2 Emergency and incident management


The State’s emergency management framework is fundamental to the effective delivery of emergency services. The framework provides for planning of and preparation for the management of crises and natural disasters; coordinating the actions of government, response agencies and communities in the lead-up to and during disasters; and assigning priorities to response and recovery efforts. On 7 February 2009 state-level emergency management arrangements faltered as a result of confusion about responsibilities and accountability.

At the incident level, AIIMS (the Australasian Inter-service Incident Management System) is an effective tool for fire managers. It relies not on technical application alone but also on individual competencies and commitment, sound operational leadership and effective planning at every level. This was evident to varying degrees on Black Saturday.

Days such as 7 February, however, highlight the crucial need for incident- and state-level management teams to prepare, plan and direct operations on the ground and to ensure that information and warnings are provided to firefighters and the community. People risking their lives at the firefront need information about the current status of and predictions for a fire, as well as warnings on safety-related matters such as the arrival of a wind change. Incident management also involves the issuing of warnings to those in the predicted path of a fire—something that is vital for community safety. These are not easy tasks, and they call for experienced, competent and well-prepared incident controllers to lead incident management teams. Fire agencies also need to judiciously select, train and prepare these teams so that they are well positioned to cope with the pressures they will face.

This chapter explores the arrangements for incident and emergency management at the local, regional and state levels as they applied on 7 February, the conduct of some individuals with statewide responsibilities, deficiencies in some emergency management arrangements, and ways in which the arrangements can be improved.


2.1     Primary Concerns

The Commission heard evidence about management of the 15 fires detailed in Volume I. Some fires were generally well managed—for example, the slower moving ‘campaign’ fires of Delburn and Bunyip and a number of the more rapidly burning ones, including those at Coleraine, Horsham, Redesdale, Pomborneit–Weerite, Upper Ferntree Gully and Beechworth–Mudgegonga. The management of other fires exposed a series of systemic shortcomings that impeded incident management and the state-level emergency management arrangements and contributed to the catastrophic consequences arising from 7 February.

The Commission identified the following primary concerns in relation to emergency and incident management:

       The State command and control arrangements for level 3 fires were inadequate and should be revised.

       The potential advantages of declaring a state of disaster were not considered by senior agency and government personnel and were not raised with the Premier at any time.

       The heads of the Country Fire Authority, the Department of Sustainability and Environment and Victoria Police did not demonstrate effective leadership in crucial areas such as ensuring that prompt and accurate warnings were issued to communities in the path of the fires.

       AIIMS proved mostly to be an effective management framework but should be refined.

       The flow of information from the fireground to the integrated Emergency Coordination Centre was at times seriously inadequate.

       Agency integration was insufficient to provide seamless fire management across the state.

       Level 3 Incident Controllers from both DSE and the CFA were not consistently trained, exercised and pre-positioned.

       Although emergency management arrangements at the municipal level generally worked well, there were coordination difficulties with some incident management teams.


2.2     Preparation and planning

2.2.1    Preparations for 7 February

Control of incidents on 7 February (as described in Chapter 2 of Volume I) rested with incident management teams in CFA and DSE regions; some of these IMTs were pre-planned while others were formed on the day. Inconsistencies in the levels of preparedness of IMTs and the facilities of incident control centres, the duplication of management between the CFA and DSE, and ambiguities in the allocation of authority and responsibility at the incident level are all described in detail in Part One of Volume I. Ultimately, responsibility for the operational preparedness of the fire agencies rests with the Chief Officer of the CFA and the Chief Fire Officer of DSE.

The need for a heightened state of preparedness was apparent before 7 February. On Thursday 5 February 2009 the Chief Officers warned the public that weather conditions on the Saturday were forecast to be worse than those on Ash Wednesday, a message reiterated by the Premier on 6 February.1

Victoria has a history of exceptionally dangerous fire danger days, among them days now known as Black Friday (13 January 1939) and Ash Wednesday (16 February 1983), both of which were characterised by temperatures above 40°C and a Forest Fire Danger Index of 100 or more, resulting in many fatalities.2

Another Black Saturday, on 12 February 1977, was also an important day in Victoria’s fire history. The fires of that day were the subject of the Report of the Board of Inquiry into the Occurrence of Bush and Grass Fires in Victoria, by Sir Esler Barber. Sir Esler rejected the notion that poor preparation for an emergency can be excused by ‘saying that our prevention preparations were adequate except on such an unexpectedly ferocious day’. He said this is particularly the case where the ‘ferociousness’ of the emergency is not in fact unexpected but instead predicted.3 The Commission makes the same point about 7 February 2009: the weather conditions and resulting fire behaviour, although extreme in terms of outcome, were not unexpected (as discussed in Chapter 1 in Volume I). They had been forecast and taken note of, and the potential danger had been publicised several days before 7 February. The fire and emergency services’ standard of preparation must be viewed in this context.

On 5 February each Chief Officer made clear to his senior staff and regional managers the arrangements that needed to be in operation for incident-level command and control on 7 February. Mr Russell Rees of the CFA asked that pre-designated ICCs be ready for a ‘hot start’, with ‘people there, all the facilities, the equipment … up and running and tested’. Similarly, Mr Ewan Waller of DSE conveyed the message that personnel should be on standby at their work locations and ready to go.4 Despite these instructions for the highest level of preparedness, the actual state of readiness of level 3 IMTs on the day varied across regions and agencies. This affected the quality of the overall operational response.

The lowest levels of compliance with the Chief Officers’ directives appear to have been in the areas affected by the most catastrophic fires—Kilmore East and Murrindindi. The CFA’s Region 12 Duty Officer and Coordinator for the North East Area, Mr Peter Creak, gave evidence that, given the personnel available, it would not have been possible to have each level 3 incident control centre staffed in his area at the ‘hot start’ level required by Mr Rees.5 The standard of preparedness at Kilmore ICC, in Region 12, certainly fell well short of this. DSE’s Land and Fire Manager for the North East, Mr Peter Farrell, did not take sufficient steps to ensure the allocation of qualified level 3 staff to ICCs in his area, resulting in the seriously underprepared Alexandra ICC, which ultimately had control of the Murrindindi fire. Chapter 10 in Volume I provides details about the preparations made in the North East Area.

The CFA and DSE did do some effective interagency planning in Regions 4 and 6, where they both worked to strengthen relationships and complement each other in order to manage incidents effectively. Region 6 met ‘regularly on the days beforehand … [to] formulate what manning or what people … [they] have to fill all the major roles in the IMT and support roles’.6 The IMT in Region 4 consisted of ‘joint teams … with the people in the IMT having practised together and worked together many times’.7

Senior officers of Victoria Police also made efforts to ensure that police were prepared. An email Chief Commissioner Ms Christine Nixon sent to all members and staff directed that municipal emergency coordination centres be ready to activate, that divisional coordination centres be on standby and that regional operations centres be activated by no later than 10.00 am on the Saturday. Police at the local level were also asked to make contact with local representatives of the CFA, DSE and Parks Victoria. Similar messages were conveyed in an email on 6 February from Deputy Commissioner Mr Kieran Walshe to all regional assistant commissioners. The evidence in relation to the individual fires demonstrates that Victoria Police succeeded in achieving a high level of preparedness, enabling police to provide valuable support to the fire agencies, both on the ground and through the municipal emergency coordination centres.8

Additionally, the Victorian Emergency Management Council Coordination Group met on 5 February to share information about operational preparations and advice to the community. At this meeting, the CFA and DSE representatives informed Police and Emergency Services Minister the Hon. Bob Cameron MP that the agencies were ‘ready in all the key high danger areas’.9

2.2.2    Planning for joint incident management teams

Joint CFA–DSE Standard Operating Procedure J2.03 (Planning for Joint Incident Management Teams), which was in force on 7 February, stipulated that a level 3 IMT requires a minimum of 14 positions. The direction from the Chief Officers to achieve the highest level of preparedness required that these 14 positions be filled on 7 February, that ICC facilities be tested and activated, and that a level 3 Incident Controller be in position.10 The purpose of this was to allow IMTs to immediately assume management of fires that could not be suppressed by initial attack. As described in detail in Part One of Volume I, implementation of this direction was not consistent across all IMTs, some of which fell well short of what was demanded.

A revised Joint SOP J2.03, issued on 16 November 2009, has increased to 30 the number of personnel required for a full level 3 IMT. It also identifies four levels of IMT preparedness—from Preparedness Level A (the highest, with facilities tested on the day and a core IMT of eight in position from 10.00 am on the day and the remaining 22 IMT members being in position within 60 minutes of a fire starting) to Preparedness Level D (facilities tested in the preceding week, basic staffing to be in position within 60 minutes of a fire starting and a core IMT of eight in position within 90 minutes).11

The default minimum preparedness level required for a location is set by reference to the fire danger index—the Grassland Fire Danger Index or the Forest Fire Danger Index, depending on the risk profile of the location in question—but a higher level of preparedness can be prescribed for any ICC on any particular day. The Commission supports this improved planning for IMT preparedness, although it notes that the CFA and DSE will need to monitor and audit compliance with the mandated preparedness levels. During the 2009–10 fire season local mutual aid plans did not consistently reflect the IMT preparedness levels stipulated in the revised SOP, and this should be rectified.

The Commission is also concerned that the revised SOP does not require either that a full IMT be pre-emptively established on the most serious fire danger days or that level 3 IMTs be led by a level 3 Incident Controller. Even at the highest level of preparedness, the SOP requires only that there be a core IMT and a level 2 Incident Controller in position by 10.00 am, with capacity to expand and scale-up within one hour of a fire starting.12

On days and in areas where the fire danger forecast is code red, a full IMT of 30 people should be in position from 10.00 am. This would be suitable recognition of the potential consequences if fires occur on such days and of the probability that initial attack will fail. In its interim report the Commission recommended that further work be done to explore the options for re-examining the fire danger ratings and the severity scale.

It is also unacceptable that fire agencies continue to prepare for days like 7 February without level 3 Incident Controllers placed in at least the highest risk locations. The events of 7 February (as discussed in Volume I) demonstrate the value of having experienced, qualified level 3 Incident Controllers in charge from the beginning of major fires. There are now about 100 qualified level 3 Incident Controllers in Victoria, and this appears to be a sufficient number to allow level 3 Incident Controllers to be allocated to the locations considered at highest risk on a particular day.13 If this number is insufficient, the agencies must give priority to the training of more level 3 Incident Controllers.

The agencies acknowledge the value of IMTs training together before an incident—in particular, joint IMTs that will have management of complex level 3 incidents. A number of expert witnesses also stressed the importance of training for emergencies; this is discussed in Chapter 10.14 The Commission considers that if an IMT can train together as a unit before a major event, that IMT will be in a better position to develop effective teamwork skills for coping in the high-pressure situation of managing a level 3 fire. The fire agencies should provide as many opportunities as possible for joint level 3 IMTs to form, practise and train.

Mr John Haynes, CFA Deputy Chief Fire Officer, described a ‘strong history’ of the CFA and DSE conducting joint training exercises and other activities. The CFA does not, however, prescribe the level of participation in joint training exercises required of members. In view of the vital importance of joint training, the CFA and DSE should prescribe the minimum number and the nature of joint training exercises in which personnel (including volunteers) must participate in order to maintain their accreditation to fulfil roles in a level 3 IMT. Compliance with the prescribed minimum should be monitored through annual audits of attendance.




The Country Fire Authority and the Department of Sustainability and Environment amend their procedures to require the following:

     that at locations that attract preparedness levels A or B there be a full incident management team under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of code red fire danger and a core incident management team (eight personnel) under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of extreme fire danger

     that a full level 3 IMT be led by a level 3 Incident Controller unless the State Controller determines otherwise.



The Country Fire Authority and the Department of Sustainability and Environment prescribe and audit the minimum number and nature of level 3 joint training exercises in which incident management team staff (including volunteers) are required to participate.


2.3     Leadership and command

2.3.1    Primary functions of emergency management: command, control and coordination

In accordance with the State Emergency Response Plan, the response to emergencies in Victoria relies on three management functions—command, control and coordination.15

Command operates vertically in an agency. In the case of the CFA, DSE and Victoria Police, the ultimate command function on 7 February lay with Mr Russell Rees, Chief Officer of the CFA, Mr Ewan Waller, Chief Fire Officer of DSE, and Ms Christine Nixon, Chief Commissioner of Police.

Control is exercised at the incident level by the IMTs and Incident Controllers. In this regard, strong and effective leadership was displayed in dealing with the Bunyip, Pomborneit–Weerite, Horsham, Redesdale and Coleraine fires, where careful planning and proactive management of both the IMT and crews on the ground resulted in the best possible outcomes given the conditions. At other fires inadequate preparation and a failure to appoint experienced and suitably qualified Incident Controllers led to a lack of leadership and sub-optimal outcomes in a number of cases. In some instances there was confusion about who was exercising the control function; this is discussed in Section 2.6.1.

On 7 February the emergency response coordination function was exercisable by Victoria Police and involved a requirement to ensure that adequate consideration was given to alerting the public to existing and potential dangers.16 It appears to the Commission that the concept of coordination became rather distorted on 7 February, with senior fire agency personnel describing their role as ‘coordinating’ the response to the fires rather than actively exercising control or command.17 In the emergency management context ‘coordination’ describes a specific role, one that on 7 February belonged to Victoria Police. The role necessitated active monitoring of an emergency situation and ensuring that specific outcomes were being achieved—that is, that warnings were being issued to communities under threat. The term ‘coordination’ should not be used loosely to describe a passive style of management or to avoid responsibility.

2.3.2    The primary positions on 7 February

Victoria’s emergency management arrangements, and the arrangements for bushfire in particular, are detailed in Chapter 2 of Volume I. On 7 February the main state-level emergency management and agency command functions were exercised by the following agencies and individuals:

       State Emergency Management

–    the Hon. Bob Cameron MP, Minister for Police and Emergency Services—Coordinator in Chief of Emergency Management (s. 5 of the Emergency Management Act 1986)

–    Ms Christine Nixon, Chief Commissioner of Police—Deputy Coordinator in Chief of Emergency Management (s. 5 of the Emergency Management Act) and State Coordinator of the State Emergency Response Plan (s. 11 of the Emergency Management Act)

–    Mr Kieran Walshe, Deputy Commissioner of Police—Deputy State Coordinator of the State Emergency Response Plan (s. 11 of the Emergency Management Act)18

–    Mr Bruce Esplin—Emergency Services Commissioner

       Victoria Police

–    Mr Stephen Fontana, Assistant Commissioner for Counter Terrorism and Emergency Management. Although not the subject of any statutory power and not in receipt of any formal delegation in respect of the powers of Ms Nixon or Mr Walshe, Mr Fontana’s portfolio of responsibilities in Victoria Police embraced responsibilities in relation to emergency management, including ‘many of the functions of the Deputy Coordinator in Chief’19

–    Mr Rod Collins, Superintendent, Victoria Police—State Emergency Response Officer. This position, created by Victoria Police, is not the subject of any statutory functions, although the responsibilities of the office are stated to include ensuring that the State Coordinator of the State Emergency Response Plan is informed of ‘all significant developments’ and ensuring the ‘ongoing efficient operation’ of the State Emergency Response Coordination Centre20

       the Country Fire Authority

–    Mr Russell Rees—Chief Officer

–    Mr Geoff Conway—State Coordinator, day shift 7 February

–    Mr Peter Baker—State Coordinator, night shift 7–8 February

–    Mr Gregory Paterson—State Duty Officer, day shift 7 February

–    Mr Thomas Glover—State Duty Officer, night shift 7–8 February

–    Mr Steven Warrington—‘Strategic Planning’, day shift 7 February

–    Mr John Haynes—State Coordinator during the Delburn fires (29–30 January) and media spokesperson, day shift 7 February

       the Department of Sustainability and Environment

–    Mr Ewan Waller—Chief Fire Officer

–    Mr Alen Slijepcevic—Chief Officer Contact, day shift 7 February

–    Mr Andrew Graystone—State Duty Officer, day shift 7 February

–    Mr Graeme Davis—State Duty Officer, night shift 7–8 February

–    Mr Andrew Brown—shared rotating position of Chief Officer Contact. Was not rostered but attended the integrated Emergency Coordination Centre during the day shift on 7 February to assist Mr Slijepcevic and Mr Waller

–    Ms Caroline Douglass—State Duty Officer, day shift 3–6 February (including during the running of the Bunyip fire) and media spokesperson, day shift 7 February.

