[95]

63 Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [74]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [26]; Rogasch T10255:4–T10255:22; Gilmore T10307:28–T10308:7

64 Exhibit 4 – Supplementary Statement of Rees (WIT.004.002.0001) [122]; Gilmore T10143:4–T10143:9

65 Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [18]; Exhibit 34 – Statement of Kane (WIT.017.001.0001_R) [1]; Exhibit 215 – Supplementary Statement of Hollowood (WIT.3010.003.0287_R) [19]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [42]; Exhibit 786 – Statement of Clow (WIT.3004.034.0004) [19.9]; Exhibit 980 – Correspondence – Houses Destroyed – Breakdown by Fire (CORR.1003.0048_R) at 0048_R at 0048; Smith T10231:10–T10231:13; Gilmore T10143:4–T10143:9, T10143:21–T10143:24

66 Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [65], [75]–[77]

67 Exhibit 458 – Statement of Gilmore (WIT.3004.019.0001) [65]; Exhibit 462 – Statement of Wilkie (SUMM.044.002.3887) at 3888; Gilmore T10273:12–T10274:11; Rogasch T10260:6–T10260:18

68 Exhibit 465 – Statement of Malone (WIT.4010.001.0001) [67]; Exhibit 464 – Statement of Morris (WIT.3010.007.0298) [30]

69 Exhibit 465 – Statement of Malone, Attachment 6 (WIT.4010.001.0206) at 0263; Exhibit 461 – Statement of Gaffee (WIT.3010.006.0199) [62]; Gaffee T10346:4–T10346:16; Smith T10239:17–T10240:2


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Source: Courtesy of Herald & Weekly Times.

14THE BEECHWORTH–MUDGEGONGA FIRE


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The Beechworth–Mudgegonga area is about 300 kilometres north-east of Melbourne, on the edge of the Alpine National Park and in Indigo Shire.

The 7 February 2009 fire in the area began at about 18:00 and burned fiercely until weather conditions moderated in the early hours of 8 February. The fire was not contained, however, until 16 February. Two people died, 38 houses were damaged or destroyed, and sheds, farming equipment and stock were destroyed. Overall, the fire burnt 33,577 hectares, including about 23,000 hectares of state park. Figure 14.1 shows the extent of the fire.

Overview

Maximum temperature The maximum temperature recorded was 45.5˚C at Wangaratta automatic weather station at 15:01.1

Minimum relative Humidity The minimum relative humidity recorded was 6 per cent at Wangaratta AWS at 15:01.2

Wind The maximum wind recorded before the wind change was a north-north-westerly at 35 kilometres an hour, gusting to 57 kilometres an hour, at Wangaratta AWS at 14:01.3

The south-westerly wind change was recorded by the Wangaratta AWS at 23:01 at 20 kilometres an hour.4

Ahead of the wind change the wind tended back to the north and eased to 15 to 20 kilometres an hour by 01:00 on 8 February.5

Fire danger index The maximum Fire Danger Index was 126 at Wangaratta AWS at 13:30.6

Cause Electrical failure.7

Fatalities Two fatalities.8

Casualties Twelve casualties.9

Houses destroyed Thirty-eight houses.10

Overall area burnt 33,577 hectares.11

Firefighting resources On 7 February, 113 CFA and 97 NEO personnel attended the fire. They were supported by 23 CFA appliances, 89 NEO appliances and 2 aircraft.12

14 THe BeecHwOrTH–MudgegOnga Fire

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The Beechworth–Mudgegonga fire

Figure 14.1 The Beechworth–Mudgegonga fire

Source: Exhibit 994 – Beechworth–Library Rd Fire – Fire Spread Map.13

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Only Nariel ski hut fire continues to burn

Power lost to Beechworth, including DSE office and ICC

Beechworth fire starts

Strike team stood down to attend Kilmore East fire on morning of 8 February

Strike team from NSW Rural Fire Service dispatched to Beechworth

21:59Spot fires at Barwidgee Creek

22:00Generator provides limited power to ICC

18:05Incident Controller first notified of fire

18:06Strike team recalled

Thirty-eight new fires start in north-eastern Victoria

Nariel ski hut fire declared under control

18:15Firefighters arrive on scene

19:00First attack deemed unsuccessful

21:25Further urgent threat message issued

21:30Large crown fire develops and spotting begins

19:10First urgent threat message issued

19:40Two fixed-wing water bombers arrive on scene

Beechworth–Mudgegonga

The following time line summarises events associated with the Beechworth–Mudgegonga fire. For the most part, the times given are approximate. Further details about the events are provided in the accompanying narrative.

1 February – 27 April

18:00 20:40 22:001–3 February 4 February 6 February 7 February

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Larger generator obtained for the ICC

South- westerly wind change

Fire through Kancoona Gap, reaching the Pinnacles

Winds ease in Mudgegonga area

07:30ICC relocated from Beechworth to Ovens

Fire spots across the Kiewa Valley into heavily forested country

18:00Northern run of fire largely controlled by tankers in cleared paddocks

Fire declared safe

Extreme fire behaviour with significant spotting 1 km from Myrtleford

00:20Incident Controller advised ‘fire storm’ approaching Mudgegonga

02:45Fire heading towards Mt Stanley tower

Fire on both sides of Running Creek Road

06:30Fire estimated to have burnt 20,000 hectares

Alpine Shire MECC activated

Fire contained

00:00 02:15 03:40 05:10 17:0011:4023:34 8 February 16 February 27 April


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14.1 Sequence OF evenTS

BeFOre 7 FeBruary14.1.1

Between 1 and 3 February 38 fires started in the Department of Sustainability and Environment’s North East Area.

All except the Nariel ski hut fire were controlled within 48 hours. On the morning of 4 February the Nariel ski hut fire was still burning and had the potential to develop into a ‘campaign’ fire. There was concern that this fire could affect DSE’s capacity to prepare for 7 February.14

Between 4 and 6 February containment lines were built around the Nariel ski hut fire. At 17:00 on 6 February the fire was declared under control, although it continued to demand resources. On 7 February 68 DSE and Networked Emergency Organisation staff were still working on the fire.15

In preparation for 7 February DSE arranged for personnel to be on duty at various work centres in the region and for others to be on standby. Alpine Shire Council positioned earth-moving and other equipment, including trucks and fuel trailers, at depots throughout the municipality. In addition, from the morning of 7 February the Benalla Integrated Fire Agency Coordination Centre was on standby.16

Table 14.1 summarises the state of preparedness for the Beechworth–Mudgegonga fire.