2.3.3    The main facilities and functions on 7 February

The state-level functions of the CFA and DSE were exercised from the integrated Emergency Coordination Centre. Functional units—Information, Resources, Logistics, Planning and Mapping—from both agencies were co-located at the iECC, although they operated independently. The DSE’s Fire Behaviour Analysis Unit, the joint CFA–DSE State Air Desk, and various representatives of other agencies (among them the MFB, Victoria State Emergency Service, Telstra and SP AusNet) also operated from the iECC on 7 February. Emergency Services Commissioner Mr Esplin was at the iECC for much of the day. The operation of the iECC is discussed in Section

At the state level, Victoria Police functions on 7 February were divided between the Police Operations Centre, the State Emergency Response Coordination Centre and the iECC. The POC and the SERCC were co-located at Police Headquarters on Flinders Street in Melbourne; the iECC was at the opposite end of the city, on Nicholson Street in East Melbourne. The POC was responsible for directing the police operational response to the fires; the SERCC was intended to be the venue from which Victoria Police exercised its coordination function; and the police presence at the iECC was intended to provide a liaison service, allowing senior police to keep up to date with the progress of and response to the fires. In the event, however, the role of the SERCC on 7 February was minimal: senior police personnel (among them Assistant Commissioner Fontana and the State Emergency Response Officer, Superintendent Collins) operated predominantly from the iECC. Dividing senior police resources and policing functions between three state-level facilities was inefficient and created confusion about the responsibilities of each facility. Allocation of emergency management functions between these facilities—in particular, the role and purpose of the SERCC—during major bushfires needs to be reviewed.



The State clarify whether, during major fires, Victoria Police should discharge its coordination functions from the State Emergency Response Coordination Centre or from the State Control Centre.


2.3.4    Control at the state level

State level

There was no single agency or individual in control of the emergency response on 7 February. Control of the various fires was divided between the CFA and DSE. DSE was the control agency for the Murrindindi, Beechworth–Mudgegonga and Bunyip fires (although control of the Bunyip fire was handed to the CFA at about 1.45 pm on 7 February). The CFA was the control agency for the other fires the Commission considered.

Although the Country Fire Authority Act 1958 vests responsibility for controlling the prevention and suppression of fires in country Victoria in the Country Fire Authority as an organisation, CFA standard operating procedures make it clear that within the agency ‘ultimate responsibility for the suppression of fires’ rests with the Chief Officer.22 In this the Chief Officer is assisted by the State Coordinator, who is responsible for ensuring that ‘all relevant information relating to fires and incidents is available to the Chief Officer’, and the State Duty Officer, who is ‘the first point of contact for Regional Duty Officers for all operational matters’.23 On 7 February this senior management team of Chief Officer Mr Rees, State Coordinator Mr Conway and State Duty Officer Mr Paterson was assisted by Mr Warrington in a ‘strategic planning’ role.24 Mr Warrington defined this role as being to ‘support the Incident Controller and the state duty officer and indeed the Chief Officer by advising him of any potential significant fires’.25 Mr Warrington sat ‘to the side’ of the CFA’s ordinary command and control structure.26

Within DSE, statutory responsibility for carrying out ‘proper and sufficient work for the prevention and suppression of fire in every State forest and national park and on all protected public land’ lies with the Secretary of the Department (on 7 February Mr Peter Harris).27 This statutory function is performed by departmental delegation, as opposed to formal delegation, to the Chief Fire Officer of DSE.28It is the Commission’s view (discussed in more detail in Chapter 10) that this position of Chief Fire Officer in the organisational structure of DSE is an unsatisfactory arrangement because it lacks a solid statutory base for the powers and responsibilities that are in practice associated with the role.

The Chief Fire Officer is supported during an emergency by a Chief Officer Contact (on 7 February Mr Slijepcevic), whose role is representing the Chief Officer and making decisions on his behalf when he is not there, and the State Duty Officer (Mr Graystone), who provides ‘statewide coordination of fire and emergency incidents’.29

New state command and control arrangements

The lack of a single individual with clear responsibility for control of the response to major bushfires has been redressed through the revised State Command and Control Arrangements for Bushfire in Victoria, adopted by the CFA, DSE and the MFB in October 2009 following a review of command and control arrangements led by Chief Commissioner of Police Mr Simon Overland.30 The purpose of the new arrangements is to provide ‘clear and unambiguous command and control of, preparedness for, and response to, level 3 bushfires in Victoria’. The new arrangements are to be read in conjunction with the revised State Emergency Response Plan and the Emergency Management Manual Victoria.31

The new arrangements apply only if specified ‘triggers’, including any one or more of the following, occur: a forecast of severe, extreme or catastrophic fire danger; one or more level 3 bushfires or the potential for a level 3 bushfire; and significant threat to life or property from bushfire. Normal agency positions and structures continue to apply during ‘routine’ operations and times of high operational activity where the trigger points for the level 3 command and control arrangements are not met.32

The new arrangements provide for three levels of control for emergency management during a level 3 bushfire—State, Area of Operations, and Incident—and detail the roles, responsibilities and reporting arrangements for each tier. A ‘Controller’ is appointed at each tier to provide leadership and management; this is consistent with the approach adopted by AIIMS.33

Where appointed, the State Controller will have overall operational control of the response activities in relation to a fire. In the absence of the appointment of a State Controller under s. 16 of the Emergency Management Act 1986, the Chief Officer of the CFA is to assume the role. The State Controller reports to the Minister for Police and Emergency Services as Coordinator in Chief.34

The new arrangements therefore provide for a single, direct line of control for level 3 bushfires (see Figure 2.1).

Figure 2.1 Current single line of control model for level 3 incidents




Source: Exhibit 547 – Staffing, Training and Resourcing of IMTs and ICCs – PowerPoint presentation by Haynes and Slijepcevic.35


The new arrangements also rename the integrated Emergency Coordination Centre the ‘State Control Centre’, a move designed to focus attention on the fact that the centre’s primary function is one of control rather than coordination.36

Command of each fire agency’s resources remains the responsibility of the agency’s Chief Officer, who must provide advice to the State Controller on agency readiness, capability and operational activity.37 Figure 2.2 shows the reporting arrangements that will apply where a State Controller and an Area of Operations Controller have been appointed; operational reporting is shown on the left, state management in the centre and fire agency command on the right.

Figure 2.2 The state command and control structure




Source: Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria.38


The Commission considers that the new arrangements have helped to clarify and strengthen lines of control to apply during major bushfires in Victoria, but it notes that the possibility of Area of Operations Controllers and State Duty Officers operating concurrently could result in an overlap in responsibilities and therefore confusion about accountability.

Further, although the new arrangements are a welcome improvement, the Commission is concerned that introducing the position of State Controller only on some days and in response to specific triggers could be less effective than a more permanent arrangement. Switching lines of responsibility and reporting either just before or during a major incident might cause dangerous confusion. These concerns and a proposed solution are discussed in Chapter 10.

2.3.5    The fundamental responsibility of those in command

The CFA Red Book, which was produced during the 1980s as an operational guide for CFA members, contains the following statement on leadership:

The leader is not a passive person, he is not someone whose main function is to be ‘up in the front’. Leadership is a working relationship among members of a group in which the leader acquires status through active participation and demonstration of his capacity for carrying cooperative tasks through to completion.39

The Commission endorses this idea of an active leader: during a statewide disaster or an emergency it is this type of leadership that is needed. On 7 February strong leadership would have required not only the presence of the leaders at all crucial times but also the active oversight of those further down the chain of command. ‘Active oversight’ does not necessarily mean issuing directions to the incident management team or responding personnel: rather, it means monitoring the activities of those with direct control of response activities, informing oneself of the situation on the ground, and seeking information and feedback from subordinates. Performing these tasks puts a leader in the position of being able to make a judgment about whether his or her intervention is necessary.

Command and control, including the need to demonstrate leadership, are distributed between various levels and functions in the fire and emergency services agencies. Important leadership roles rest with the brigade captain on the fireground, the Incident Controller in charge of the incident management team, and the police officer at the roadblock. These duties must be performed in accordance with known standard operating procedures, incident control systems, and command and control arrangements. Effective emergency management requires the successful execution of leadership functions at all levels, but it is the individuals with statewide responsibility, those who communicate with and are accountable to government, to whom the highest expectations are attached.

On 7 February 2009 the leaders with ultimate responsibility for the operational response to the bushfire emergency were the Chief Officer of the Country Fire Authority, Mr Russell Rees, the Chief Fire Officer of the Department of Sustainability and Environment, Mr Ewan Waller, and the Chief Commissioner of Police, Ms Christine Nixon. Ms Nixon not only had ultimate command and control over the resources and personnel of Victoria Police: she also had statutory functions as Deputy Coordinator in Chief of Emergency Management and Coordinator of the State Emergency Response Plan. Although many of the functions associated with each individual’s role might have been delegated to subordinates, this delegation of powers and functions (formal or informal) does not amount to an abrogation of responsibility or a transfer of accountability.

In organisational terms Ms Nixon was at the apex of Victoria Police command, with a direct reporting relationship to the Minister for Police and Emergency Services. In contrast, Mr Rees reported through the Chief Executive Officer to the Board of the Country Fire Authority, which in turn reported to the Minister (see Chapter 10). The CEO of the CFA has responsibility for carrying out the functions of the CFA and must comply with directions of the CFA, as given through the board. The Country Fire Authority Act 1958 does not clearly set out the relationship between the Chief Officer and the CEO, and there is potential for operational responsibilities to become confused. The Chief Fire Officer of DSE, Mr Waller, reported through an Executive Director and General Manager to the Secretary of the department, who in turn reported to the Minister for Environment and Climate Change (see Chapter 10). Again, responsibility for operational matters over which the Chief Fire Officer has control is not clear.40

Effective control of operational decisions in connection with fire prevention, mitigation and suppression seems crucial to agencies’ effective honouring of their responsibilities in this regard. It follows that clear lines of authority for operational matters are necessary to support the command and control arrangements that have been established since 7 February. But the current arrangements do not achieve this: they are uncertain, ambiguous and confusing, and they should be reviewed so as to vest clear operational responsibility in the Chief Officers of the CFA and DSE, subject to the organisational changes the Commission recommends in Chapter 10.

The Commission also notes the evidence of the Secretary of the Department of Justice that the Government is reviewing the roles and organisational placement of the Chief Officer of the CFA and the Chief Fire Officer of DSE. These reporting relationships and accountabilities are discussed in Chapter 10.

The Commission acknowledges that Ms Nixon, Mr Rees and Mr Waller all had very different capacities to control the directions of their organisations, to influence decisions about budgets and staffing, and to operate autonomously.

The strategic directions of Victoria Police, the CFA and DSE and the decisions taken by each organisation in the years leading up to Black Saturday all affected the capacity of the agencies and their leaders to perform effectively on the day. The impact of previous decisions can be negative (for example, Victoria Police’s inflexible arrangements for the management of roadblocks, the CFA’s poorly equipped incident control centres, and DSE’s poor record of meeting its prescribed burning targets) or positive (for example, Victoria Police’s strong coordination arrangements at the municipal level, the CFA’s improved focus on firefighter safety since the Linton inquiry, and DSE’s successful use of the Networked Emergency Organisation to provide emergency ‘surge’ capacity). All such decisions have affected the capacity of fire agency personnel to perform effectively, and the performance of the leaders on 7 February must be viewed against the backdrop of these factors.

The Commission nevertheless considers that the leaders of each of the major agencies involved in the response to Black Saturday—Mr Rees, Mr Waller and Ms Nixon—should in significant measure be held accountable for the performance of their organisations as well as for the execution of their personal responsibilities and leadership functions at that time. The Commission observed a disturbing tendency among senior fire agency personnel—including the Chief Officers—to consistently allocate responsibility further down the chain of command, most notably to the incident control centres.41 Although incident management teams certainly have direct management responsibility for the response to the fires, under the AIIMS arrangements this should be seen as a delegation of authority, rather than a shifting of responsibility or accountability. This principle that accountability must rest ultimately at the top of the chain of command applies to Victoria Police as well as to the CFA and DSE.

The Commission notes that the examinations of Mr Rees, Mr Waller, Ms Nixon and Mr Cameron (whose role and activities are discussed in Section 2.4) varied in length and manner of questioning. These variations can be explained by reasons such as the level and accuracy of detail available in written statements, the willingness of witnesses to make sensible concessions as to areas that could have been improved or actions that were ill-judged, and the time constraints facing the Commission. The Commission rejects, however, any suggestion that counsel assisting’s questioning of these witnesses was unfair, unbalanced or otherwise inappropriate, and it considers it has sufficient evidence to make decisions in relation to the state of leadership and state-level command and control exhibited on 7 February 2009. These individuals were senior public officials with leadership responsibilities in each of their respective organisations, and it is within ordinary expectations that these positions be subjected to rigorous public examination of their own performance and the performance of those they led.

2.3.6    Chief Officers

Although the Chief Officer of the CFA and the Chief Fire Officer of DSE were undoubtedly in command of the resources in their respective agencies, neither was directly controlling the response to any of the fires. Nor is it either Chief Officer’s role to take direct control while the operational response is sound and incident-level management structures are operating effectively. Ensuring that those structures are operating effectively, however, required that Mr Rees and Mr Waller make inquiries and actively oversee the preparedness and then the activities of the incident management teams. Without such active oversight, neither Chief Officer could judge whether personal intervention was necessary.

Mr Rees did not speak to the Incident Controller of any of the major fires. He said it was the responsibility of the CFA’s State Coordinator or State Duty Officer and of the regional emergency coordination centres to ensure that competent Incident Controllers were in position across the state. The State Coordinator relied on the State Duty Officer to ensure the preparedness of incident management teams, but the information in relation to preparedness on which the State Duty Officer was relying was later demonstrated to be inaccurate or at least incomplete.42

Mr Rees justified his delegation of IMT supervision by saying he risked ‘losing focus’ if he drilled down into the detail of any particular fire. He therefore remained operationally removed from the fires and as a result was not in a position to appreciate the deficiencies in the staffing and expertise of some incident management teams whose activities the Commission examined (see Part One of Volume I). The chain of command for which Mr Rees was responsible also failed to bring these matters to his attention.43

Mr Rees did not review the warnings being issued for the Kilmore East fire, despite the fire’s obviously disastrous potential. He did not review any predictive maps for any of the fires and would therefore not have been in a position—even had he reviewed the warnings being issued—to assess whether it was appropriate to warn communities in the predicted fire path. Neither Mr Rees nor Mr Waller had any system for monitoring the quality of warnings being issued by Incident Controllers.44

Although during the afternoon the CFA State Coordinator took steps to develop priorities in relation to the fires, including making his own predictions of the fire paths, he then stepped back from active oversight and instead relied on the State Duty Officer and the integrated Emergency Coordination Centre’s Information Unit to monitor the situation of those fires he had identified as being of major concern. The State Coordinator took no steps to ensure that suitable warnings were being issued. The State Duty Officer, on whom the State Coordinator was relying, did authorise a number of warnings but did so without checking their content: he was of the view that the content of warnings was the responsibility of the Incident Controller and that he ought not ‘second-guess’ information coming in from the field.45 These senior personnel—the State Duty Officer and the State Coordinator—failed to keep Mr Rees adequately apprised of the situation on the fireground.

Like Mr Rees, Mr Waller did not descend into the detail of the fires. Although both Chief Officers discussed the potential of the various fires and made some efforts to rank them according to priority, there is no evidence that this led to actions being taken or directions given. Mr Waller conceded that the warnings that were issued to the community did not adequately convey the significance of the wind change but said that responsibility for ensuring that this information was conveyed lay with the incident management teams and that if there was any deficiency in warnings he would have expected the State Duty Officer to bring this to his attention. It was the DSE State Duty Officer’s view, however, that his role was not to ‘value-add’ to warnings or do anything in the authorisation process other than check for ‘obvious error’. The State Duty Officer also took the view that warnings in relation to CFA-controlled fires were primarily a matter for the CFA, which appears reasonable.46

The Commission notes that the situation on 7 February 2009—whereby fire information releases prepared at incident control centres had to be uploaded to the CFA website by central personnel at the integrated Emergency Coordination Centre—no longer pertains. The One Source One Message portal allows personnel at incident control centres to upload information directly to both the CFA and the DSE websites.47 The Commission welcomes the use of this tool to speed up the release of information to the public but notes that this does not take away from the responsibility of those at the state level to monitor the content of warnings issued by incident control centres and to ‘value-add’ where required.

The Commission understands the logic in the notion that senior DSE and CFA personnel at the integrated Emergency Coordination Centre were the ones with primary responsibility for ensuring that all functions performed by elements under their control were working effectively, given that the agencies were not operating as a single integrated team. They were two teams working together in a common location, sharing information but not responsibility.

In this situation, senior officers’ quality checks of warnings did not extend, in the Commission’s view, to each other’s operations. The organisational separation of the agencies on 7 February weakened the management oversight that might have been expected had there been in charge a single agency with responsibility for the total operation and having unified, rather than duplicated, management arrangements. Introduction of a single State Controller to manage bushfire emergencies following Chief Commissioner of Police, Mr Simon Overland’s review is a step in the right direction, but it still leaves the fire agencies divided at the operational level.

The significance of a south-westerly wind change in the Victorian fire context is well known. Such a change was a feature of the destructive Ash Wednesday fires in 1983, and Sir Esler Barber noted, in relation to the 1977 Black Saturday fires, that it was an important and dangerous feature not only of the 1977 fires but of Victorian bushfires generally.48

Mr Rees and Mr Waller were both aware of the impact the south-westerly wind change would have on the fires. Mr Rees said information about the wind change should have been included in warnings to the communities ‘as a routine’. This did not happen. When the wind change arrived sooner than expected across the state, the Chief Officers did direct staff at the iECC to issue a public warning about it. In what appears to have been a failure of the chain of command, however, a warning was prepared but never issued.49

These examples are illustrative of the deficiencies in the oversight role of the two Chief Officers and the senior staff supporting them in the iECC. The Commission, however, also notes its concern in relation to the following:

       Resourcing decisions were often made without regard to predictive maps and therefore without a full understanding of the potential run of the major fires.

       No statewide plan was finalised on 7 February to assist with assigning priority to the most threatening fires and allocating resources with that in mind.

       The focus on maintaining a ‘strategic’ or ‘statewide’ overview appears to have come at the expense of a detailed awareness of the performance of incident management teams, including in connection with the central task of warning the community.50

The Commission concludes that CFA Chief Officer Mr Rees and DSE Chief Fire Officer Mr Waller should have done more in relation to warnings, supporting incident management teams and statewide planning. To the extent that they relied on their subordinates to perform these tasks, this reliance was ineffective. Responsibility for the failure of the chain of command must rest at the top. Further, Mr Rees and Mr Waller were in a unique position—with the ability to oversee and assess the potential of multiple fires as they developed across the state and to monitor the progress of the south-westerly wind change—to appreciate the need for a strong emphasis on warnings to the public and for increased support for incident management teams that would inevitably be sorely stretched by events on the day. Although the Commissioners were repeatedly told the Chief Officers were managing at a strategic level and taking a statewide view, there was little of greater strategic importance than monitoring the passage of the wind change because of its deadly potential. This was not done in a manner that would have led to the maximum advantage being gained from the meteorological information.

A number of relatively simple practices would have greatly assisted in identifying shortcomings in warnings and in the composition and effectiveness of incident management teams:

       once a fire had been reported, requiring the responsible incident management team to provide to the iECC as soon as practical an incident action plan summary, which should have been used to ascertain whether critical matters such as warnings, resourcing and firefighter safety were being factored into the strategy for the fire

       requiring provision of predictive maps—either by the IMT or by the fire behaviour analysis unit within the iECC itself—and a list of all warnings issued for an incident (and updated as required)

       on the basis of the predictive map and the list of warnings

–    confirming that communities in the probable path of the fire had been warned

–    ensuring that the warnings took adequate account of known weather information, such as forecast wind changes

–    issuing additional warnings as required

       on the basis of predictions for all the fires, developing priorities for the fires according to the greatest threat to life and safety and allocating state resources with that in mind.

These things were not effectively done by either of the Chief Officers or by their senior staff on 7 February.

This kind of systematic gathering and analysis of information should be standard practice. If the Chief Officers had adhered to these practices on Black Saturday or directed their senior staff to do so, the Commission would not—regardless of the outcome—have needed to criticise the Chief Officers in the way it does.

Both Mr Rees and Mr Waller conceded there were serious failures on the part of the fire agencies in relation to warnings. The failures occurred notwithstanding Mr Rees’ acknowledgment that, once it became obvious that the most serious of the fires were unstoppable, high priority should have been given to warning communities in the probable paths of those fires.51 This level of emphasis was not given to warnings, and it appears that to have given them the emphasis they merited would not have reflected the ‘normal’ warning protocols of the fire agencies.

Traditionally, and unsurprisingly, the fire agencies’ focus has been the suppression of fires, which goes some way towards explaining why insufficient priority was given to warnings on 7 February. This lack of prominence attached to warnings should also be seen in the context of the ‘Prepare, Stay and Defend or Leave Early’ policy, which, with its emphasis on individual fire plans and making decisions in advance of a fire, tends to diminish the importance given to the provision of targeted warnings to communities in the potential path of a fire. A central message of the Prepare, Stay and Defend or Leave Early policy is that householders are ‘on their own’ in terms of their individual safety because the fire authorities will be fully engaged in fire suppression. The policy is discussed in Chapter 1.

On a day such as 7 February 2009—when the predictions were for a day more dangerous in terms of fire behaviour than any previously faced in Victoria—the fire agencies needed a change in mindset to recognise that the most effective way of protecting communities would not be through fire suppression (which would probably prove ineffective) but by giving much more prominence to timely and accurate warnings. The tragic outcome of the fires brought this need for a change in priorities into sharp focus.

In the week leading up to 7 February the State and the fire agencies put considerable effort into encouraging people to implement their fire plans and to leave early if they were not suitably prepared and ready to actively defend. This reinforced the traditional approach whereby the fire agencies would be responsible for fire suppression and individuals were expected to have their own plans to enact. Although not wishing to play down the need for people to take a suitable degree of responsibility for their own safety, the Commission considers that a more innovative approach to the partnership between fire agencies and the community was called for on 7 February: greater emphasis on warnings by the fire agencies would have placed communities and individuals in a better position to make decisions about their own safety. It was for the leaders of the Country Fire Authority and the Department of Sustainability and Environment to call for this change of emphasis, but the call did not come.

2.3.7    Victoria Police

Among Victoria Police’s coordination functions was ensuring that consideration had been given to alerting the public to existing or potential dangers arising from the emergency.52 Superintendent Collins understood this to be a requirement to ensure that warnings were being issued (and he was satisfied that this did occur) and not a requirement to assess the content or accuracy of such warnings.53 As discussed in Chapter 10 of the Commission’s interim report, there was ambiguity about the precise duties of emergency response coordinators at any level in Victoria Police in connection with the issuing of warnings and the content of those warnings.

Ms Nixon agreed that it was the practice of Victoria Police to leave the content of warnings to the fire agencies. On 7 February she did not seek assurances that warnings were being issued but assumed from the size of the fires and the consequent danger to the community that the fire agencies would be issuing warnings.54 The Commission accepts that the fire agencies are best placed to design the content of warnings, but the situation on 7 February was that Victoria Police had a degree of responsibility in relation to warnings as part of its coordination function. There was at the time ambiguity as to how far Victoria Police had to go to ensure that fire agencies were properly exercising their functions in relation to warnings. The Commission welcomes the steps the Government has since taken to remove that ambiguity: inclusion of the new ss. 50B, 50C and 50D in the amended Country Fire Authority Act 1958 means that responsibility for issuing warnings now clearly rests with the fire authorities under the leadership of the Chief Officer of the CFA. This is referred to in Chapter 10.

2.3.8    The Chief Commissioner of police

On 7 February Ms Nixon took a ‘hands-off’ approach to her responsibilities as State Coordinator of the State Emergency Response Plan and Chief Commissioner of Police. She arrived at the State Emergency Response Coordination Centre at about midday. Although she spent some time there being briefed on the developing fire situation, she also spent about an hour-and-a-half attending to matters unrelated to the fires, including personal matters. At about 3.30 pm she attended the integrated Emergency Coordination Centre and received a series of briefings from Assistant Commissioner Fontana, Superintendent Collins and Chief Officers Rees and Waller. During these briefings Ms Nixon was told that a number of major fires were burning across the state, that important elements of state infrastructure were under threat, that the Kilmore East fire had the potential to kill people in at least Strathewen, that a wind change was forecast, and that it was possible the situation would deteriorate.55

Ms Nixon’s meeting with the fire chiefs, at about 5.00 pm, left her with the clear impression that Victoria was ‘facing a disaster’.56 Despite this, she left the integrated Emergency Coordination Centre at 6.00 pm, returned to her home and then attended a dinner with her husband and some friends between about 7.00 pm and 8.15 pm. Although her phone was switched on and she believed she would be contacted if her assistance was needed, Ms Nixon neither made nor received any phone calls, nor did she write or receive any text messages, during this time. While at dinner she was also not in a position to monitor media sources.57

On returning home, Ms Nixon’s first contact was a phone call from the Victoria Police media liaison officer at about 9.00 pm. Between about 6.00 and 9.00 pm, therefore, Ms Nixon neither received nor initiated any contact with her subordinate officers or other personnel involved in the emergency response.58 It is not satisfactory that at this time—when she was aware of the potential for disaster and, in fact, while the magnitude of the disaster was becoming apparent with confirmation of fatalities—Ms Nixon was absent from both the State Emergency Response Coordination Centre and the integrated Emergency Coordination Centre and did not take action to inform herself of events as they unfolded.

Ms Nixon considered that her leadership functions were discharged by establishing a competent team and being available if needed.59 But on a day when conditions were predicted, and then proved, to be worse than Ash Wednesday something more was required. This is especially so in Ms Nixon’s case: for most of the crucial period from 6.00 pm until 9.00 pm her delegates were not in their position.

Deputy Commissioner Walshe, the only recipient of a formal delegation of emergency management powers from Ms Nixon, was not on duty on 7 February. He remained at home, ‘on standby’ to assist Ms Nixon if required, until the evening. At 6.30 pm he learnt that Ms Nixon had gone home and—partly as a consequence of this but also because of his concern about the situation with the fires and reports of fatalities—he decided to come on duty. His arrival at Victoria Police headquarters was, however, delayed until 8.50 pm because the fires were threatening his son-in-law’s family and he became involved in inquiries about their welfare.60

Assistant Commissioner Fontana appears to have taken primary responsibility for discharging Victoria Police’s state-level emergency coordination functions on 7 February, despite not being the subject of any direct or delegated statutory responsibility. Mr Fontana began active duty at 6.00 am and moved during the day between the integrated Emergency Coordination Centre, the State Emergency Response Coordination Centre and the Police Operations Centre. He attended numerous interagency meetings and briefings and worked to stay fully abreast of the fire situation throughout the day, including making detailed personal notes and regularly forwarding information by text message to Chief Commissioner Nixon and other senior police personnel. Although he remained on duty until 1.10 am on 8 February, for part of the time from 6.00 to 9.00 pm when neither Ms Nixon nor Mr Walshe was present at the state-level control centres, Mr Fontana was also absent. He went home at 7.15 pm to take a short break and collect some computer equipment. By this stage he had been on duty for almost 13 hours. He did, however, make and receive a number of phone calls during this time, and he tried (unsuccessfully) to participate remotely in the State Emergency Strategy Team meeting at 8.00 pm. He returned to the Police Operations Centre at 9.30 pm and did not attend the integrated Emergency Coordination Centre again until 11.00 pm.61

The Commission considers that Ms Nixon’s approach to emergency coordination and the manner in which she purported to execute her statutory responsibilities left much to be desired. Ms Nixon herself acknowledged that leaving the integrated Emergency Coordination Centre and going home was an error of judgment: ‘In hindsight I … should have stayed’.62 The Commission shares this view.

The Commission also expresses dismay at Ms Nixon’s approach to giving evidence before it. Her written statement dated 22 January 2010 and her oral testimony on 6 April 2010 were in a number of respects inaccurate and incomplete. After her first appearance before the Commission, Ms Nixon released a media statement providing additional information about her movements on 7 February: this meant the Commission had to recall her on 14 April 2010 to clarify her initial evidence. Ms Nixon attributed the deficiencies to poor memory, to making assumptions on the basis of how she would normally act during an emergency, and to a lack of support in preparing her statement.63

The inconsistencies in Ms Nixon’s evidence were the subject of extensive comment in submissions both from counsel assisting (who sought a finding that Ms Nixon attempted to mislead the Commission) and from counsel representing Ms Nixon (who resisted such a finding). Counsel for Ms Nixon further submitted that the questioning of Ms Nixon by counsel assisting was unfair, a submission the Commission rejects. The examination of Ms Nixon was, albeit certainly thorough and testing, entirely appropriate.64

Despite the foregoing, the Commission does not find that Ms Nixon tried to mislead the Commission. It is notoriously difficult to make an accurate assessment of whether a witness is lying or intentionally trying to mislead. Moreover, during her second appearance Ms Nixon made a number of concessions in relation to the inadequacy of her earlier testimony, her lack of attention to the contents of her written statement and her failure to properly prepare for giving evidence—all of which helped the Commission form the view that Ms Nixon did not intentionally mislead it.65

The difficulties associated with Ms Nixon’s evidence—in particular, her inability to refresh her memory by referring to contemporaneous notes about her movements and activities on 7 February—constitute a salutary reminder to emergency services personnel at all levels of the importance of keeping an activity log. Ms Nixon did not have a practice of keeping notes or a logbook during her tenure as Chief Commissioner.66 Such a practice would have served her well. It would also have been prudent had Ms Nixon obtained copies of her telephone records from 7 February before adopting her written statement and giving oral evidence: in the absence of written notes, these records helped her verify some of her activities and contacts on the day.67


2.4     The Minister and emergency management

2.4.1    Role of the Minister

Pursuant to s. 5(1) of the Emergency Management Act 1986, the Minister for Police and Emergency Services is the Coordinator in Chief of Emergency Management. The Coordinator in Chief’s role is to ensure that government agencies take adequate emergency management measures and to coordinate the activities of government agencies carrying out their statutory functions, powers, duties and responsibilities in relation to emergency management. The Minister is also required to arrange for the preparation and review of the State Emergency Response Plan.68 Additionally, the Minister oversees a series of state committees responsible for emergency mitigation, response planning and recovery planning. The Emergency Management Act established the Victorian Emergency Management Council to advise the Minister.69

In relation to the interaction between the minister as Coordinator in Chief and the Chief Commissioner of Police as State Coordinator of the State Emergency Response Plan, Mr Cameron said he was responsible for the ‘overall system of continuous emergency management’ while the State Coordinator was responsible for ‘actions around a response’ to a particular emergency. He opined that the purpose of the Emergency Management Act was not to give the minister operational responsibilities in relation to an emergency, although he acknowledged that the designation ‘Coordinator in Chief’ might give an ‘operational impression’.70

The Commission agrees that the designation ‘Coordinator’ and the description of the role as including coordination of agency activities can lead to confusion about the minister’s role. The Commission is clear that it was not intended for the legislation to imply that the minister had any operational responsibilities and that the responsibilities of the control agency are separate and distinct from those of the ministers; rather, the minister is responsible for monitoring the emergency services’ planning and preparation for and responses to emergencies, providing an interface between the agencies and government and generally being accountable to parliament for the maintenance of an effective emergency management system.