Table 14.1 The Beechworth–Mudgegonga fire – IMT preparedness

Pre-designated level 3 ICC Yes17

Pre-formed IMT at ICC No18

Pre-identified level 3 IC No19

Pre-identified IMT members No20

Time fire started About 18:0021

Full IMT in place by 8 February 200922

Safety adviser appointed No23

7 FeBruary14.1.2

The area around Beechworth remained relatively free of fire during much of 7 February. Local firefighters and senior personnel were focusing on helping with the firefighting effort for the Kilmore East and Murrindindi fires, which by 18:00 were at their height. During the day personnel were sent to these fires, among them one of the two qualified level 3 Incident Controllers, who acted as Deputy Incident Controller for the Kilmore East fire. Only one qualified level 3 Incident Controller remained in the Beechworth area. At 18:00 a 21-member strike team was stood down to rest and told to report for duty at 06:00 on 8 February, to travel to the Kilmore East fire.24

Origin and cause

At about 18:00 on 7 February a fire started 3 kilometres south of Beechworth. A number of witnesses told the Commission they had difficulty contacting emergency services via 000.25

A tree had fallen on a power line on Buckland Gap Road, pulling the conductor furthest from the road off the supporting insulators at poles 169 and 170 on the Myrtleford-7 feeder. The conductor was energised when it fell, and as it fell it came into contact with pole 170. The Commission is satisfied that arcing between the conductor and pole 170 was the probable cause of the fire, which started in vegetation at the base of that pole. The incident resulted in the power supply to Beechworth being cut.26

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The tree that fell divided into two ‘leader’ trunks approximately 3.5 metres above the ground. The northern side of the divided trunk was dead, possibly as a result of a lightning strike, and had probably been dead for about 18 months. Mr Colin Bertuch, an arborist for Alpine Shire Council, told the Commission that, because the dead section contained most of the tree’s weight, it was likely that at some stage the tree would fall towards the road, in the direction of the power lines.27

The tree in question was outside the regulated clearance zone but was ‘hazardous’, as determined by the SP AusNet guidelines. As at 7 February SP AusNet had not identified any hazardous trees between poles 169 and 170 of the Myrtleford-7 feeder. Standard SP AusNet procedures do not incorporate a systematic method for detecting hazardous trees. Vegetation assessors—who are not trained arborists—are responsible only for identifying hazardous trees while carrying out standard assessment tasks. They are obliged to look only for ‘obvious defects’ and are not required to examine every tree. SP AusNet’s Hazardous Tree Program, which is applied to some parts of the network, provides for qualified arborists to inspect all trees in designated areas. Had the tree that fell on the power line on 7 February previously been seen by an arborist, the potential hazard would probably have been apparent.28

Automatic circuit reclosers, or ACRs, are circuit breakers that open to break the circuit when a fault is recorded and then reclose the circuit to restore power. ACRs had been installed on the Myrtleford-7 feeder power line. The settings could have been changed to suppress the reclose function entirely (which could be done remotely) or to make other changes (which might have been possible remotely, depending on the model). Because the ACR was not suppressed on 7 February it reclosed twice for 1.5 seconds (in addition to the initial 1.5 seconds before the ACR first operated) before the current was stopped by the ACR tripping to lockout. This resulted in about 200 amperes of current flowing for 4.5 seconds rather than for 1.5 seconds (as it would have if the ACR had been suppressed). It is not possible to determine whether ignition of the fire occurred as a result of current flowing during the 1.5 seconds before the ACR operated for the first time or whether it occurred during the two subsequent recloses. Nevertheless, the probability of a fire starting was greater with current flowing for 4.5 seconds than with it flowing for 1.5 seconds.29

Chapter 4 in Volume II discusses the role of ACRs, inspection of electrical assets, and Chapter 7 in Volume II discusses vegetation management.

Fire run, response and management

From the point of ignition the fire burned on public land in eucalypt forest, moving south-east under the influence of a strong north-westerly wind. Initial witnesses described a small fire—only 2 to 3 square metres—burning directly under power lines on the eastern side of Buckland Gap Road (also known as the Beechworth–Myrtleford road), just south of Library Road.30

Mr Brian McKenzie immediately assumed the role of Incident Controller and established an Incident Control Centre at the Beechworth DSE office. Mr McKenzie was Planning Manager, Land and Fire, for the DSE Ovens District and duty officer on the day. He was a level 2 Incident Controller with extensive fire experience and an intimate knowledge of the local area, having worked for DSE and its predecessors for 33 years. The intention was to ‘run [Mr McKenzie] through the first night’ and if possible bring in a level 3 Incident Controller at the change of shift on the morning of 8 February.31

Mr McKenzie understood the importance of first attack in extreme weather conditions. On being notified of the fire at about 18:05, he immediately dispatched crews from the Beechworth DSE depot; they were at the fire within minutes. At 18:06 the strike team that had been stood down to attend the Kilmore East fire the next morning was recalled. But containment by first attack was not possible: the fire was in a difficult location; the power line was down; and weather conditions did not permit placing crews in front of the fire.32

There were insufficient resources to have a level 3 incident management team at every level 3 incident control centre in the area. The regional strategy was to ensure that there were sufficient resources available to manage first attack and enough people to build a team to ‘come in behind’ once an incident had started, wherever the fire might occur. Within an hour of the Beechworth–Mudgegonga fire being reported an IMT was ready.33 Although the strategy proved adequate in this instance, it was found wanting in the case of other fires the Commission examined—namely, the Kilmore East and Murrindindi fires. Chapters 5 and 10 of this volume discuss how incident management evolved for those fires; Chapter 2 in Volume II discusses incident management more broadly.


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An initial fire report issued at 18:20 noted that 14 personnel had been dispatched to the Beechworth–Mudgegonga fire, along with three slip-on units and one first-attack bulldozer. The report noted that the potential for losses and the risk of the fire spreading were high.34

Soon after the initial fire report from crews on the scene, Mr McKenzie contacted Victoria Police to ask it to establish a Municipal Emergency Coordination Centre for Indigo Shire. He also contacted Mr Mark Green, the Municipal Emergency Resource Officer for Indigo Shire, to ask for his assistance in establishing the MECC.35

The fire initially burned in areas where the amount of fuel had been reduced by the 2003 bushfires and by fuel-reduction burns in the autumns of 2005 and 2008. As a result, the fire’s behaviour in its initial run was moderate, with flame heights of about 10 metres and spotting of about 500 metres. This meant the fire did not initially develop into a crown fire, which would have had the potential to progress much more rapidly. Between 18:00 and about 21:30 to 22:00 the fire travelled about 8 kilometres.36

At 18:45 Mr McKenzie telephoned the Benalla Integrated Fire Agency Coordination Centre to arrange for the issuing of an urgent threat message. The first message was issued at 19:10. It described the fire as burning 4 kilometres south of Beechworth and moving in a south-easterly direction and said the communities of Stanley, Barwidgee Creek and Mudgegonga should prepare for direct ember attack. The message was uploaded to the DSE external website at 19:30. Similar messages were released at 19:50 and 20:40. In all, 14 threat messages were released between 19:10 on 7 February and 05:15 on 8 February.37

In keeping with arrangements developed before the fire season, ABC Goulburn–Murray began rolling coverage of the fire soon after ignition and broadcast warnings throughout the night.38

At about 19:00 it became clear to DSE personnel fighting the fire that first attack had been unsuccessful and the fire would become a level 3 incident. By 19:15, 16 Country Fire Authority tankers, 12 DSE slip-on units, two first-attack bulldozers, one large bulldozer and a helicopter were at the scene.39