It would be preferable if the minister were referred to in the Emergency Management Act not as ‘Coordinator in Chief’ but simply as ‘the Minister’ (being the minister responsible for the Emergency Management Act, at present the Minister for Police and Emergency Services). The Act should then specify the powers and responsibilities of the minister and make it clear that, in relation to emergency management (including planning and response), the State Coordinator of the State Emergency Response Plan is subject to the direction of the minister.

Other than in relation to consideration of a state of disaster (see Section 2.5), Mr Cameron’s performance during the February 2009 fires was in accordance with the Commission’s expectations of ‘the Minister’. On 5 February, in the light of the forecast for 7 February as being a day worse than Ash Wednesday, Mr Cameron sought and received assurances from the agencies that they ‘were ready to perform their functions’ and ‘would all be doing whatever they could’. On 7 February, although located for most of the day at his home in Bendigo, Mr Cameron was regularly updated on the fire situation by the Emergency Services Commissioner and his staff and, on one occasion, by Mr Fontana. When told at about 5.30 pm that Victoria was facing substantial losses and potential loss of life, Mr Cameron formed the view that he should come to Melbourne to determine the size and nature of the recovery effort that would be required of government and to institute the necessary arrangements.71

Mr Cameron arrived at the integrated Emergency Coordination Centre at 8.00 pm. He spoke with other ministers and with the Opposition, apprising them of the fire situation, and arranged for a meeting of the Security and Emergencies Committee of Cabinet to take place on 8 February.72 His actions were appropriate. Having taken steps to satisfy himself before the event that the system for emergency response was prepared, he then endeavoured to keep aware of the situation and, as soon as it became apparent that the state was facing a disaster, took active steps to ensure the effectiveness of the recovery phase.

2.4.2    Keeping the Minister informed

Although Mr Cameron ultimately received the vital piece of information he needed in order to make the decision to go to Melbourne—that losses were significant and there was potential for loss of life—the Commission considers the process for informing the minister in relation to emergency situations is inadequate.

On 7 February the Minister had no direct liaison with the Chief Officers of the fire services before arriving at the integrated Emergency Coordination Centre. Nor was there substantial contact between the Minister and senior Victoria Police officers. Ms Nixon spoke to the Minister twice before he came to Melbourne, but neither Ms Nixon nor Minister Cameron could recall details of the conversations. Mr Walshe (who was not formally on duty) had no contact with the Minister. Mr Fontana briefed the Minister once, at 5.25 pm, but for the greater part all agencies relied on Mr Esplin, as Emergency Services Commissioner, to be the conduit of information to the Minister.73

In 2001, at the request of the then Minister, the Office of the Emergency Services Commissioner assumed the role of coordinating the provision of information to the minister during emergencies. Thereafter the liaison role of the Emergency Services Commissioner became ‘standard practice’. This meant that the Emergency Services Commissioner needed to obtain accurate and timely information, which was not always the case on 7 February. Although the practice had been adopted through a protocol accepted by the fire agencies, the Commission is of the view that allocating the role of providing information to the minister through a non-operational official will not necessarily produce to the best outcomes.74

The Commission accepts that requiring the heads of the fire agencies to be primarily responsible for informing the minister could be a distraction from their operational duties, but it considers that Victoria Police, and the State Coordinator specifically, would be well positioned to fulfil this role. As coordinator of the emergency response, Victoria Police itself requires all the information that should be conveyed to the Minister.



The State consider amending the Emergency Management Act 1986 and the Emergency Management Manual Victoria in order to achieve the following:

     remove the title of Coordinator in Chief of Emergency Management from the Minister for Police and Emergency Services

     clarify the function and powers of the Minister

     designate the Chief Commissioner of Police as Coordinator in Chief of Emergency Management, who would have primary responsibility for keeping the Minister informed during an emergency.


2.5     A state of disaster

Section 23(1) of the Emergency Management Act 1986 provides as follows:

If there is an emergency which the Premier of Victoria after considering the advice of the Coordinator in Chief and the State Coordinator is satisfied constitutes or is likely to constitute a significant and widespread danger to life or property in Victoria, the Premier may declare a State of Disaster to exist in the whole or in any part or parts of Victoria.

If a state of disaster is declared the minister assumes responsibility for directing and coordinating the activities of all government agencies and for the allocation of all available resources of government that he or she considers necessary or desirable for responding to the disaster. The minister may also do the following:

       direct any government agency to do any act or to exercise any function, power, duty or responsibility

       relieve government agencies of compliance with subordinate instruments if compliance would inhibit response or recovery

       take possession of and make use of property

       control and restrict entry into and movement within disaster areas

       compel the evacuation of people from a disaster area.75

2.5.1    Lack of advice

A state of disaster has never been declared in Victoria, and the senior figures in Victoria’s emergency management structure gave no active consideration to advising the Premier to consider making such a declaration on or in the aftermath of 7 February. Each of Ms Nixon, Mr Walshe, Mr Esplin and Mr Rees gave evidence that they either did not consider whether a state of disaster should be declared or that they did not discuss it with each other or with the Minister. The Minister did not discuss the question with the Premier; nor did he seek or receive any advice about whether a declaration should be made.76

Mr Cameron, Ms Nixon, Mr Rees and Mr Esplin all expressed the view that declaration of a state of disaster was not necessary since the additional powers conferred by virtue of such a declaration were not required.77 These comments reflect a very narrow reading of the purpose of the ‘state of disaster’ provisions in the Emergency Management Act—namely, that a state of disaster ought to be declared only if the coercive powers conferred by s. 24 are required. There is, however, nothing in the Act that supports this restrictive interpretation.

The Commission considers that declaring a state of disaster would offer benefits beyond the grant of additional powers. First, it would provide symbolic recognition of the gravity of a situation—a recognition that on 7 February might have sharpened the focus of emergency services agencies on community safety factors such as warnings. Second, it would place the State’s political leaders firmly in charge of the emergency, reassuring the public that their government had the situation in hand and facilitating rapid mobilisation of Cabinet and high-level government attention if required.

These benefits could also be achieved through the declaration in relation to a particular emergency that falls short of a full-blown state of disaster. The Commission notes the South Australian model, whereby the Emergency Management Act 2004 provides for a scale of emergency declarations—major incident, major emergency and state of disaster. The first two can be declared by the Commissioner of Police as State Coordinator, but only the State Governor may declare a disaster.78

The circumstances on 7 February met the statutory precondition for declaring a state of disaster: the emergency constituted a significant and widespread danger to life or property in Victoria. The Commission considers that where such a situation exists, or there is a reasonable possibility that it might exist, the Minister and Chief Commissioner of Police should formally discuss with the Premier the prospect of declaring a state of disaster. The discussion should involve an assessment of the status of the emergency and the provision to the Premier of advice on whether a declaration would be of benefit (in the broad sense just discussed). Even if the decision is not to declare a state of disaster, to have had such a discussion allows the matter to be raised at the highest level of government and ensures that the Premier is briefed on a matter of importance to the State.




The State consider either amending the Emergency Management Act 1986 or adopting a standing practice to require the Minister for Police and Emergency Services or the Chief Commissioner of Police to consult the Premier about the possibility of declaring a state of disaster for all of or any part of Victoria whenever the Minister or the Chief Commissioner of Police becomes aware of circumstances that make it a reasonable possibility that the criteria for making such a declaration will be satisfied.



The State consider amending the Emergency Management Act 1986 to introduce a graded scale of emergency declarations short of a state of disaster.


2.6     Using AIIMS and what can be improved

The AIIMS framework was used to manage incidents on 7 February. The framework’s effectiveness varied from incident to incident as a result of the way it was planned and prepared for and the competency of and resources available to those who were implementing it. Apart from relatively isolated incidents, AIIMS appears well understood and accepted by fire agencies. No-one suggested to the Commission that AIIMS should not be used.

The Commission supports the continued use of AIIMS in the management of fire incidents in Victoria. It offers a consistent approach to incident management throughout Australia, as well as allowing for effective interoperability with fire management personnel from New Zealand, the United States and Canada, where comparable incident control systems are used. In Victoria, it provides a consistent framework for incident management between fire agencies and, although it is not identical to the incident command and control system used by police, both systems follow the same principles and are very similar in operation and function.79

Although the Commission supports the continued use of AIIMS, it notes that the interaction of AIIMS structures with the new State command and control arrangements will need to be carefully managed. Further, although AIIMS operates at the incident level, there is a need to ensure that the common language and consistent approach and understanding are applied at the area of operations and state levels in order to respond to the challenges posed by managing multiple incidents. Agencies should take account of the interaction between these levels in order to avoid ambiguities in relation to control and lines of reporting.

2.6.1    Control of incidents

AIIMS makes it clear that the Incident Controller is in charge of an incident. This is reflected in Country Fire Authority standard operating procedures, whereby the officer in charge of the first responding brigade or the most senior officer on the scene will be the Incident Controller until a more formal incident management structure is in position and control is transferred.80 The transfer of control did not always operate smoothly on 7 February.

In the absence of a pre-established level 3 incident management team, CFA resources responding to the Murrindindi fire were initially managed from the Yea CFA Group headquarters. Although a DSE IMT in Alexandra was subsequently established and took control of the fire at 4.15 pm, there was no handover from the Yea Group and CFA resources continued to report to Yea. This was not the fault of those in charge at the Yea headquarters: they were not told that control of the fire had nominally been transferred to the Alexandra IMT.81 When the Alexandra IMT was established, the Alexandra Group continued to coordinate CFA resources and, although in the same town as the IMT, operated independently.

In Bendigo, control of the fire was initially assumed by the senior officer on the ground. He was not told for nearly two hours that control had been formally assigned to the IMT at the Adam Street incident control centre. Even after this information had been conveyed, there was no formal handover of control.82

The Commission accepts that, in the absence of an established IMT, reverting to CFA Group command is a fall-back position. Under AIIMS, however, an Incident Controller is with the first arriving crew and once an incident control centre is established to manage a particular fire (such as the Alexandra ICC for the Murrindindi fire) it is unacceptable, and indeed potentially dangerous, that a CFA Group continues to manage CFA resources. Such a practice must stop, and all in the CFA must commit to AIIMS incident control throughout all incident management—regardless of which agency is providing incident management staff. When an IMT is established during a fire, that IMT must pay careful attention to ensuring that proper transfers of control are effected.

2.6.2    The Information Unit

Management of information by means of the AIIMS structure proved unsatisfactory on 7 February. The Information Unit deals not only with collection of information from the fireground and from media and state and regional levels of emergency management but also with dissemination of information to fireground personnel, other agencies and the community (via agency websites and the media).83

The existing AIIMS structure, which positions the Information Unit as a sub-function of Planning, fails to reflect the quantity, demands and priority surrounding information management in the 21st Century. These demands are particularly heavy during a fast-moving multi-agency emergency event. On days such as 7 February, when the prevailing conditions might render first attack ineffective, the information function becomes as important as, if not more important than, that of operations.

A number of witnesses highlighted the merits of separating the information function from the planning section to give it greater priority and prominence in the AIIMS structure. Mr Rees, for example, said, ‘the information function needs to become a discrete function of ICS [predecessor to AIIMS] in itself for major events and it needs to get a more prominent focus’.84 Chief Commissioner of Police Mr Simon Overland gave evidence that ‘Victoria Police considers the function of public information to be vital in responding to bushfires and therefore this function should be separated from the planning function and be reported directly to the controller’.85 Mr Waller was more cautious, fearing that if too many people report directly to the Incident Controller he or she might become overloaded. Nevertheless, he acknowledged the importance of information flow during fires of the type experienced on 7 February and said, ‘… if I was an incident controller I may well have pulled the information [unit] out and had them reporting to me direct’.86

Since 7 February the CFA and DSE have modified AIIMS to introduce the position of Public Information Officer, or PIO. Joint Standard Operating Procedure J4.01 describes the PIO as being ‘responsible for the preparation and dissemination of information and warnings to the community during an incident’. Such a person is to be appointed where the Incident Controller considers it necessary, and they will report directly to the Incident Controller. The Information Unit more broadly remains part of the Planning section and is responsible for ‘movement of non-operational incident information and dissemination of public information to communities, stakeholders, volunteers and staff’. The purpose of having the PIO report directly to the Incident Controller is to emphasise the importance of warnings to the public.87

Although SOP J4.01 notes that appointment of a PIO is at the discretion of the Incident Controller, SOP J2.03 requires that a full incident management team (30 members) contain a PIO as one of the ‘foundation’ positions. Mr John Beasley of the CFA was asked about this apparent inconsistency: his understanding was that a PIO would be a mandatory position for a ‘level 3 fire of significance’ but that otherwise the Incident Controller has discretion to appoint a PIO where required.88

In its interim report the Commission noted that the role and status of the Information Unit needed to be elevated; but at that stage there was insufficient evidence to allow a definitive recommendation that the Information Unit be given a separate and more important identity within the AIIMS structure.89 Evidence is now before the Commission to support such a recommendation. The inadequacies in information highlighted in Part One of Volume I of this final report extended not only to warnings and community advice but also to the flow of information between agencies and across various levels of emergency management.

The Information Unit as a whole should be given increased prominence through the creation of a separate function, sitting alongside, rather than underneath, Planning, Operations and Logistics and reporting directly to the Incident Controller. This is consistent with the approach adopted by Victoria Police.

The Commission considers that a Public Information Officer whose focus is community information and warnings would be a valuable addition to the Information Unit but should not be separated from the rest of the information function. Formulation of warnings that are accurate and timely and take full account of the situation on the fireground depends on an adequate flow of information; this flow of information is the responsibility of the Information Unit and the role of the Public Information Officer should not be divorced from it.

For smaller, less complex incidents the Information Unit might consist of only one member, who will combine the roles of unit leader and Public Information Officer. For larger incidents, there might be a dedicated PIO as well as a number of information officers supporting the unit leader. For all level 3 fires, where a full IMT is required by SOP J2.03, a dedicated PIO should be mandatory.

Although noting that this would deviate from the existing national approach to AIIMS, the Commission considers this matter to be of such importance that a deviation is appropriate. It also notes that any concerns about too many people reporting to the Incident Controller might be alleviated if more effective use were made of a Deputy Incident Controller.

2.6.3    The Deputy Incident Controller

Much is asked of the Incident Controller, and the demands will increase as a result of the Commission’s recommendations, including those relating to warnings and evacuation.

AIIMS contemplates that an Incident Controller may appoint a deputy to ‘assist in managing the number and array of issues involved at an incident’ and, indeed, a Deputy Incident Controller was appointed on 7 February for each of the major fires. A good example of the type of role a deputy could play is the effective manner in which Mr Ivan Smith assisted Incident Controller Mr David Nugent on 7 February during the Bunyip fire. Mr Smith took on the role of team leader of the Operational Contingency Planning Team on 5 February and prepared an operations plan to be used on 7 February in the event that the fire escaped Bunyip State Park. The existence and subsequent execution of this plan led to a well-ordered and effective operational handover from DSE to the CFA when the fire did in fact escape the park.90

Valuable assistance was also provided by Mr Rocky Barca, deputy to Mr Jason Lawrence at the Kangaroo Ground Divisional Command. As part of his role, Mr Barca maintained a constant focus on analysing fire information and assessing the likely direction of the fire. He used this information to oversee the preparation of warnings and recommend to the Incident Controller that a red flag warning be issued to firefighters. In the Redesdale IMT, the Incident Controller and his deputy agreed that the deputy would be responsible for internal management of the IMT while the Incident Controller concentrated on external relationships and keeping the integrated Emergency Coordination Centre and the public informed.91

The role of Deputy Incident Controller should be to reduce the burden on the Incident Controller by providing leadership and oversight in relation to specified areas within the Incident Controller’s field of responsibility. Such oversight should not, however, be confused with a handover of responsibility: the Incident Controller remains in control of the fire and accountable for the overall performance of the incident management team.

It would be valuable if the CFA and DSE were to agree on a set of specific functions that, in the absence of an alternative arrangement being agreed between a specific Incident Controller and their deputy, will come under the oversight of the Deputy Incident Controller. This ‘default’ list of functions could include the following:

       predictions of fire spread

       warnings and public information

       liaison with police in relation to evacuation

       preparation of the incident action plan.

2.6.4    Local knowledge

The benefits of incorporating local knowledge in an incident management team cannot be overstated. An understanding of local geography, infrastructure and community concerns can help the IMT identify priorities for both asset protection and community warnings. Local knowledge was used to good advantage in the Bunyip fire, where a local CFA captain was assigned to help the team preparing the operational plan by ‘providing local knowledge of the area’. In contrast, a greater appreciation of local conditions could have been of benefit in the Churchill IMT. The importance of local knowledge was also highlighted by Mr Ewan Waller, who noted that the issuing of warnings requires not only accurate predictions of the run of a fire but is also dependent on ‘local knowledge’.92

The existing AIIMS structure does not specify that an IMT include people with knowledge of the area in which the incident is occurring. Indeed, in a level 3 fire it is likely that personnel will have been drawn from across a region or even from elsewhere in the state. The Commission considers local knowledge to be invaluable to IMTs in relation to both operations and community warnings.

DSE and the CFA should modify the AIIMS incident management structure to require that IMTs for level 3 incidents include an individual whose function is to advise on local matters. This role could be incorporated in the Planning, Operations or Information Units but should be responsible for advising generally wherever local knowledge is required. For incidents below level 3, DSE and the CFA should emphasise the value of local knowledge and give the Incident Controller discretion to appoint a local adviser if required. Ensuring the incorporation of local knowledge in an IMT does not necessarily require a separate position, but if the IMT consists predominantly of personnel drawn from outside the local area the Incident Controller should appoint a dedicated local adviser.




The Victorian fire agencies amend the AIIMS framework before the 2010–11 fire season in order to do the following:

     designate the Information Unit as a separate section reporting directly to the Incident Controller and require that the Information Unit contain a dedicated Public Information Officer whenever a full incident management team is required

     specify a set of functions in relation to which the Deputy Incident Controller for a level 3 incident will have oversight, which may be adjustable for a particular incident by agreement between the Incident Controller and the Deputy Incident Controller

     ensure that an individual with local knowledge is incorporated in an incident management team.


The Commission is conscious that AIIMS is a nationally adopted standard for emergency services. The Commission’s recommendations focus on the use of AIIMS by Victorian fire authorities and the changes proposed are aimed at remedying weaknesses exposed by the 2009 bushfires. They may well have a wider relevance to authorities elsewhere in Australia, but that is a matter for those authorities. At a general level, the Commission supports the adoption of common terminology and operational practices among fire agencies. This brings considerable advantages when during major emergencies support is provided by personnel moving between states and territories. In this way the national capability is strengthened.


2.7     Information sharing on 7 February

Information gathering, analysis and subsequent distribution are vital functions of incident management teams. Information about a fire comes from various sources, among them spot fire weather forecasts, predictive maps, air reconnaissance and reports from the fireground. This information needs to be provided to the IMT while it is still current and to be distributed, with appropriate analysis, within the IMT and externally to support agencies and the community. An effective flow of information is crucial to the IMT’s ability to formulate a strategy for managing community protection, fire response and firefighter safety.

Some IMTs managed this function well on 7 February. Efficient gathering and sharing of information by the IMT for the Redesdale fire enabled the IMT to develop a suitable firefighting strategy and to deliver timely community warnings. Other IMTs were hampered by a lack of information or failed to analyse and make use of the information that was available. The Alexandra IMT lacked information on which to base planning and decision making for the Murrindindi fire: information that should have been provided was not; information that should have been sought was not sought; and information that was available was not analysed or used effectively.

The IMTs that functioned well on 7 February were able to use and interpret incoming information, convert information into ‘intelligence’ in order to develop a strategy, and document the information in summary form so that it was understood up and down the chain of command. In contrast, IMTs that were characterised by poor preparation, inadequate numbers of level 3–trained officers and under-qualified Incident Controllers generally demonstrated poor information flows to and from both the field and the integrated Emergency Coordination Centre.

The link between effective information flows and safety also warrants emphasis: in general, those fires where the IMTs were unsuccessful in managing information flows were also the fires that resulted in fatalities and exposed firefighters to greater danger.

Examples of IMTs’ collection, dissemination and use of information are provided in Part One of Volume I. In summary, the fires of 7 February revealed deficiencies in the sharing of information between the integrated Emergency Coordination Centre and incident control centres, within some IMTs, between some IMTs and the fireground, and between some IMTs and municipal emergency coordination centres.

The Commission notes in particular the failures in information flow from the iECC to ICCs. Specialists trained in weather forecasting, fire behaviour analysis and predictive mapping were at the iECC, and yet for some fires these capabilities were not made use of or in some cases even known about. The Incident Controllers for both the Murrindindi and Kilmore East fires were not aware that the iECC could have offered predictive mapping assistance. Similarly, the Churchill Incident Controller was not aware that Bureau of Meteorology forecasters were at the iECC. Fire agencies should ensure that all IMT personnel are aware of the services that can be provided by the iECC (now the State Control Centre).93

2.7.1    Information sharing: incident action plans

An incident action plan is one of the primary tools available to an IMT to improve information flows and help with the development of a strategy for fire management based on information available to the Incident Controller.

The AIIMS manual states, ‘An Incident Action Plan should provide critical information to users to enable them to do their job. Lack of information may compromise safety and hinder efficiency’. Under AIIMS, an incident action plan must be approved by the Incident Controller.94

On 7 February Joint Standard Operating Procedure J3.03 governed the development of an incident action plan during an integrated response to an incident. It provided that responsibility for incident planning rested with the Planning section of an IMT, that an incident action plan must be prepared for all incidents and that the plan be based on the following priorities:

         safety of incident personnel

         protection of members of the community

         protection of critical infrastructure and community assets

         aggressive first attack on new outbreaks of fire

         protection of conservation and environmental values.95

SOP J3.03 did not stipulate a time frame within which the incident action plan should be developed, but it did note that during the first-attack phase the incident action plan could simply be recorded in a log, whereas any incident progressing ‘beyond extended first attack’ required a formal incident action plan.96

The Commission recognises that it is extremely difficult to produce an incident action plan during the first shift or the early stages of a fast-running fire. One of the reasons for this difficulty is that the incident action plan, in its complete form, is a complex document that has attached to it a number of maps and can be up to ‘70 or 80 pages long’.97

Nevertheless, in the stressful environment of a level 3 incident the development of an incident action plan operates as a trigger to ensure that important aspects of fire management are taken into account. The absence of a written plan could mean that important matters requiring the Incident Controller’s consideration are neglected.98

Before 7 February fire agencies were aware of the difficulty of developing an incident action plan in the early stages of a fire as a result of being overrun by events or suffering from ‘data overload’. They had sought to implement the abridged incident shift plan in order to limit the difficulties. Despite the challenges of 7 February, some IMTs were in fact able to produce a documented plan.99

The incident action plan summary developed for the Redesdale fire used the incident action plan summary template DSE had created. This template provided a concise format to document essential information necessary to communicate a strategy for managing the fire. Anyone reading the summary developed for the Redesdale fire could quickly ascertain where the fire was, where it was travelling, the towns it was near, and the Incident Controller’s objectives. The IMT for the Redesdale fire was first notified of the fire at about 3.11 pm; the incident action plan summary was produced at 5.46 pm, about two-and-a-half hours later.100

In the Commission’s view the DSE incident action plan summary is a useful template for all IMTs. The CFA and DSE should ensure that the template is readily available in all incident control centres by including it in the online IMT Tool Box available through the CFA and DSE internal websites.101

The IMTs managing the Beechworth–Mudgegonga, Bendigo, Churchill, Kilmore East and Murrindindi fires did not produce an incident action plan, incident action plan summary or incident shift plan on 7 February 2010.102 Of those fires, all but the Beechworth–Mudgegonga one are criticised by the Commission for poor incident management (see Part One of Volume I).

Neither of the IMTs managing the Kilmore East and Murrindindi fires had pre-positioned level 3 Incident Controllers, and each IMT fell short of constituting a full IMT (14 people as at 7 February).103 Many of the functional leaders within those IMTs lacked level 3 qualifications for the roles they were performing.104 In such circumstances preparing an incident action plan is even more difficult.

In contrast, the Redesdale IMT had a number of characteristics that facilitated exemplary management of that fire and enabled the IMT to develop an incident action plan summary within only two-and-a-half hours of being notified of the fire:

       The team was staffed with level 3–qualified personnel from both fire agencies. In particular, all functional units were led by experienced and properly qualified personnel.

       Members of the team were familiar with each other and aware of each other’s skills and experience, and key staff had worked together previously.

       Members of the team did predictive work before and after the fire began in order to plot the expected path of the fire and identify vulnerabilities.

       The team was pre-positioned such that when the fire broke out the team could react instantly.

       The team had a pre-planned trigger for assuming control of the fire: if crews were unable to control the fire within 30 minutes the IMT would take over management of the fire.105

The team’s level of planning and preparedness allowed it to operate effectively on the day and is the level at which all IMTs must be prepared in future. This, in conjunction with the initiatives introduced by the fire agencies since 7 February 2009, will facilitate the vital task of gathering, analysing and disseminating information in relation to bushfires.

2.7.2    Incident action plans: the way ahead

On 3 February 2010 the CFA and DSE approved a revised joint standard operating procedure for incident action planning.106 Revised SOP J3.03 requires the production of a written incident action plan for a level 2 or 3 incident as soon as practicable but ‘generally within four hours’ of an incident appearing to progress beyond ‘extended first attack’.107 It also requires that, at a minimum, the incident action plan consist of a summary of incident objectives and primary risks and attach an incident map, communications plan and incident structure chart. The incident action plan is to be developed with reference to input from ground commanders, available local knowledge, any relevant township protection plans, and the location of any designated ‘neighbourhood safer places’ that are likely to be threatened. The plan must be communicated to personnel at the incident.108

The Commission supports the idea of having a defined time frame in which an incident action plan must be produced but considers that linking the time frame to the concept of extended first attack could create confusion and ambiguity. Instead, the requirement should be for an incident action plan summary to be produced within four hours of reported ignition.

It should also be mandatory for the incident action plan summary to be provided to the State Control Centre (and to the relevant Area of Operations Command Centre if established) since this would help senior fire agency personnel maintain their oversight of IMTs and fulfil their leadership responsibilities. If an incident action plan summary has not been provided for an incident within four hours, that would be a clear sign to those at the higher levels that an IMT might not be functioning effectively.

Both the CFA and DSE are working on finding better ways of gathering data and turning it into usable information. Examples are technology for automatic vehicle location and an updated portable IT field kit with geospatial capability, which could collate data and send it to an ICC in the form of a map or footage.109 The Commission encourages these and other similar initiatives.



The Country Fire Authority and the Department of Sustainability and Environment:

     amend their procedures to require that an incident action plan summary be completed within the first four hours of an incident being reported and be provided to the State Control Centre and, where established, to the relevant Area of Operations Control Centre

     adopt DSE’s incident action plan summary as the template to be used by all incident management teams and ensure that the template is included in the online IMT Tool Box

     provide regular training to IMT staff, highlighting the importance of information and reinforcing the support available from specialists within the State Control Centre.


2.8     Agency integration

2.8.1    The integrated Emergency Coordination Centre

As noted, the CFA’s and DSE’s state-level functions were exercised on 7 February from the integrated Emergency Coordination Centre in Melbourne. Also present were representatives of many other agencies, among them Victoria Police, the MFB, the Department of Human Services, Networked Emergency Organisation partners (Parks Victoria, the Department of Primary Industries and Melbourne Water), the Bureau of Meteorology, Ambulance Victoria, the Office of the Emergency Services Commissioner, Victoria State Emergency Service, SP AusNet and Telstra—in all, about 200 people from nearly 30 agencies.110 The Commission discussed the history of the iECC and made some preliminary comments about its operation on 7 February in its interim report.

Mr Ewan Waller described the benefits of the iECC as being ‘effective strategic level planning and coordination … enhanced information sharing … and quicker decision making’.111 True integration, however, was not achieved in practice. The CFA and DSE operated according to separate standard operating procedures, using separate technology systems and in many cases doing the same things. Apart from the State Air Desk, which is a joint operation of the CFA and DSE, other iECC functions continued to be performed by both agencies in separate units; these units were at best cooperative but more often they operated independently.

The Commission identified a number of shortcomings in the logistical operation of the iECC, including in relation to the location of various units, security procedures, deficiencies in systems and technology, and duplication in connection with weather forecasts and media releases and requests for resources. Some of the problems identified might be attributable simply to the fact that the 2008–09 fire season was the first in which the iECC had operated. Mr Gregory Paterson of the CFA said that on the ‘blow-up day’ of 7 February the individual agencies ‘went back to our level of training … and [CFA] went back into our cell and DSE went back into their cell and we’d come together for five or 10 minutes’.112Nevertheless, the new model of co-location did deliver substantial benefits for interagency communication and coordination.

Since 7 February the emergency services agencies have adjusted the physical layout of the iECC, upgraded its communications systems, developed joint standard operating procedures to govern its operations, and renamed the facility the ‘State Control Centre’—a name favoured by Chief Commissioner of Police Mr Simon Overland because it emphasises that the centre’s function is ‘control’ and not ‘coordination’.113

Although there were obviously problems with the operation of the iECC on 7 February, it is of note that the overwhelming majority of people who worked from the centre on the day thought the consequences of the fires would have been far worse had the agencies not been positioned together at the iECC.114 The Commission agrees that the iECC represents an important step in achieving a more coordinated approach to emergency management and response at the state level. Taking into account the changes that have been implemented since 2009, the Commission supports continued use of the iECC—with its new name, the State Control Centre—to achieve an integrated approach to emergency management.

2.8.2    A lack of integrated systems

The Commission identified a number of systems that effectively reinforced single-agency approaches. Among them are mapping, global positioning and fire prediction.


Fire agencies use maps in all aspects of emergency management—prevention, preparation, response and recovery.115 Good mapping systems, as well as effective sharing of the available spatial information, are particularly important in responding to fires and in incident management. The maps fire agencies use range from the hastily sketched map on the bonnet of a vehicle to the well-thumbed spatial vision VicMap books kept in a fire truck and fire-prediction maps produced through computer modelling of fire behaviour.116

Victoria has a well-established spatial information strategy within DSE, and VicMap is a central component of this.117 VicMap is a digital geographic information database that is continually updated. It uses data from a wide range of sources and is available to Victorian government agencies, local government and the private sector.118 At present DSE has free access to the VicMap database, while the CFA pays an annual licence fee.119 The Commission cannot see any justification for charging the CFA (and other emergency response agencies) for publicly owned data essential to CFA operations: the CFA should have access to the VicMap database on the same basis as DSE.

DSE uses FireMap, a mapping system accessed through FireWeb (DSE’s primary source of integrated fire management information) to create and view maps. FireWeb offers weather information, incident support, IRIS (Incident Resources Information Systems) and mapping. FireMap is used to create and view maps. It was built using the suite of GIS software used by the CFA and is a networked service that, like FireWeb, is available to DSE, Networked Emergency Organisation members and CFA personnel.120

FireMap was designed to be a single source for map-based fire information but was not based on VicMap data. The CFA uses two systems—ArcGIS and, in response to difficulties with achieving and maintaining proficiency when using this complex software, EIMS Mapper. Both systems use VicMap data, so that data entered into one application can readily be exported to the other.121

The operational requirements for EIMS Mapper were that it should be able to operate both in the CFA’s ‘tin shed’ brigades without an internet connection and in a sophisticated technical environment.122 EIMS Mapper is designed to work during the initial bushfire attack before specialised GIS support can be provided and uses VicMap books as the basis for all mapping.123 The CFA trialled EIMS Mapper during the 2008–09 fire season and it performed well under pressure.124 The system was rolled out across the CFA in the 2009–10 fire season.125

The CFA, DSE and other emergency services personnel also distribute the spatial vision VicMap books to operational staff. The VicMap books consist of a series of five hard-copy regional map books covering Victoria. The books used on 7 February 2009 contained numerous errors.126 Although the Commission did not hear evidence that any firefighters were endangered or unduly delayed in responding because of these errors, it notes that such inaccuracies create obvious and concerning risks for firefighters and other emergency services personnel. Despite this, the Commission accepts that there is a satisfactory process for continuing improvement and updating of the VicMap database.