Aerial support had been sought almost immediately after the fire was reported. At about 19:40 two fixed-wing water bombers arrived and dropped retardant near the pine plantation on the fire’s eastern flank in an effort to slow the fire’s spread. It was getting dark, though, and the water bombers were not able to reload and return for any further drops.40

The primary operating difficulty the IMT faced on 7 February was the lack of electricity. The DSE office in Beechworth lost power at about the time the fire started. (A back-up generator for the district had previously been dispatched to DSE’s Broadford office, which was dealing with the Kilmore East fire.) Without power, the staff found conditions difficult: the office was hot because there was no air-conditioning and staff had to use torches in order to see.41

Additionally, the lack of electricity seriously constrained communications and reporting and planning. The ICC was unable to fax incident reports and press releases; nor could it map fires electronically. Reports had to be phoned through to the Ovens office or the Benalla Integrated Fire Agency Coordination Centre to be written up and forwarded to the integrated Emergency Control Centre. Communication and coordination were done using mobile phones and radios.42

The power failure also affected the Indigo Shire MECC, which was initially set up in a ‘booze bus’ (mobile breathalyser unit) that had been dispatched from Wangaratta. Because of the limited space in the vehicle, police liaison officers were not able to operate from it on 7 February.43

By 20:30 the number of CFA tankers had increased to 20. Shortly after, a strike team from the New South Wales Rural Fire Service was sent to Beechworth to help with asset protection.44

A Bureau of Meteorology forecast issued at 20:36 said the south-westerly change was approaching the area and would probably reach the fire ground between 23:00 and 24:00. At about 21:30 to 22:00 the fire emerged from the fuel-reduced areas, and there was a marked increase in fire activity. A large crown fire developed, and spotting began to occur up to 9 kilometres ahead of the main firefront. The fire was still burning mainly in forested public land, although some private property and private pine plantations were affected.45

A further urgent threat message was issued at 21:25, warning residents of the potential impact of the wind change. Throughout the night, threat messages continued to be issued, alerting residents of Barwidgee Creek, Mudgegonga, Stanley, Yackandandah, Bruarong, Rosewhite, Murmungee, Ovens, Myrtleford, Glen Creek, Kancoona, Kancoona South, Running Creek and Dederang and along Carrolls Road (near Mudgegonga).46

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At about 21:30 Senior Sergeant Douglas Incoll, Municipal Emergency Response Coordinator for Alpine Shire, was told of the fire and that the Indigo Shire MERC had established a temporary MECC.47

At 21:50 Mr McKenzie received reports of a spot fire in Mudgegonga. This was earlier than expected, and it meant the fire was spotting long distances. He issued a fire situation report at 21:59, advising that there were new spot fires east of the firefront at Barwidgee Creek.48

At about 22:00 the Beechworth ICC obtained a small generator from the Victoria State Emergency Service, but it provided only enough power for a floodlight to light part of the ICC.49

At 22:35 a further local forecast had the wind change reaching the fire area between midnight and 01:00, with a wind speed of 30–40 kilometres an hour.50

At 23:34 Mr McKenzie reported that there was extreme fire behaviour and significant spotting, including up to 1 kilometre from the township of Myrtleford. He issued a fire situation report saying the fire was ‘going’. At about 23:46 he received word that the fire had crossed the Yackandandah–Myrtleford road; this meant the fire was moving very quickly. Between 21:30–22:00 on 7 February and 02:30–03:00 on 8 February the fire travelled 24 kilometres.51

The location of roadblocks in the area of the Beechworth–Mudgegonga fire on 7 February was largely determined by Victoria Police, with heavy reliance on the observations of police in the field. At the time and subsequently, the roadblocks were ‘constantly’ being relocated because of the encroaching fire and the immediate threat to police. Inspector David Ryan stated that police received from the ICC very little information about the location or direction of the fire. All road closures introduced on 7 February were full closures; in subsequent days some closures were only partial.52

8 FeBruary and SuBSequenTly14.1.3

The predicted south-westerly wind change reached the fire ground at about midnight, turning the northern flank—which was at that stage about 32 kilometres long—into the main firefront. The fire began heading north-east, towards cleared agricultural land, mountainous forest and Mudgegonga.53

At about 00:20 on 8 February Mr McKenzie was told a ‘firestorm’ was approaching Mudgegonga and heading into the Rosewhite Valley.54 Ms Pat Easterbrook and her husband, Lindsay, lived across the road from the two people who were killed by the fire. She described the fire as it approached Mudgegonga:

It … sounded as though a few jets were … taking off over the top of our house. I said to Lindsay, ‘What the hell is that?’ He said, ‘That’s the fire’ … [Shortly after] everything just burst into flames … It was like bombs were going off. The mountain on the left side, on the creek side, the north side, that just exploded. The tree breaks that were coming up from the creek were on fire. The shed was burning down. It was roaring down from the south side as well.55

At about 01:00 on 8 February, Mr Andrew Taylor, Alpine Shire Municipal Emergency Resource Officer, and Senior Sergeant Incoll were told the fire was heading towards Carrolls Road in Mudgegonga. At about 01:50 they decided to defer a decision on establishing the Alpine Shire MECC until they had further discussions with the Ovens ICC in the morning.56

Between midnight and 02:00 the Beechworth ICC obtained a larger generator; this provided enough power to operate some of the computers, the air-conditioning and the lights. The phones were still inoperable, though, because they were part of the La Trobe University Commander® phone system, which did not have power. A generator was also obtained and set up at the Senior Citizens Hall in Beechworth at 02:30. The Indigo Shire MECC moved to the hall, and a number of police liaison officers were then able to operate there.57

The only communication available to the Beechworth ICC until restoration of power in the township at about 02:00 on 8 February was radio and mobile phones. Threat messages were approved by the Incident Controller and relayed by mobile phone to the Benalla Integrated Fire Agency Coordination Centre, which then relayed them to ABC radio and the integrated Emergency Coordination Centre in Melbourne for posting to the DSE website.58

At about 02:15 the fire had passed through Kancoona Gap and reached the Pinnacles. At 02:45 it was heading towards the Mt Stanley tower. It was so intense that the radio communication domes on the tower melted and a building—which was two to three bricks thick and thought to be fireproof—collapsed.59


218

Soon after, the weather and the fire behaviour moderated. The fire was, however, on both sides of Running Creek Road by 05:10. At about 06:00 Mr McKenzie started deploying new crews for changeover. Resources from the New South Wales Rural Fire Service, Hancock Victorian Plantations, DSE, the CFA and the Network Emergency Organisation had all been involved in the firefighting.60

By 06:30 on 8 February the fire had burnt about 20,000 hectares. The IMT understood that houses had been burnt and that there might have been fatalities, although the extent of the destruction had not yet been confirmed. Access to parts of the fire was restricted because a major transmission line through the fire ground needed to be ‘rebooted’. In addition, there had been many lightning strikes throughout the region, and a fire near Bogong Village also required firefighting resources.61