The Commission considers it crucial that adequate systems exist for the CFA and DSE to automatically share fire mapping information. Despite the fact that the CFA and DSE use different systems, the systems are interoperable in that both use the same software and the VicMap database. The Commission notes, however, that although the systems are capable of exchanging spatial data, it is vital that formal arrangements exist for integrating the two systems.

As the 2008–09 fire season approached, the CFA and DSE mapping teams had agreed how they would support the integrated Emergency Coordination Centre and, through this, field operations.127 The main features of their agreement were as follows:

       integrating wherever possible with mapping tasks and map production

       VicMap data being loaded into DSE’s FireMap before the season, so that CFA users had a familiar mapping background

       EIMS Mapper being installed on a DSE mapping computer

       the CFA using FireMap to map fires during the fire season.128

Most of the actions identified in this agreement failed to materialise. DSE did not load VicMap data onto FireMap and, although all CFA Mapping Unit staff had ‘write’ access to FireMap, they produced most of their maps using their own system, ArcGIS.129

DSE and the NEO have more than 3,700 registered FireMap users, and this led to huge demand on 7 February. Within the CFA, FireMap is available for viewing by all with access to the CFA’s network, but only a limited number of CFA staff had write access, enabling them to add data about a fire to FireMap.130 The huge demand on 7 February resulted in the Fire Systems Duty Officer having to restart the system a number of times.131 The result was that FireMap was unavailable for a total of about 25 minutes. DSE has since upgraded the server infrastructure so that FireMap can now handle the level of demand experienced on 7 February.

There were also numerous instances on 7 February when useful spatial information was not available to the relevant incident management team or between the CFA and DSE. In particular, crucial prediction, situation and line scan maps for the Kilmore East, Murrindindi and Coleraine fires—which were available at the integrated Emergency Coordination Centre or the Regional Emergency Coordination Centre—failed to reach the relevant incident control centres and Incident Controllers either at all or in time to be of any use.132

Further, there was wide variation in the IMTs’ mapping capabilities. For example, the Epsom ICC had several people in the Planning Unit who could produce both status and prediction maps for the Redesdale fire, yet the nearby Adam Street ICC lacked the range of paper maps it required to manage the Bendigo fire and had to obtain these from the Epsom ICC.133 The ICCs for the Coleraine and Bunyip fires had good mapping capability, while the Traralgon IMT had adequate mapping capability but lacked vital wind change information and so did not factor this into the fire prediction maps.134 The Kilmore ICC did not have internet access to enable staff to view available mapping products when managing the Kilmore East fire, and a power failure prevented the Beechworth IMT from using its computer mapping facilities.135

These differences in mapping capability highlight the importance of properly preparing facilities, communications and personnel to produce and share vital information within and between IMTs, fire agencies and broader statewide support resources.

The organisations’ respective mapping teams have since reached a new agreement, documented in a memorandum dated 16 October 2009, that provides guidelines for integrating the various mapping tasks and map production.136 An important step has been to incorporate the VicMap books in FireMap. The agreement specifies that CFA and DSE mapping teams use EIMS Mapper, FireMap and ArcGIS for iECC (now State Control Centre) and ICC mapping.137 The agreement requires the CFA and DSE to incorporate all mapping data in FireMap, so that data are readily accessible to all agencies statewide, and that they provide incident action plan maps and media maps using FireMap where possible.

FireMap is also now used in the One Source One Message tool, which provides a geographical map–based interface to identify the area where a fire is expected to burn and generates a list of towns and localities in the area so that warnings can be issued.138

These arrangements will result in better integration of the two systems and should be formalised in a joint standard operating procedure before the 2010–11 fire season. To fully implement the guidelines, mapping personnel in each agency need to be more familiar with the mapping systems of the other agency. The CFA should give priority to greatly increasing the number of personnel who have ‘write’ access to FireMap and, where required, upgrade the ICC computers and internet facilities to enable reliable access. Until this happens there will be double-handling of spatial information, which inevitably creates inefficiencies and delays in sharing vital information.139 This situation should be resolved by the development and delivery of a joint training program for mapping unit personnel from the CFA, DSE and the NEO to ensure that these people can successfully operate the mapping systems of both agencies.



The Country Fire Authority and the Department of Sustainability and Environment improve mapping support in the following ways:

     DSE providing mapping data free of charge to emergency response agencies

     greatly increasing the CFA’s ‘write’ access to FireMap for incident management team staff

     establishing a joint DSE–CFA training program to ensure that mapping officers in level 2 and 3 incident management teams are fully trained in using FireMap, including in producing fire prediction maps

     requiring before the 2010–11 fire season that FireMap be used for joint incidents.


Global positioning systems

There is in the CFA no organisation-wide approach to harnessing fireground spatial data using global positioning systems. GPS units are not currently issued to brigades and are not standard equipment on CFA appliances, and no single unit or range of units is recommended.140 Some CFA brigades have bought their own GPS units.141 In contrast, DSE issues the same makes and models of GPS units to all operational staff. This means training and data uploaded into the units can be standardised across the organisation.142 Until the CFA equips all its appliances with GPS units, the CFA should give its personnel guidance on the most suitable makes and models of GPS units and advice about configuring the units to record data in a format that can be imported into the CFA’s mapping systems. Although maintaining far fewer brigades than the CFA, Hancock Victorian Plantations, provides GPS and automatic vehicle location systems to all its firefighting appliances: this should be a goal for both DSE and the CFA.

Although it is desirable that the CFA equip all its appliances with GPS units as soon as possible, the Commission acknowledges the work being done by the Department of Justice to develop and implement a statewide cross-agency communications framework.143 The type of GPS unit the CFA chooses needs to be capable of interfacing with the data communications systems used by other agencies, and ensuring such interoperability could extend the time frame for use of GPS capability to all CFA appliances. This is discussed in Chapter 3.

Fire prediction

On 7 February 2009 FireMap did not offer templates, so maps produced by fire behaviour analysts were hand drawn, unavailable in FireMap, and could not easily be shared with incident management teams.144 As noted in the Commission’s interim report, the maps were not easily shared—even in the integrated Emergency Coordination Centre. This situation has now been rectified.

During the 2009–10 fire season DSE tested the Phoenix RapidFire simulation model developed by Dr Kevin Tolhurst of the University of Melbourne. The model calculates potential fire spread on the basis of topography, vegetation, fire history and forecast weather.145 When a fire is reported and the details are entered into the agencies’ incident management systems, Phoenix RapidFire is triggered to automatically generate a simulation producing maps showing the predicted hourly fire spread, flame height and ember spread.146 Although DSE is still formally evaluating the model, the Commission commends it for conducting the trial.


2.9     Facilities for incident management and coordination

2.9.1    Incident control centres

The ICC facilities from which level 3 IMTs operated on 7 February 2009 were in some cases deficient. Debriefing after the fire season revealed that some facilities did not have suitable ‘space, power, and telephone and internet connections to rapidly serve as ICCs for large and fast moving fires’. The Kilmore and Adam Street (Bendigo) ICCs stood out in the evidence as having been ill-equipped for their roles as level 3 ICCs. Problems with communications systems had a particularly big impact; they are discussed in Chapter 3.147

In its interim report the Commission recommended that pre-designated level 3 ICCs be properly staffed and equipped to enable immediate operation in the event of a fire on a day of high fire risk. The State allocated $28 million to the CFA and DSE in 2009–10 to upgrade the equipment in level 3 ICCs and divisional command points to common minimum standards. The CFA and DSE identified 43 pre-designated level 3 ICCs and adopted joint minimum standards, including in relation to accommodation, networks, IT systems, and radio and telephone equipment. The ICC upgrade project is scheduled for completion by 30 June 2010; the Commission urges compliance with this time frame.148

2.9.2    Municipal emergency coordination centres

A municipal emergency coordination centre is a facility where municipal resources for supporting emergency response, relief and recovery are coordinated. Liaison between personnel at MECCs and incident control centres is essential for ensuring the timely activation of relief and recovery arrangements. MECCs and ICCs have traditionally been established in separate locations, and on 7 February communication between the facilities was at times inadequate or delayed. This is covered in Part One of Volume I.

During the Bunyip fire, however, the MECC was located alongside the ICC at the Police and Emergency Services complex in Pakenham. This facilitated communications between the centres, allowed MECC personnel to easily attend ICC briefings, and ensured that the MECC was able to maintain an overview of the emergency response.149 The co-location worked well. Municipal councils and the fire agencies should consider co-locating MECCs and ICCs in designated level 3 ICCs to gain the benefits of improved interagency communications in the future.

2.9.3    Level 3 incident controllers

On 7 February not all designated level 3 ICCs were properly staffed before the outbreak of fires and not enough qualified level 3 Incident Controllers were appointed and pre-positioned. The Commission accepts that each Incident Controller appointed on 7 February worked hard and tried to satisfy onerous responsibilities, but an examination of the shortage of level 3 Incident Controllers on the day revealed serious problems in the selection, training and accreditation processes for these officers.

There are important differences between the DSE system of accreditation (which involves formal assessment of a candidate against known criteria) and the CFA system of endorsement (involving the nomination or approval of a person to perform a particular role).150Since both agencies provide members for joint IMTs, it is highly desirable that there be uniformity in selection, to ensure that each Incident Controller, regardless of their agency, has a similar level of experience and competence.

DSE accreditation

DSE accreditation of level 3 Incident Controllers involves staff volunteering to progress from operational firefighter to Incident Controller level 1, 2 and 3. Historically, the full progression from firefighter to level 3 Incident Controller has taken 20 to 24 years, but recent opportunities to gain experience more rapidly, through overseas deployments and attending a greater number of fires have led to this period being reduced.151 To qualify as a level 3 Incident Controller in DSE, the aspirant must be both assessed and accredited. Since 2006 DSE personnel seeking to move from level 2 to level 3 accreditation have taken the following pathway:152

       Staff who satisfy the full prerequisites for the role are nominated by an area manager and nominations are assessed by a nominations panel.

       Nominees undergo psychometric testing to determine their suitability for demanding and stressful roles. The results of this are fed into a development plan.

       Candidates maintain a ‘work book’, listing incidents they believe demonstrate their experience and knowledge.

       Candidates present a summary of their relevant experience. This includes up to three incident action plans for which the candidate has been responsible, extracts from logbooks, peer testimonials, lists of simulation exercises and leadership courses completed, and their development plan.

       Candidates are interviewed and assessed by a panel, and the assessments are validated by the Chief Officer.

       Candidates who do not meet all assessment criteria are required to undergo additional scenario-based training.

This accreditation process is both rigorous and thorough and would be suitable for use by both DSE and the CFA.

CFA endorsement

The CFA’s approach to level 3 qualification is as follows:153

       Both career and volunteer personnel wishing to take on an IMT role must participate in a series of five AIIMS courses—in total, 145 hours of instruction and 60 hours of study.

       The Chief Officer annually endorses members to perform the roles of Incident Controller and Operations, Planning and Logistics Officers for level 3 incidents. Endorsement is ‘based on competencies, endorsements and experience and an assessment of the CFA member’s aptitude for the role’.154

       In practice, endorsement of IMT personnel occurs on the recommendation of operations managers.155

       The endorsement of level 3 Incident Controllers is based on a candidate’s performance in level 2 roles, their aptitude for the role, and previous exposure and mentoring at level 3 incidents.156

The CFA acknowledges that its existing endorsement process is subjective and lacks transparency.157

In 2006 the CFA participated in the ‘Level 2–3 Transition Project’ that led to the development of the DSE accreditation process.158 The Commission was not told why the CFA did not adopt the same process, but the situation should certainly be remedied. A standardised and rigorous approach to accreditation on the part of both agencies would deliver considerable benefits in ensuring that Incident Controllers of high calibre are appointed.

Training and performance review

The accreditation process should also involve a dedicated training course for level 3 Incident Controllers. The emphasis should be on the skills and attributes, including leadership, that were identified in the Level 2–3 Transition Project as being desirable for level 3 Incident Controllers. In addition, the CFA and DSE should introduce a performance review system for level 3 Incident Controllers to allow for effective monitoring of performance and feedback to personnel and to provide opportunities for identifying areas for improvement and additional training for people needing assistance in the role.

The system needs to be introduced before the 2010–11 fire season. Further, the CFA must implement a system for recording the endorsement and accreditation of its staff and volunteers. The system should be arranged in such a way as to allow the location, qualifications and experience of the individual concerned to be easily identified and kept in a form (such as a secure online database) that is readily accessible to regional staff and area of operations controllers.


The Commission stresses the intent of its recommendation in the interim report that Incident Controllers be appointed on the basis of experience, qualifications and competence, as opposed to the identity of the control agency. If accreditation is standardised across agencies, however, the requirement for the ‘most experienced’ person to be appointed should be replaced with a ‘suitably experienced’ person. This will ensure that recently accredited personnel are not denied the opportunity to further their experience. The Commission considers that the requirement for a suitably experienced, qualified and competent Incident Controller to be appointed, regardless of the control agency, should be made explicit in the revised joint standard operating procedure in relation to appointment of the Incident Controller.159

Although CFA Deputy Chief Officer Mr Haynes said that area of operations controllers and the State Controller would ensure that the most suitable person for the job was appointed to a level 3 Incident Controller position, DSE Assistant Chief Officer Mr Slijepcevic was of the view that incorporation of suitable wording in the joint standard operating procedure would reinforce the message.160 The Commission shares this view.

2.9.4    Volunteers

On 7 February only 14 volunteer members of the CFA were endorsed to perform the role of level 3 Incident Controller without a mentor; this represents less than 0.1 per cent of the number of operational volunteers.161 The Commission heard evidence that there are barriers to volunteer members filling positions in level 3 incident management teams, among them difficulties attending training for senior IMT positions and a cultural preference within the CFA for using career officers rather than volunteers.162

The Commission considers that volunteers, with their diverse work and personal backgrounds, can bring skills and experiences to the role of Incident Controller (and other senior IMT roles) that might be extremely valuable. The CFA should increase its efforts to ensure that training for senior IMT positions is made available to volunteers and that volunteers are considered for nomination in the Incident Controller accreditation process and, once accredited, for appointment as Incident Controllers for level 3 incidents.

2.9.5    Trainees

At present the appointment of a mentor is a central element of the CFA process for moving from being a level 2 to a level 3 Incident Controller. Yet the CFA does not have a formal mentoring program. Mr Haynes explained that in practice mentoring was organised by appointing individuals to deputy position roles. On 7 February, however, at least one Incident Controller was appointed to lead a level 3 IMT without having received any formal or informal mentoring, including operating as a deputy.163

DSE uses a variety of techniques it describes as mentoring—including shadowing, supervision and on-the-job training—but acknowledges that it does not have a consistent, structured mentoring program at the statewide level. The need for a formal mentoring system was pointed out in the 2002 report of the coronial inquiry into the Linton fires, and it is unacceptable that such a system had still not been implemented by the time of the 2009 fires. DSE and the CFA have now made a commitment to develop a formal, comprehensive mentoring program: such a program should be implemented as a matter of urgency.164

DSE commissioned Mr Bill van Bruggen, a forester and Type 1 (level 3–equivalent) Incident Controller from the United States, to prepare a report on training and mentoring.165 Mr van Bruggen’s draft report described the coaching and mentoring required for progression through specific fire roles in the US Forest Service. The approach there involves the use of ‘work books’ to record experience in a range of IMT positions and the appointment of personnel as trainees in various IMT positions before they are tested and accredited in the role. Mr van Bruggen noted that IMTs in the United States can have up to 25 per cent of their additional staff operating as IMT trainees.166

In view of the limited number of accredited level 3 Incident Controllers who could be removed from their operational role to become mentors, the Commission supports adoption of the traineeship approach described by Mr van Bruggen in preference to sole reliance on a mentoring scheme; in other words, train personnel before they are accredited rather than mentor them after the fact. Where sufficient personnel are available, mentoring might continue to be useful in further developing the skills of accredited personnel, but it should not be used as the primary pathway to accreditation.