At about the same time Mr Taylor discussed with the Alpine Shire Municipal Recovery Manager the possibility of opening an emergency relief centre. They had very little information about which areas of the municipality had been burnt or were burning, so they decided to wait for further advice from Senior Sergeant Incoll.62

At 07:30 Mr McKenzie handed over as Incident Controller to Mr Shaun Lawlor, air attack supervisor on 7 February and DSE District Manager for the Ovens District. At the same time the incident control centre was moved from Beechworth to Ovens because the only power supply to the level 2 Beechworth ICC was provided by the generator and the fire was moving away from that area and towards the level 3 Ovens ICC. The Commission was advised that an earlier transfer of the ICC from Beechworth to Ovens was neither appropriate nor feasible since it would have necessitated the establishment of another IMT overnight. This would have been extremely difficult to resource and would have resulted in even fewer IMT resources being available for the following shift, and an interruption to information flows.63

The main challenge for the IMT on 8 February was to devise a strategy for bringing the fire under control. The areas of greatest concern were those between Mudgegonga and Bruarong and between Kancoona and Running Creek. The Commonwealth Government had also asked that the telecommunication towers and infrastructure on nearby Mt Big Ben be protected.64

At 09:30 on 8 February Senior Sergeant Incoll was informed that a dead person had been found at burnt-out premises near Mudgegonga (in Alpine Shire). Soon after, at about 10:00, Mr Taylor began preparations for activating the Alpine Shire Municipal Emergency Coordination Centre.65

At 11:40, following discussions with Senior Sergeant Incoll and a briefing at the Ovens ICC, the Alpine Shire MECC was activated. A call centre was established in a room adjacent to the MECC; it was staffed by Alpine Shire personnel. The purpose of the call centre was to be a central information point for the community.66

About midday the south-westerly wind began to increase in strength, and the fire began major runs between Mudgegonga and Bruarong in the north and Rosewhite and Running Creek in the east. As the fire approached Running Creek, between about 17:00 and 18:00, it spotted for several kilometres across the Kiewa Valley into heavily forested terrain. This area had undergone fuel-reduction burning in the autumn of 2007, and the result was that the fire behaviour moderated considerably.67

Shortly after 18:00 on 8 February the northern run of the fire was largely controlled by fire crews in cleared paddocks.68

On 9 February weather conditions moderated further, and fire crews constructed control lines and conducted back-burns. This work continued until 10:30 on 16 February, when the fire was declared contained. The fire was reported under control on 25 March.69

219


Image 14.1


During the fire, emergency relief centres were opened at Myrtleford, Dederang and Mudgegonga.70

Two people died in the Beechworth–Mudgegonga fire. The circumstances of their death are described in Chapter 20 of this volume.

Thirty-eight houses were destroyed, as well as sheds and farming equipment. Overall, the fire burnt 33,577 hectares—about 10,000 hectares of private land and the remainder state park. The fire burnt already drought-ravaged pasture, and farmers faced difficult decisions: should they slaughter their stock, try to sell them, or pay substantial sums to agist them until feed became more available.71

14.2 cOOrdinaTiOn wiTH THe Mecc

Between 7 February and 30 March the Municipal Emergency Coordination Centre received requests for the following:

assistance with residents’ emergency evacuation and access ■■

equipment, machinery and water tankers■■

stockfeed■■

disposal of injured stock■■

drinking water for people and stock■■

fuel.■■72


220

During the initial stages of the fire the MECC received these requests for support and resources directly from the field or from residents. Mr Taylor said this led to inefficiency and frayed tempers because each direct request had to be reported to the incident control centre, which would then respond. Usually, all requests for support are channelled through the ICC or CFA regional headquarters, which avoids confusion and duplication of responses.73

Mr Taylor reported that in the first few days of the emergency it was difficult to obtain from the Ovens ICC information about the location and spread of the fire in the municipality. During this time the MECC relied on ABC radio and the DSE website. A liaison officer from the Ovens ICC was not provided to the MECC until Tuesday 10 February. To compensate for this, staff from the MECC went to the ICC to obtain information.74

14.3 THe iMpacT OF Fuel reducTiOn

The firefighters’ experience on 7 and 8 February at Beechworth–Mudgegonga was that, because the fire burned through fuel-reduced areas, at critical stages the fire’s behaviour was reduced in intensity. Mr Lawlor noted, ‘If the initial phase of the fire had developed in areas where fuel loads had not been reduced, then the main run of the fire on 7 February would have been at least an extra 12 kilometres based on the observed fire behaviour on that day’. If the run had extended that extra 12 kilometres, the front would have become much wider when the wind changed to the south-west.75

Mr Lawlor also considered that fuel-reduction burns helped protect the telecommunications towers and infrastructure on Mt Big Ben and helped halt the fire before it spread into forested areas on the eastern side of the Kiewa Valley. If the fire had spread to that extent it would have been extremely difficult to bring it under control: the area is remote, and the terrain makes firefighting very difficult.76

Having observed the fire behaviour, firefighters considered that, were it not for the fuel reduction, it was highly probable that the entire Ovens Valley between Myrtleford and Bright would have been directly affected, with significant potential for further loss of life and damage to infrastructure and assets. Fuel-reduced areas were also used as a basis for the containment strategy that was implemented on 9 February.77

Dr Lachie McCaw, a principal research scientist for the Department of Environment and Conservation in Western Australia, and Dr Kevin Tolhurst, a senior lecturer in Fire Ecology and Management at the University of Melbourne, assessed the effect of previous burning on the Beechworth–Mudgegonga fire. Both agreed that the rate of spread and the final perimeter of the fire were greatly moderated because of previous prescribed burning.78

Dr McCaw agreed with Mr Lawlor that, had the same fire started in a non-fuel reduced area on a day of such extreme conditions, the fire would have become more intense, travelled faster and spotted further in the initial two hours than actually occurred. He also agreed that the effect of the reduced fuel load was to slow the run of the fire before the south-westerly wind change and that previous fuel-reduction burning helped with containing the fire by providing ‘anchor points’ for suppression activity.79

Fuel reduction is discussed in greater detail in Chapter 7 of Volume II.

14.4 warning THe puBlic

In addition to warnings issued by the Benalla Integrated Fire Agency Coordination Centre and the incident control centre, local police and firefighters warned residents about the impending fire. After being notified of the fire, Sergeant Geoffrey Still, Municipal Emergency Response Coordinator for Indigo Shire, asked the Yackandandah police to personally alert residents of Stanley to the potential fire risk. Other units were directed to warn residents on the southern side of the Beechworth–Stanley road and the Stanley–Myrtleford road.80

Senior Sergeant Incoll placed a police liaison officer at the ICC as soon as the Municipal Emergency Coordination Centre was opened. He said that once he became aware that fire was approaching an area he arranged for the Victoria State Emergency Service and police to do doorknocks in that area to warn people of the approaching fire and give them the fire agency warning.81

221


Despite the efforts of Victoria Police, the CFA and the Victoria State Emergency Service, not all residents who chose to defend their house could be personally warned or assisted. Ms Pat Easterbrook, who with her husband saved their house, said nothing could have prepared them for the impact of the inferno they experienced.82

14.5 cOncluSiOnS

With commitments to the Nariel ski hut fire before and on 7 February and to the Kilmore East and Murrindindi fires, DSE resources in the North East Area were much depleted by 18:00 on 7 February. Although this reduction in resources did not compromise the first-attack capability, it did cause some delay in getting additional resources to the Beechworth–Mudgegonga fire. The Commission notes the appropriate focus on first attack and the rapid response of ground crews.

The way the Beechworth–Mudgegonga fire started suggests that examination of the role of the particular type of electrical circuit breakers used on the power line (automatic circuit reclosers) and the management of vegetation around power lines is warranted.

On a day such as 7 February 2009 it was a high-risk strategy to develop an incident management team once a fire had started and first attack had been initiated. It did prove adequate in this instance, but the Commission, noting the shortages of staff, does not accept it was a suitable approach for such a severe day and reflected flawed judgment on the part of those concerned with regional planning and management.

Mr McKenzie did not consider that the lack of a generator and the delay in locating a back-up generator for the incident control centre interfered with the effort of firefighters on the fire ground. He said that, although the power loss created difficulty, the incident management team was ‘able to cope’ and did the best job it could in the circumstances. The lack of power did not delay the issuing of warnings. Mr McKenzie praised his team for working together very effectively on the night of 7 February.83 There is no evidence that the initial absence of a level 3 Incident Controller or the lack of power adversely affected the management of the fire.

The Commission accepts Mr Lawlor’s evidence that, even if aircraft had been immediately available, their effectiveness would have been limited in the conditions of the day in the absence of support from ground crews.

Although the fire did result in substantial losses, had the same fire started in a non-fuel reduced area, the fire could have resulted in far greater destruction.

The use of liaison officers was not routinely effective. In some cases liaison officers were not appointed; in others, police liaison officers, although appointed, were unable to gain the information they needed.

The Commission notes the efforts of police, the Victoria State Emergency Service and others to personally warn residents, but it considers it will never be possible to guarantee that such action will be feasible in all cases, and nor should individuals expect it. CFA material distributed to the community consistently stresses this.


222

1 Exhibit 557 – Meteorological Aspects of the Murmungee Fire (BOM.901.0131) at 0149


3 Exhibit 557 – Meteorological Aspects of the Murmungee Fire (BOM.901.0131) at 0149; Exhibit 6 – Supplementary Statement of Waller (WIT.002.002.0001) at 0101



6 Exhibit 6 – Supplementary Statement of Waller (WIT.002.002.0001) at 0101

7 Exhibit 6 – Supplementary Statement of Waller (WIT.002.002.0001) [359]

8 Exhibit 215 – Supplementary Statement of Hollowood (WIT.3010.003.0287_R) [22]

9 Exhibit 215 – Supplementary Statement of Hollowood (WIT.3010.003.0287_R) [22]


11 Exhibit 787 – Further Statement of Fogarty, Annexure 1 (WIT.3024.005.0260) at 0262

12 Exhibit 939 – Details Regarding Emergency Response (CFA.600.005.0195) at 0195, 0196, 0198; Exhibit 939 – Day by Day Breakdown – Beechworth (DSE.HDD.0048.0545_18); Exhibit 939 – Aircraft Data 0809 (DSE.HDD.0048.0544_20) at 0544_25

13 Exhibit 994 – Beechworth–Library Rd Fire – Fire Spread Map (CFA.600.006.0006)

14 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [30]

15 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [34], [44]

16 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [9]; Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [47]; Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [27]

17 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [12], [14], [17]; Farrell T7288:8–T7288:11

18 Farrell T7289:30–T7290:13, T7290:21–T7290:28

19 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [54]

20 Farrell T7290:21–T7290:28

21 Lawlor T6916:14–T6916:19

22 Farrell T7291:26–T7292:5

23 Edgar T16751:3–T16751:4

24 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [14], [51]; Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [15], [17]–[18]; Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [14]; Farrell T7292:5–T7292:12; Lawlor T6916:14–T6916:15

25 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [18]; Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [53]; Exhibit 230 – Statement of Johns (BCHM.001.001.0001) at 0002; Exhibit 226 – Statement of Matthews (WIT.3010.003.0172) at 0173; Exhibit 228 – Statement of Higgins (SUMM.044.002.2255_R) [6]–[11]; Higgins T6932:24–T6934:20; Lawlor T6916:14–T6916:15; Johns T6940:25–T6941:26; Matthews T6927:16–T6928:9

26 Exhibit 237 – Statement of Lane (WIT.5100.001.0001) [183]–[184]

27 Bertuch T7134:13–T7134:18, T7136:7–T7136:26, T7141:12–T7141:17, T7144:28–T7145:3, T7146:16–T7146:22

28 Exhibit 243 – Statement of Peters (WIT.5101.001.0001) [143], [146]–[153], [172]–[175], [221], Annexure 7 (WIT.5101.001.0225) at 0232; Peters T7187:3–T7187:20, T7193:31–T7195:19, T7203:23–T7204:11; Bertuch T7141:19–T7142:24

29 Exhibit 237 – Statement of Lane (WIT.5100.001.0001) [108]; Exhibit 520 – Supplementary Statement of Lane (WIT.5100.002.0001) [35], [43]; Lane T7031:21–T7031:28, T7032:10–T7032:17; Sweeting T11376:2–T11377:27

30 Exhibit 228 – Statement of Higgins (SUMM.044.002.2255_R) [3]; Exhibit 230 – Statement of Johns (BCHM.001.001.0001) at 0001; Johns T6938:17–T6938:24, T6940:18–T6940:20; Matthews T6925:9–T6926:6, T6928:15–T6928:17; Lawlor T6916:14–T6916:19; Higgins T6931:4–T6931:20

31 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [2]–[3], [8], [18]; Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [54]–[56]

32 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [51]; Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [17]–[18]; McKenzie T7217:5–T7217:19, T7233:23–T7233:30

33 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [22]; Farrell T7288:17–T7289:4

34 Exhibit 245 – Statement of McKenzie, Annexure 2 (DSE.HDD.0032.0222_R)

35 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [21]

36 Lawlor T6915:24–T6915:27, T6916:19–T6918:10

37 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [30], Annexure 3 (DSE.0017.0115.0070), (DSE.0017.0115.0067), (DSE.0017.0115.0039); Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [59];

38 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [65]; McKenzie T7223:24–T7223:27

39 Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [54]; Exhibit 245 – Statement of McKenzie, Annexure 4 (DSE.0001.0004.0093_R)

40 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [27]; Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [24]–[25]; McKenzie T7229:5–T7229:10

41 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [19]–[20]; McKenzie T7215:27–T7216:2

223



43 Exhibit 251 – Statement of Still (WIT.3010.004.0337) [38]

44 Exhibit 245 – Statement of McKenzie, Annexure 3 (DSE.0017.0115.0039), Annexure 5 (DSE.0001.0004.0092_R)

45 Lawlor T6918:11–T6918:16, T6918:30–T6919:2

46 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [30], Annexure 3 (DSE.0017.0115.0033)