The Commission also supports the use of work books for recording and then assessing a candidate’s demonstrated aptitude in the skills required by a level 3 Incident Controller. Use of work books is already part of the DSE accreditation process, which the Commission considers should be adopted by both agencies.




The Country Fire Authority and the Department of Sustainability and Environment establish before the 2010–11 fire season:

     a uniform, objective and transparent process based on the current DSE approach for the accreditation of level 3 Incident Controllers

     a performance review system for level 3 Incident Controllers

     a traineeship program for progression from level 2 to level 3 incident management team positions.



The Country Fire Authority and the Department of Sustainability and Environment amend their procedures to require that a suitably experienced, qualified and competent person be appointed as Incident Controller, regardless of the control agency for the fire.


2.10  Roadblocks during the 2009 Victorian bushfires

Roadblocks play an important role in preserving public safety and facilitating appropriate and effective responses during a bushfire and in the immediate aftermath. They can also be established or maintained in the days and weeks following a bushfire because of continuing health and safety concerns or to facilitate investigation of a fire-affected area by emergency services personnel and police.

On 7 February 2009 and in the ensuing days and weeks more than 4,500 roadblocks—referred to by Victoria Police as ‘traffic management points’—were established to regulate traffic flows on roads leading into and around fire-affected areas.167 Full and partial road closures were instituted because of the presence of fires and burning vegetation and also because of the risk of trees falling onto roads and preventing access to the fireground. Roads were also closed in order to restrict access to a fire area where a death had occurred or where the cause of the fire was suspicious, pending a coronial investigation. The legislative basis for the closures can be found in Victoria’s Country Fire Authority Act 1958 and Coroners Act 1985.168

In its interim report the Commission recommended a review of the 2006 Guidelines for the Operation of Traffic Management Points during Wildfires, under which roadblocks were established on 7 February.169 As a consequence of this, revised guidelines were issued in October 2009. This section further reviews the 2006 guidelines and looks at the new guidelines to see how they might be improved.170

Roadblocks and redirection of traffic can occur on the basis of the CFA Chief Officer’s powers (generally delegated to Incident Controllers) to protect life or property where a fire is burning or has recently been extinguished.171 Police officers also have power to close a road in the vicinity of a fire, as does a coroner investigating a fire.172

2.10.1  Previous coronial findings

The findings of two coronial inquests—one in Victoria, which concerned the death of a father and son during the Grampians fire in January 2006, and one in Western Australia, which concerned the deaths of three truck drivers in the Boorabbin fire in December 2007, highlight the potentially fatal consequences of permitting access to areas in which bushfires are burning and the need to restrict road travel in order to protect life and maintain public safety.173

In the case of the Victorian inquest, there was a question as to whether s. 31(3) of the Country Fire Authority Act obliged police officers to allow people who had a pecuniary interest in property to pass through a roadblock in order to return to their property.174 The Coroner ruled that s. 31(3)(a) of the Act gave police ‘power to close a road irrespective of whether nearby property owners, who were claiming a pecuniary interest, wished to travel on the road.’175 During the course of the inquest Victoria Police, the CFA and DSE prepared the 2006 guidelines.176

In the case of the Boorabbin inquest, the Western Australian Coroner was critical of the decision by an Incident Controller to remove a roadblock ahead of a predicted wind change and found that the roadblock’s removal contributed to the deaths.177 The Coroner recommended a review of the Western Australian Department of Environment and Conservation’s ability to manage major fires.178 In January 2008 an interagency review of the operation of road closures during bushfires was initiated.179 A set of guidelines developed during the ensuing month was used during the bushfires in January 2009; the guidelines were based on the Victorian 2006 guidelines.180

2.10.2  The 2006 guidelines

The 2006 Guidelines for the Operation of Traffic Management Points during Wildfires provided for full and partial road closures. A full road closure could be activated by police officers on their own initiative or at the request of the Incident Controller; only ‘responding fire agency personnel engaged in fire fighting operations on fire appliances’ were permitted entry.181 A partial road closure could be established only by the Incident Controller, who had discretion to authorise groups or individuals (including fire agency personnel travelling by car), utility providers, private firefighters, media and people with a pecuniary interest to travel through the roadblock and to apply conditions to such authorisations.182 Victoria Police members at roadblocks did not have discretion to allow non-authorised people to pass a partial road closure.

Under the 2006 guidelines police officers at roadblocks could upgrade a partial road closure to a full road closure, but only the Incident Controller could downgrade a full road closure to a partial road closure.183 The Incident Controller was responsible for communicating any changes to the conditions of entry at a roadblock to Victoria Police, the public, the municipal emergency coordination centre and VicRoads.184

The 2006 guidelines were communicated to police by means of a reference card entitled ‘Traffic Management Points during Wildfires’. The substance of the guidelines was summarised by a catchphrase on the cover of the reference card—‘If in doubt, keep them out’.185 From the point of view of Victoria Police, the roadblocks established for the fires on 7 February 2009 saved lives. Many people tried to and did breach the roadblocks, however, and one former member of the CFA was later charged with assault-related offences.186 Sergeant Mick Salter of Victoria Police acknowledged that the use of total road closures was often excessive and counterproductive and operated to prevent people attending with private units to mop up in the wake of the firefront.187

Roadblocks also caused frustration for, and added to the distress of, local residents. At times the roadblocks were ineffective because people familiar with the area were able to circumvent roadblocks to reach their desired destination. Additionally, local residents experienced inflexibility and inconsistency on the part of roadblock coordinators, exacerbating their frustration and distress.188 Agencies involved in recovery also experienced problems with roadblocks: Mr Robert Anderson, the Manager of Operations for Goulburn Valley Water, which supplies water to Buxton, Marysville and Alexandra, reported that it was not until 9 February that staff were able to enter Marysville to start repairing damaged services and restore water.189

A number of systemic shortcomings emerged from the evidence relating to roadblocks for each of the fires on 7 February 2009:

       Inflexibility. In the days following the fires people who had left their homes ahead of the fire wanted to return and people who had stayed to defend their homes needed to leave to obtain supplies and to communicate with loved ones. Under the 2006 guidelines this was not possible while full road closures remained in place. There were also instances of services that were desperately needed in the early stages of relief and recovery being delayed by roadblocks—including ambulances and contractors attending to restore essential services.190 Police staffing the roadblocks were placed in an invidious position.191 A system of wristband identification was successfully introduced for residents and the providers of essential services in the areas affected by the Kilmore East and Murrindindi fires.192

       Communication. A consistent theme among many fires was poor communication between the incident control centre and the police responsible for traffic management.193 In many instances police established road closures without directions from the Incident Controller.

       Denying access to firefighters. In several instances roadblocks delayed or prevented firefighters and private firefighting units from reaching the fireground.194 Strict enforcement of the 2006 guidelines by police on 7 February was a cause of frustration and conflict between police and firefighters responding to the fires. Mr Robert McGennisken, a CFA volunteer who acted as a sector commander for the Horsham fire, witnessed several occasions when firefighters and private firefighting appliances were prevented from reaching or returning the fireground. He also noted the importance of private units in the Horsham fire-suppression efforts and that most of the CFA volunteer units that were confronted by roadblocks managed to get around them by using local knowledge.195 This serves to emphasise the need for a way of identifying CFA volunteers so that they may pass through roadblocks to reach the fireground and for effective communication between an Incident Controller and police at roadblocks.

2.10.3  The new guidelines

Deputy Commissioner Walshe acknowledged that the 2006 guidelines needed some refinement. The Victoria Police internal debrief process in June 2009 also identified a need to review the guidelines.196 After broad consultation, including with community groups, revised Guidelines for the Operation of Traffic Management Points during Wildfires were agreed by Victoria Police, the CFA, DSE and VicRoads and were issued in October 2009.197 The 2009 guidelines are referred to in a new DSE–CFA Joint Standard Operating Procedure for Traffic Management during Bushfires.198

Deputy Commissioner Walshe pointed out three central differences between the 2009 guidelines and the 2006 ones:

       Greater clarity about the implementation and operation of full and partial roadblocks is provided.

       The span of responsibilities an Incident Controller has when managing a fire is acknowledged, and the Incident Controller is able to delegate responsibility for the establishment and operation of roadblocks and to be supported by a dedicated traffic management police liaison officer provided by Victoria Police.

       The wristband procedure developed in the Kilmore East and Murrindindi areas in the aftermath of the 7 February fires is formalised.199

The 2009 guidelines provide for a roadblock to be assigned one of four levels of restricted access.200 Each level of access has explanations and authorisations. The most restrictive level can be used because of operational dangers and permits access to emergency services only. For the least restrictive level, access is managed by the relevant road authority—that is, VicRoads or the local council—until the roadblock is removed and the road is re-opened to the public.201

In addition, the statement of general principles at the start of the 2009 guidelines says:

… circumstances may occur that require TMP [Traffic Management Point] Staff to make decisions outside of the procedures detailed in this document. In all cases, the safety of all people is paramount and TMP Staff are advised to contact their supervisor for direction or clarification where possible prior to permitting access.202

Guidance on the exercise of discretion is provided in a document entitled Traffic Management Points (TMPs)—frequently asked questions, available on the police intranet.203 That document acknowledges that police have discretion to permit access through a roadblock and may exercise that discretion in appropriate circumstances.204 This is an important change from the advice given under the 2006 guidelines—‘If in doubt, keep them out.’ The Commission welcomes Victoria Police’s new emphasis on compassion and commonsense in the exercise of the discretion.

Proper implementation of the 2009 guidelines depends on the member of the incident management team with responsibility for traffic management doing several things:

       establishing effective communications with police who are staffing the roadblocks

       determining early in the response whether anyone other than fire agency personnel should be given access in order to fight the fire, then communicating that determination to police staffing roadblocks

       giving consideration to downgrading the status of a roadblock from Emergency Services Access Only as soon as possible after the fire has been contained.

Proper implementation is also dependent on police who instigate roadblocks establishing contact with the Incident Controller and seeking direction from that person as soon as possible.205 The CFA and DSE have developed a Joint Standard Operating Procedure for traffic management during bushfires (SOP J3.10) that describes ‘the procedure to be followed by all CFA and DSE members involved in traffic management during bushfires’ and refers to the 2009 guidelines.206

Deputy Commissioner Walshe’s evidence about the 2009 guidelines made it clear that the guidelines were designed to facilitate access where safety permits. This change in emphasis is in keeping with recommendation 10.5 in the Commission’s interim report. It is disappointing to find that SOP J3.10 does not give any particular priority to facilitating access: it should be revised to require the CFA and DSE staff responsible to limit access for no longer than is necessary for public safety.

The 2009 guidelines do little to resolve the communication problems identified in the evidence.207 They are more dependent on effective communication between the ICC and police responsible for traffic management than the 2006 guidelines because of the graduated levels of access introduced by the 2009 guidelines. Introduction of the ability of an Incident Controller to delegate responsibility for traffic management to another member of the incident management team and Victoria Police’s commitment to provide a dedicated liaison officer to deal with traffic management should result in a big improvement in communication between the ICC and police on roadblocks during large fires.

As to the access permitted firefighters, there is little difference between the 2006 guidelines and those developed in 2009. Only fire agency personnel engaged in firefighting operations on fire appliances have access through an Emergency Services Only Access road closure. Access for contractors and private units remains a matter for the Incident Controller. The 2009 guidelines provide for CFA personnel travelling in private vehicles to be given access on production of ‘a form of CFA identification agreed to by Victoria Police and CFA’, but when Deputy Commissioner Walshe gave evidence in late November 2009 no agreement on the arrangements for identifying CFA volunteers had been reached.208

Mr John Haynes, the CFA’s Deputy Chief Officer, Operations Policy and Planning, told the Commission that identification cards are issued to volunteers in some regions and that, in the absence of an identification card, a volunteer’s uniform or helmet should get them through a roadblock.209 Reference to firefighting gear might be a commonsense fall-back measure, but it is not a sufficient response to the need for proper identification arrangements to help police at roadblocks identify CFA volunteers. It is the Commission’s view that the CFA should issue to all operational and operational support volunteers an identification card or other similar document to facilitate their passage through roadblocks. The 2009 guidelines leave questions of access for contractors, other emergency services and essential services to be determined by the Incident Controller or a delegate.

2.10.4  The Coroner

Roadblocks remained in position in the Marysville and Kinglake areas until about 21 March 2009 because of a Coroner’s direction restricting access to those areas.210 The 2009 guidelines provide that where the coroner invokes the power to restrict access to a geographical area, the roadblocks used to implement these restrictions will operate as Emergency Services Only Access roadblocks.211 At present, changing this would be a matter for negotiation between Victoria Police and the Coroner, since the 2009 guidelines do not extend to the exercise of the coroner’s powers under ss. 37 and 38 of the Victorian Coroners Act 2008.

Like Mr Walshe, the Commission agrees that the Coroner should be a party to the next revision of the 2009 guidelines, which should incorporate advice aimed at ensuring that any restriction of access is the minimum necessary.212




The Country Fire Authority provide to all CFA volunteers an identification card or similar to facilitate their passage through roadblocks established in accordance with the 2009 Guidelines for the Operation of Traffic Management Points during Wildfires.