47 Exhibit 250 – Statement of Incoll (WIT.3010.004.0001) [29]

48 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [38]–[39]


50 Exhibit 557 – Meteorological Aspects of the Murmungee Fire (BOM.901.0131) at 0169–0170

51 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [41]–[42]; Lawlor T6918:11–T6920:7

52 Exhibit 253 – Statement of Ryan (WIT.3010.004.0408) [40]–[41], Attachment 13 (WIT.3010.004.0479)

53 Exhibit 557 – Meteorological Aspects of the Murmungee Fire (BOM.901.0131) at 0137, 0144–0146; Lawlor T6920:8–T6920:14


55 Easterbrook T7169:16–T7169:31

56 Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [49]; Exhibit 250 – Statement of Incoll (WIT.3010.004.0001) [30]

57 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [19]–[20], [45]–[46]; Exhibit 251 – Statement of Still (WIT.3010.004.0337) [31]–[33], [37]–[38]; Exhibit 253 – Statement of Ryan (WIT.3010.004.0408) [25]

58 McKenzie T7223:3–T7223:6, T7223:16–T7223:23

59 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [47], [61]

60 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [51]–[53]; Lawlor T6920:8–T6920:21, T6920:26–T6921:10

61 Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [31]–[32]; Exhibit 6 – Supplementary Statement of Waller (WIT.002.002.0001) [372]

62 Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [51]

63 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [52]; Exhibit 254 – Statement of Farrell (WIT.3024.002.0219) [71]–[72]; McKenzie T7227:16–T7227:31

64 Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [39], [44]–[45]

65 Exhibit 250 – Statement of Incoll (WIT.3010.004.0001) [31]; Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [53]

66 Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [55]; Exhibit 250 – Statement of Incoll (WIT.3010.004.0001) [33]

67 Lawlor T6920:16–T6920:21, T6920:26–T6921:10

68 Lawlor T6921:11–T6921:25

69 Exhibit 6 – Supplementary Statement of Waller (WIT.002.002.0001) at 0100; Lawlor T6921:14–T6921:28


71 Exhibit 240 – Statement of Van Dorsser, Attachment (WIT.3010.003.0242) at 0246; Exhibit Exhibit 246 – Statement of McDonald (WIT.084.001.0001) [53]–[64]; Exhibit 787 – Further Statement of Fogarty, Annexure 1 (WIT.3024.005.0260) at 0262; Exhibit 980 – Correspondence – Houses Destroyed – Breakdown by Fire (CORR.1003.0048_R) at 0048_R



74 Exhibit 248 – Statement of Taylor (WIT.4002.001.0001) [60], [62]

75 Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [27]–[28]; Lawlor T6922:1–T6922:16

76 Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [45]–[47]

77 Exhibit 249 – Statement of Lawlor (WIT.3024.002.0187) [28], [49], [51]; Lawlor T6922:1–T6922:16

78 Exhibit 722 – Expert Report of McCaw on Fuel Management (EXP.026.001.0001) at 0011–0013, 0020; McCaw T14897:17–T14898:4; Tolhurst T15340:8–T15349:14

79 Exhibit 722 – Expert Report of McCaw on Fuel Management (EXP.026.001.0001) at 0011–0013; McCaw T14897:17–T14898:19

80 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [30]; Exhibit 251 – Statement of Still (WIT.3010.004.0337) [29]–[30]; Exhibit 121 – Statement of Ward (WIT.052.001.0001_R) [20]; Hollowood T7653:23–T7653:26, T7653:28–T7653:31

81 Exhibit 250 – Statement of Incoll (WIT.3010.004.0001) [40], [50]

82 Exhibit 244 – Statement of Easterbrook (WIT.085.001.0001_R) [81]–[82]

83 Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [58]; McKenzie T7216:10–T7216:16


224


CONCLUSIONS 15


226

The Commission’s primary focus was to find where improvements can be made to preparation for, response to and recovery from bushfires. The Commission is conscious that this results in a light treatment of what worked well and a heavier focus on shortcomings. This is regrettable but inevitable in an inquiry of this nature. The Commission heard ample evidence of the commitment, courage and skill of men and women who worked to protect their communities and their state on Black Saturday. Where specific actions are highlighted this is done both to commend the individuals involved and to illustrate instances of exemplary actions. Space did not permit an exhaustive account of the enterprise and valour of individuals and teams on 7 February 2009. The Commission acknowledges this and offers its conclusions in the hope that its analysis will minimise the likelihood of a recurrence of a bushfire of this magnitude in the future.

This chapter summarises the main themes and trends that emerged from the Commission’s fire-by-fire hearings. In some cases those themes and trends reflected systemic shortcomings that the Commission then considered in more detail at subsequent hearings. Accordingly, many of the themes and trends summarised here are discussed in detail in Volume II, which draws on a more specialised range of evidence than is summarised in this chapter.

15.1 Firecauses

Most of the major fires that burned in late January and in February 2009 started as a direct or indirect result of human activity:

Failure of electricity assets was responsible for five fires—Kilmore East, Beechworth–Mudgegonga, Horsham, ■■

Coleraine and Pomborneit–Weerite.

The causes of four fires—Murrindindi, Churchill, Delburn and Bendigo—are thought to be suspicious.■■

One fire—Harkaway—was started accidentally. ■■

Only the Bunyip fire is thought to have been the result of natural causes (lightning), although fire investigators have been unable to definitively reach this conclusion. The causes of both Lynbrook fires and the Upper Ferntree Gully and Redesdale fires are not known.

Chapters 4 and 5 in Volume II deal with electricity and arson respectively.

15.2 FireBehaviour

Fuel management15.2.1

Even in the catastrophic conditions experienced on 7 February, previous fuel reduction by prescribed burning slowed the rate of spread of some fires and also reduced the final size of the Beechworth–Mudgegonga fire. Where the fuel-reduced area was of insufficient size or the fuel reduction was insufficiently intense—for example, around Marysville—the areas treated did not moderate fire behaviour and so-called strategic firebreaks had little, if any, effect.

Fuel management is discussed in Chapter 7 of Volume II.

the wind change15.2.2

In Victoria a wind change is one of the most crucial factors in managing a bushfire and the associated risks to firefighter and public safety. In most cases on 7 February, where the wind change directly impinged on the path of a fire it changed the direction of and breathed new severity into the fire. In many areas the change arrived earlier than incident management teams and firefighters expected. This, combined with inadequate planning and advice on the part of a number of IMTs, resulted in insufficient warnings for firefighters and communities.

The wind change is discussed in Chapter 1 of Volume II.

15 conclusions

227

Conclusions

15.3 FireFightingeFForts

detection, reporting and First attack15.3.1

Fires were detected in a number of ways, among them the observations of local residents, the public, firefighters and fire tower observers. In a number of cases reporting of fires to fire agencies was hindered by difficulties contacting 000—particularly for the Beechworth–Mudgegonga and Bendigo fires. Detection of fires is discussed in Chapter 3 of Volume II.

The catastrophic weather conditions of 7 February made successful first attack extremely problematic, even when firefighting resources arrived soon after ignition. At Pomborneit–Weerite, for example, firefighters were in attendance before members of the public reported the fire, but first attack still failed to suppress the grass fire. In some cases, delays in reporting or in the arrival of firefighting resources, including aerial resources, contributed to the ineffectiveness of first attack.

aerial support15.3.2

Before 7 February, when weather conditions were milder, aircraft had been used to good effect at the Bunyip and Delburn fires. On 7 February, however, the use of aerial support—in particular, water bombers—was limited by the weather; this restricted opportunities for aircraft to operate and limited the effectiveness of water bombing because the suppressant dispersed before it hit the vegetation. Water bombing was more effective at the Narre Warren and Upper Ferntree Gully fires, which occurred later in the day and where local water supplies allowed a number of drops in a short period.

Aerial support is discussed in Chapter 3 of Volume II.

FireFighter saFety 15.3.3

Dedicated safety advisers were appointed during the peak period of firefighting activity at only two of the fires—Bunyip and Pomborneit–Weerite.1

One interstate firefighter was killed while engaged in firefighting after 7 February. That sad event aside, there were very few firefighter injuries and most of those incurred were minor, although the Commission received evidence of a considerable number of crews trapped in burnovers, where fire passed over their vehicles as they sheltered inside or nearby. The small number of injuries relative to the extraordinary exposure suggests that the training and equipment provided by fire agencies contributed much to firefighter safety.

The risks faced by the crews were heightened by a failure to promptly transmit accurate information about the arrival of the wind change. Country Fire Authority and Department of Sustainability and Environment standard operating procedures recommend the use of red flag warnings to communicate time-critical information on factors that might affect firefighter safety. In a number of cases, however, inconsistent or inaccurate warnings—or no warnings at all—were sent to firefighters on the ground.

Firefighter safety is discussed in Chapter 3 of Volume II.

15.4 incidentManageMent

aiims15.4.1

The AIIMS structure generally proved effective in relation to fire management, but there were deficiencies. The structure was most effectively implemented in the case of incident management teams that had pre-established before 7 February. Information functions often did not receive sufficient priority or resourcing. Warnings to firefighters and communities were too often lacking in timeliness and accuracy.


228

Although all fires on 7 February should have been managed using the AIIMS framework, there were occasions when incident management teams were not pre-positioned and incident control was conducted by CFA Group Officers. This use of group management continued at Alexandra even after an IMT was established to manage the Murrindindi fire.

Incident management is discussed in Chapter 2 of Volume II.

preparation and resourcing15.4.2

In the week preceding 7 February Victoria’s fire agencies understood that the conditions they were to face would be extreme. Resources and personnel were already committed to the Delburn fire, and during the week additional resources and personnel were directed to the Bunyip and Nariel ski hut fires.

On 5 February the CFA and DSE Chief Fire Officers held a teleconference with key operational staff. Both officers emphasised the need for pre-formed task forces and pre-positioned incident management teams to meet the demands of the day. The CFA Chief Officer envisaged that ‘the pre-designated [incident control centres] would be ready to operate in what we call a warm start or a hot start—that is, there are people there, all the facilities, the equipment is up and running and tested’.2

In most regions preparations for 7 February were in keeping with the Chief Officers’ understanding of a ‘hot start’. But in CFA Region 12 and DSE North East Region IMTs were not in place and this was not identified at the state level. In part, this was because that status was not adequately reported up the chain of command. This meant that, despite the fire agencies making every effort to warn and prepare the public before 7 February, the CFA and DSE had not adequately prepared their resources in the region that experienced the devastating Kilmore East and Murrindindi fires. As a consequence, there were extensive delays in establishing effective IMTs for those fires.

Elsewhere, firefighting and incident management staff were identified and rostered for duty while others were placed on alert; equipment was positioned and regional emergency coordination centres and the Benalla Integrated Fire Agency Coordination Centre were on standby; municipal emergency response coordinators confirmed their readiness.

The result was that, despite every effort being made to warn and prepare the public in the lead-up to 7 February, and despite the expectations of the CFA and DSE Chief Officers, regional preparations varied. Pre-positioned, pre-prepared level 3 incident management teams were not in readiness in all regions. In the regions that were poorly prepared there were extensive delays in establishing effective incident management.

management oF the Fires15.4.3

leadership

Strong and effective leadership was displayed at some fires. In these cases careful planning and effective management of both the IMT and crews on the fire ground resulted in the best outcomes possible in the conditions that applied. At other fires the Commission examined IMTs, and specifically Incident Controllers, did not provide the necessary leadership to manage the ferocious fires. This largely resulted from a lack of preparation and a failure to appoint Incident Controllers with the necessary experience, training and competence.

Leadership, training and pre-positioning of Incident Controllers are discussed in Chapter 2 of Volume II.

incident action plans

For a number of the fires the Commission examined incident action plans were not developed, were delayed or were developed in response to major fire damage; an example is the Murrindindi fire, where the IMT did not start preparing the plan until after midnight on 7 February, some nine hours after the fire had been reported and long after it had swept through Marysville.

Incident action planning is discussed in Chapter 2 of Volume II.

229

Conclusions

information gathering and analysis

Some IMTs, such as that at Bunyip, managed their information gathering and analysis well, and this enabled them to develop an informed and viable firefighting strategy. Other IMTs, such as that at Kilmore and Alexandra, were hampered by unreliable information on which to base planning decisions. In part, this was because those IMTs did not effectively collect or make the best use of the available fireground information. Confusion on the fire ground about who actually had responsibility for managing the fire also hindered information collection.

Information analysis is discussed in Chapter 3 of Volume II.

tracking of resources

At the Churchill fire there were shortcomings in management and tracking of resources because the IMT’s Planning Unit inadequately identified, recorded and tracked fireground resources and personnel. This led to inefficient use of the available resources and at times increased the risks for firefighters.

Tracking of resources is discussed in Chapter 3 of Volume II.

record keeping

Record keeping was inadequate, and this made it difficult to determine whether red flag warnings were sent. It also resulted in confusion about the location and roles of personnel on the fire ground and associated difficulties with communication and resourcing decisions. Inevitably, it led to inefficiencies and confusion.

management of campaign fires

‘Campaign’ fires both before and after 7 February were managed well. The Commission notes in particular the impressive performance of regional and incident management staff during the campaign fire at Bunyip and the efforts of firefighters after 7 February to manage the Kilmore East–Murrindindi, Beechworth–Mudgegonga and Churchill campaign fires.

handovers

The handover at Bunyip was effective. Pre-planning ensured the smooth transfer of control from DSE to the CFA when the fire left Bunyip State Park, then the transfer back once the fires on private land had largely been controlled. There was no formal handover at Murrindindi, which meant that CFA resources continued to report to their Group Officer, despite a DSE incident management team having taken responsibility for management of the fire. Handovers are a critical period in incident management, when information and responsibility are transferred. Every effort, including the use of incident action plans, needs to be made to ensure they occur as smoothly as possible.

15.5 coMMunications

emergency calls 15.5.1

A large number of calls were made to 000 on 7 February, and a number of these were from people reporting the initial sighting of a fire. Many callers, however, were either unable to get through to an operator or had to make numerous attempts before being connected. This delayed initial responses during the crucial early stages of some of the fires. This matter was considered in the Commission’s interim report. Information on the measures implemented to deal with the problem is provided in Chapter 1 of Volume II.


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operational Fire communications15.5.2

Communications from incident control centres to firegrounds on 7 February were impeded by system congestion and inadequate planning and management. Communication difficulties between ICCs and the fire grounds were often attributed to the amount of radio traffic or the facilities at the incident control centre. In the case of the Bendigo fire, heat and smoke were said to have caused radio interference, although this was not investigated by the Commission. Some firefighters resorted to using mobile phones when unable to raise ICCs by radio. Many attempts at such communication were either unsuccessful or very delayed.

Fixed communications were also problematic. Throughout the afternoon a significant proportion of the Kangaroo Ground ICC’s attempts to contact the Kilmore ICC seeking information and updates were unsuccessful.

operational police communications 15.5.3

Police across the state experienced difficulties communicating with other police at a number of fires. These difficulties were a consequence of two factors—the high volume of radio traffic directed through the police communications centres on the day and the incompatibility of the digital metropolitan and analogue rural police radio networks.

Communications are discussed in Chapter 3 of Volume II.

15.6 Warnings

The nature, timeliness and quality of warnings, for both firefighters and communities, varied among the fires the Commission examined. The warnings some IMTs issued were generally timely and appropriate, taking account of the path of the fire and the potential impact of the wind change. At other fires there were delays in issuing warnings or posting warnings to the CFA and DSE websites, and warnings failed to contain vital information about the path of the fire and the predicted wind change. The level of IMTs’ preparation—including the lack of pre-positioned information officers—appeared to be a central factor in determining whether timely, accurate and detailed warnings were issued.

In general, warnings were largely distributed via the CFA and DSE websites and by radio—notably ABC local radio and community radio stations such as UGFM. Where time allowed, community meetings were held, and at one fire a CFA officer sounded the fire station siren to warn residents of the approaching danger. The Standard Emergency Warning Signal was never activated on 7 February.

In addition to warnings issued by IMTs, the Commission notes the efforts at a number of fires of police, Victoria State Emergency Service personnel, and CFA and DSE crews to personally warn residents.

Warnings are discussed in Chapter 1 of Volume II.

15.7 evacuationandrelocation

Many residents made the decision to leave either of their own volition or on the advice of individual police, firefighters, VICSES personnel or others. Evacuations of vulnerable people were carried out in an ad hoc way, with little, if any, input from IMTs. Residents made their way out of affected towns or to places of possible refuge within towns. These were simply places where residents felt they would be safe—for example, the CFA sheds in Marysville and Kinglake and Gallipoli Park oval in Marysville.

The State Emergency Response Plan provides that the decision to evacuate people rests with the Incident Controller. In accordance with agency practice, however, Incident Controllers and their IMTs did not consider evacuation of any towns or localities affected by the fires. Local police, VICSES personnel and firefighters did, however, make ad hoc arrangements to evacuate some areas.

Evacuation and relocation are discussed in Chapter 1 of Volume II.

231

Conclusions

15.8 eMergencyManageMent

planning and preparation15.8.1

Before 7 February local councils and Victoria Police made substantial preparations for the extreme conditions predicted. In Yarra Ranges Shire, long-term preparations involved simulated emergency exercises. Additional resources were mobilised and extra staff were rostered on; municipal emergency coordination centres were placed on standby.

The Commission was not confident, however, that municipal plans gave adequate attention to bushfire risks. It is important that those councils that cover bushfire-prone communities take account of major risks such as bushfire and incorporate appropriate strategies in their municipal emergency management plans. The Commission reviewed the Shire of Murrindindi’s arrangements. Despite the shire’s MEMP being assessed as technically complying with the guidelines of the Emergency Management Act 1986, the MEMP lacked substance, detail and precision and, in particular, did not accommodate planning for responding to bushfire. There was insufficient detail to enable responses to be actioned if an emergency were to occur.

response15.8.2

Municipal emergency coordination centres, on the other hand, provided valuable support for firefighting operations and subsequently during recovery, some remaining open for weeks. They were activated soon after they received reports of fires from local incident control centres and provided various types of assistance:

support with emergency evacuation ■■

activation of emergency relief centres for residents who had evacuated■■

assistance with coordinating road closures■■

equipment, machinery and water tankers■■

drinking water and food ■■

feed for stock■■

material aid such as clothing and personal items■■

transportation assistance, fuel and first aid supplies■■

disposal of injured stock.■■

Emergency relief centres provided support and accommodation for residents who had evacuated. Some of these centres remained open as recovery centres for months after the fires, providing continuing support services and assistance for displaced residents and others affected by the fires.

roadblocks15.8.3

The operation of roadblocks on 7 February and in the following days and weeks raised important questions about access for firefighters, other service providers and residents and about the roadblocks’ overall effectiveness.

Although the roadblocks appear to have been operated in accordance with the guidelines agreed by the CFA, DSE and Victoria Police, enforcement of the guidelines became a source of frustration and some animosity between police and firefighters because private firefighting appliances, CFA personnel in private vehicles, and maintenance and supply crews were restricted from gaining access to the fire ground.

In some areas affected by the Murrindindi fire, access for residents was restricted for many weeks as coronial investigations continued. Problems with access were aggravated by inconsistencies in the application of ‘full’ and ‘partial’ roadblocks and confusion about who should be allowed through. In Bendigo, Redesdale and Churchill it was reported that people were able to bypass road closures by taking smaller or less direct roads: this calls into question the effectiveness of roadblocks in restricting access, especially in urban areas.

Emergency management is discussed in Chapter 2 of Volume II.


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15.9 inForMationsharing

Police and local councils said they faced difficulties as a result of a lack of information flowing from incident control centres. Among the concerns they expressed were difficulties obtaining information about the location and spread of the fire and about the location of roadblocks. The lack of information also created difficulties for police and municipal emergency coordination centres when trying to make decisions about effective deployment of resources and when providing advice to the community.

Most of the difficulties appeared to arise as a result of incident control centres not providing liaison officers to municipal emergency coordination centres, despite a requirement in the State Emergency Response Plan for response agencies to deploy liaison officers.3 To resolve these problems, in a number of instances police and local councils appointed liaison officers to ICCs. In these cases this action largely proved effective. In Horsham the local council made alternative arrangements, co-locating the municipal emergency response officer at the ICC.

Information sharing is discussed in Chapter 2 of Volume II.

15.10 utilities

Loss of power and water supplies is to be expected during major natural disasters. Saturday 7 February made it abundantly clear that people in areas of bushfire risk cannot rely solely on reticulated water and external power supplies in the event of a bushfire.

1 Exhibit 548 – Correspondence – Safety Advisors (CORR.0911.0107_R); Exhibit 611 – Statement of Owen, Annexure 20 (WIT.3004.032.0051) at 0057; Edgar T16751:3–T16751:4

2 Rees T2415:21–T2415:25

3 Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0180

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