1       Exhibit 11 – Statement of Esplin (WIT.005.001.0001) [184], [194], Attachment 63 (WIT.005.001.2363), Attachment 76 (WIT.005.001.2383)

2       Exhibit 32 – Tolhurst Report (EXP.003.001.0017) at 0030

3       Exhibit 151 – Report of the Board of Inquiry Into the Occurrence of Bush and Grass Fires In Victoria (TEN.058.001.0001) at 0016

4       As to directions for CFA preparedness: Exhibit 3 – Statement of Rees (WIT.004.001.0001) [303]; Exhibit 219 – Statement of Warrington, Annexure 2 (WIT.3004.011.0177) at 0179; Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [65]–[66]. For DSE: Exhibit 6 – Revised Statement of Waller (WIT.002.002.0001) [275]–[276], Annexure 39 (WIT.002.001.0832); Exhibit 408 – Statement of Tainsh (WIT.3024.003.0353) [42], Annexure 2 (DSE.HDD.0012.1560), Annexure 3 (DSE.HDD.0032.0237); Slijepcevic T6365:19T6365:23; Graystone T6045:9T6045:15; Rees T1852:20T1854:18, T2622:19T2623:27

5       Creak T10857:26T10858:3

6       Exhibit 309 – Statement of Fallon (WIT.3004.015.0001) [42], [127]; Fallon T7956:19T7956:28

7       Speirs T7520:12T7520:18, T7523:19T7523:30, T7524:11T7524:17

8       Exhibit 852 – Statement of Fontana (WIT.3010.010.0046) [22]–[32]; Exhibit 836 – Statement of Nixon (WIT.3010.009.0377) [27]–[30], Annexure 1 (WIT.3010.009.0390)

9       Exhibit 3 – Statement of Rees (WIT.004.001.0001) [303.6]–[303.7]; Exhibit 11 – Statement of Esplin, Attachment 57 (WIT.005.001.2350); Cameron T19745:7T19745:10

10     Exhibit 701 – Joint SOP J2.03 (as at 7 February 2009) – Planning for Joint Incident Management Teams (DSE.USB9.0035.1602); Exhibit 3 – Statement of Rees (WIT.004.001.0001) [303.1], [325], [328]; Exhibit 595 – Statement of Owen (WIT.3004.031.0001) [65]–[66]; Exhibit 219 – Statement of Warrington, Annexure 2 (WIT.3004.011.0177) at 0179; Rees T1852:20T1854:18, T2622:19T2623:27

11     Exhibit 547 – Statement of Haynes, Annexure 32 (WIT.3004.027.0373)

12     Exhibit 547 – Statement of Haynes, Annexure 32 (WIT.3004.027.0373)

13     Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [172]; Haynes T12036:6T12036:24, T12016:17T12017:11     

14     Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [78]; Exhibit 547 – Partnerships Guidelines (CFA.300.040.0007); Exhibit 547 – Heads of Agreement (CFA.300.040.0004); Molan T18756:8T18757:3; ‘t Hart T19045:22T19046:20

15     Exhibit 831 – Emergency Management Manual Victoria (RESP.3001.003.0001_R) at 0041_R–0043_R, 0051_R

16     Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0176

17     Exhibit 197 – Statement of Conway (WIT.3004.011.0023) [7]; Rees T21:4T21:19; Paterson T4313:16T4313:24; Graystone T6108:9T6108:25

18     Exhibit 836 – Instrument of Delegation (VPO.001.081.0096_R)

19     Exhibit 852 – Statement of Fontana (WIT.3010.010.0046) [65]–[71]

20     Exhibit 836 – Coordination Officer (VPO.001.081.0150); Nixon T17309:19T17310:3

21     Exhibit 82 – Review of the Integrated Emergency Coordination Centre (iECC) Functionality, April 2009 (OESC.001.001.0031); Exhibit 205 – Statement of Ong (WIT.5102.001.0001) [11]–[19]; Exhibit 203 – Statement of Poll (WIT.5005.001.0001) [8]; Graystone T6079:17T6079:21

22     Country Fire Authority Act 1958, s. 11; Exhibit 127 – Statement of Paterson, Annexure 1 (WIT.3004.010.0015)

23     Exhibit 127 – Statement of Paterson, Annexure 1 (WIT.3004.010.0015)

24     Exhibit 219 – Statement of Warrington (WIT.3004.011.0163) [6], [19]–[20]

25     Warrington T6669:3T6669:9

26     Warrington T6676:18T6676:25

27     Exhibit 730 – Statement of Harris (WIT.006.001.0001) [2]; Exhibit 931 – Statement of Armytage (WIT.3003.002.0001) [79]

28     Exhibit 6 – Revised Statement of Waller (WIT.002.002.0001) [19]; Waller T20639:26T20639:30

29     Exhibit 210 – Statement of Brown (WIT.3024.002.0280) [12]; Exhibit 191 – Guideline 5.1.1 State Duty Officer Duty Statement (WIT.3026.001.0074) at 0074

30     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300); Exhibit 443 – Statement of Overland (WIT.3010.009.0229) [8]; Exhibit 443 – Command, Control and Coordination Arrangements for Emergency Management in Victoria (EXH.443.0001)

31     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300) at 0303

32     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300) at 0303–0304

33     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300)

34     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300) at 0303–0304, 0307–0308; Emergency Management Act 1986, s. 16

35     Exhibit 547 – Staffing, Training and Resourcing of IMTs and ICCs – PowerPoint presentation by Haynes and Slijepcevic (CFA.001.032.0338) at 0345

36     Overland T10052:2T10052:14

37     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300) at 0309

38     Exhibit 547 – State Command and Control Arrangements for Bushfire in Victoria (CFA.001.032.0300) at 0324 (with annotations)

39     Exhibit 133 – Operations – Tactics and Administration in the Field Volume 1 (TEN.050.001.0008) at 0011

40     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [25]–[34]; Exhibit 730 – Statement of Harris, Annexure 3 (WIT.006.001.0020); Exhibit 931 – Statement of Armytage (WIT.3003.002.0001) [67]–[68], [74]–[79], Annexure 10 (WIT.3003.002.0172); Exhibit 836 – Statement of Nixon (WIT.3010.009.0377) [19]

41     Exhibit 197 – Statement of Conway (WIT.3004.011.0023) [54]–[55]; Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [10]; Rees T22:12T22:18; Conway T6199:19T6199:26, T6184:25T6185:4; Paterson T4299:5T4299:7; Waller T4361:10T4361:16, T4366:27T4367:2

42     Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [28]–[29], Annexure 8 (WIT.3004.010.1057); Rees T2547:7T2547:22, T19522:8T19522:19; Conway T6190:1T6190:12

43     Rees T19515:4T19515:7, T2547:7T2547:22

44     Rees T2536:20T2537:21, T19530:21T19530:26, T19532:31T19533:1

45     Conway T6180:26T6181:4, T6183:20T6183:26, T6187:18T6187:31; Paterson T4290:4T4290:31, T4292:22T4293:29

46     Waller T4354:12T4354:16, T4360:4T4362:8, T4363:17T4364:10, T4366:27T4367:2; Graystone T6050:29T6051:3, T6094:25T6094:30

47     Exhibit 828 – Statement of Duckmanton (WIT.3004.041.0056) [14.6]–[14.12]

48     Exhibit 151 – Report of the Board of Inquiry Into the Occurrence of Bush and Grass Fires In Victoria (TEN.058.001.0001) at 0154–0155; Exhibit 3 – Statement of Rees (WIT.004.001.0001) [234]; Exhibit 32 – Tolhurst Report (EXP.003.001.0017) at 0022

49     Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [65]; Rees T19508:16T19510:31; Waller T4359:29T4361:4

50     As to the focus on ‘strategic’ and ‘statewide’ overview, see, for example, Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [10], [15]; Exhibit 219 – Statement of Warrington (WIT.3004.011.0163) [9]; Rees T2514:14T2514:21; Conway T6256:12T6257:1; Paterson T4253:27T4254:1

51     Waller T4360:31T4361:9; Rees T19530:8T19530:19, T19552:25T19552:26

52     Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0176

53     Collins T2165:10T2166:19

54     Nixon T17339:27T17340:12

55     Exhibit 836 – Statement of Nixon (WIT.3010.009.0377) [34]–[42]; Nixon T17315:26T17316:2, T17334:17T17335:26, T17338:5T17338:23, T17351:7T17351:17, T17702:17T17702:30

56     Nixon T17334:24T17334:31, T17351:27T17351:29

57     Exhibit 836 – Statement of Nixon (WIT.3010.009.0377) [44]; Exhibit 836 – Calls to/from Nixon (TEN.259.001.0001); Nixon T17668:18T17669:30, T17671:17T17672:10, T17681:22T17681:23

58     Exhibit 836 – Calls to/from Nixon (TEN.259.001.0001); Nixon T17670:8T17670:29

59     Nixon T17673:16T17673:24

60     Exhibit 836 – Instrument of Delegation (VPO.001.081.0096_R); Exhibit 836 – Version No.040 – Emergency Management Act 1986, (TEN.254.001.0001) at 0014: see further Emergency Management Act 1986, s. 12; Exhibit 899 – Supplementary Statement of Walshe (WIT.3010.010.0124) [20]–[21], [27]; Walshe T18802:18T18803:13, T18813:26T18814:2, T18818:22T18819:23

61     See generally, Exhibit 852 – Statement of Fontana (WIT.3010.010.0046); Fontana T17605:3T17668:10

62     Nixon T17682:27T17683:3

63     For inaccuracies/incompleteness, compare: Nixon T17353:15, T17355:31T17356:15 with T17668:18T17669:11, T17681:14T17681:23; also compare Exhibit 836 – Statement of Nixon (WIT.3010.009.0377) [44]; Nixon T17296:26T17297:10 with Exhibit 836 – Calls to/from Nixon (TEN.259.001.0001); Nixon T17694:24T17696:9. As to reasons for inaccuracies/incompleteness, see: Nixon T17345:24T17345:29, T17701:2T17701:6, T17678:29T17679:8

64     Submissions of Counsel Assisting – Leadership, Emergency Management, Coordination, Command and Control (SUBM.1000.002.0001) [10.155]–[10.178], [15.6]; Submissions on Behalf of Christine Nixon (RESP.7512.001.0001) [7]–[39]

65     Nixon T17708:7T17708:19, T17689:12T17689:22

66     Nixon T17317:6T17317:22, T17319:30T17320:4

67     Exhibit 836 – Calls to/from Nixon (TEN.259.001.0001)

68     Emergency Management Act 1986 (Vic), ss. 5, 6, 10

69     Emergency Management Act 1986 (Vic), ss. 8, 9; Exhibit 11 – Statement of Esplin, Attachment 2 (WIT.005.001.0123) at 0218

70     Cameron T19709:10T19709:16, T19763:5T19763:19

71     Exhibit 948 – VEMCCG Brief and Minutes, 5 February (SOV.001.001.0108); Cameron T19715:16T19715:27, T19717:2T19721:22, T19735:22T19735:27

72     Cameron T19750:29T19751:30

73     Exhibit 836 – Calls to/from Nixon (TEN.259.001.0001); Nixon T17694:17T17696:15; Cameron T19713:15T19713:18, T19722:3T19723:3, T19736:26T19736:28; Walshe T18822:26T18822:28; Fontana T17639:12T17640:9

74     As to the protocol: Exhibit 945 – Selected Incident Notification Documents (TEN.298.001.0010), (TEN.298.001.0007_R); Exhibit 946 – Bundle of Incident Notification Documents (TEN.298.001.0001), (TEN.298.001.0002), (TEN.298.001.0004), (TEN.298.001.0006), (TEN.298.001.0011_R), (TEN.298.001.0014), (TEN.298.001.0015), (TEN.298.001.0016_R), (TEN.298.001.0018_R), (TEN.298.001.0020_R), (TEN.298.001.0022); Esplin T18879:18T18880:18, T18887:30T18888:10. As to delays and inaccuracies in information, see for example, the 5pm Situation Report issued by OESC: Exhibit 11 – Statement of Esplin, Annexure 19 (WIT.005.001.1661) at 1749–1753; compared with state of knowledge of fire agencies – see for example: Exhibit 4 – Supplementary Statement of Rees, Annexure Volume 1 (WIT.004.002.0018) at 0332–0334; Esplin T371:9T371:31, T364:2T364:5

75     Emergency Management Act 1986, s. 24

76     Cameron T19739:21T19739:27, T19742:4T19743:11; Nixon T17354:25T17355:7; Walshe T1210:11T1210:24, T1245:19T1245:23; Esplin T212:14T213:24; Rees T2407:22T2408:17

77     Cameron T19740:29T19743:6; Nixon T17355:10T17355:17; Esplin T18884:3T18885:4; Rees T2408:18T2409:8

78     Emergency Management Act 2004 (SA), ss. 22–24

79     Exhibit 995 – US Mentoring Program Report (DSE.HDD.0158.0234) at 0235; Exhibit 443 – Command, Control and Coordination Arrangements for Emergency Management in Victoria (Overland presentation) (EXH.443.0001) at 0019

80     Exhibit 475 – AIIMS Manual (TEN.121.001.0001) at 0038–0046; Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0429–0432

81     Exhibit 350 – Statement of Beer (WIT.3004.016.0016) [63]; Exhibit 347 – Statement of Farrell (WIT.3024.003.0154) [28]; Exhibit 339 – Statement of Miller (WIT.3024.003.0093) [59]; Beer T8572:10T8572:23, T8567:26T8567:28, T8569:5T8569:14; Miller T8327:25T8327:26; Webb Ware T8227:2T8227:8; Creak T8290:13T8290:31; Rice T8524:22T8525:17

82     Exhibit 456 – Statement of Smith (WIT.3004.020.0219) [22]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [20]; Rogasch T10249:28T10250:1; Smith T10232:31T10233:16

83     Exhibit 475 – AIIMS Manual (TEN.121.001.0001) at 0058–0059

84     Rees T2420:15T2420:18

85     Exhibit 443 – Command, Control and Coordination Arrangements for Emergency Management in Victoria (Overland presentation) (EXH.443.0001) at 0020

86     Waller T4381:18T4382:22

87     Exhibit 854 – Statement of Beasley, Annexure 18 (WIT.3004.043.0288); Beasley T17869:31T17870:6

88     Exhibit 547 – Statement of Haynes, Annexure 32 (WIT.3004.027.0373) at 0375; Beasley T17867:15T17868:27

89     B Teague, R McLeod, S Pascoe, 2009 Victorian Bushfires Royal Commission: Interim Report, Parliament of Victoria, Melbourne, August 2009 [9.216]

90     Exhibit 584 – Statement of Nugent (WIT.3024.004.0268) [64]–[65], [71]–[75]; Exhibit 587 – Statement of Smith (WIT.3004.030.0001) [81]

91     Exhibit 584 – Statement of Nugent (WIT.3024.004.0268) [65], [71]–[75]; Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [35]–[36], [39]–[40], [56]; Exhibit 452 – Statement of Deering (WIT.3004.019.0192) [36]–[37], [75]; Deering T10154:4T10154:27

92     Exhibit 587 – Statement of Smith (WIT.3004.030.0001) [36]; Waller T139:2T139:11

93     Murphy T1268:8T1268:16; Lovick T8378:29T8379:20; Lockwood T9237:25T9237:30

94     Exhibit 475 – AIIMS Manual (TEN.121.001.0001) at 0027, 0088–0090; Beasley T17845:18T17846:11

95     Exhibit 701 – SOP J3.03 – Incident Action Planning (as at 7 February 2009) (DSE.0034.0291.0316) at 0317

96     Exhibit 701 – SOP J3.03 – Incident Action Planning (as at 7 February 2009) (DSE.0034.0291.0316) at 0316; Beasley T17852:9T17852:13

97     Exhibit 475 – AIIMS Manual (TEN.121.001.0001) at 0089; Beasley T17848:15T17849:2; Esnouf T16698:21T16698:31, T16703:10T16703:14

98     Beasley T17850:6T17850:18

99     Exhibit 854 – Statement of Beasley (WIT.3004.042.0001) [112.1]–[112.5], Annexure 14 (WIT.3004.043.0173), (WIT.3004.043.0176), (WIT.3004.043.0217), (WIT.3004.043.0224); Beasley T17861:1T17861:6; Esnouf T16702:21T16705:9

100    Exhibit 854 – Statement of Beasley (WIT.3004.042.0001) [75], Annexure 8 (WIT.3004.043.0044); Exhibit 854 – CFA Wildfire – Redesdale – Coliban Rd – Fire 81 (DSE.0045.0363.0019); Exhibit 452 – Statement of Deering (WIT.3004.019.0192) [36]

101    Exhibit 854 – Statement of Beasley (WIT.3004.042.0001) [85]

102    Exhibit 854 – Statement of Beasley, Annexure 12 (WIT.3004.043.0081) at 0081, 0083, 0086, Annexure 14 (WIT.3004.043.0139), (WIT.3004.043.0148), (WIT.3004.043.0158), (WIT.3004.043.0189), (WIT.3004.043.0197)

103    Exhibit 701 – SOP J3.03 – Planning for Joint Incident Management Teams (DSE.USB9.0035.1602) at 1603. Under the revised standard operating procedure endorsed on 17 November 2009, a full level 3 IMT consists of 30 personnel: Exhibit 701 – Incident Management Teams – Preparedness Arrangements (DSE.HDD.0082.0241) at 0244

104    Submissions of Counsel Assisting on the Kilmore East Fire (SUBM.202.004.0001) [2.4]–[2.8]; Submissions of Counsel Assisting on the Murrindindi Fire (SUBM.202.009.0001) [5.14]

105    Submissions of Counsel Assisting on the Redesdale and Bendigo Fires (SUBM.202.010.0001) [5.5]–[5.7], [5.9], [11.3], [11.5]–[11.7]; Deering T10155:1T10155:9

106    Exhibit 542 – SOP J3.03 – Incident Action Planning (RESP.3001.018.0323)

107    Exhibit 542 – SOP J3.03 – Incident Action Planning (RESP.3001.018.0323) at 0323–0324. ‘Extended First Attack Incident’ is defined as ‘A fire that has not been contained by initial attack resources’

108    Exhibit 542 – SOP J3.03 – Incident Action Planning (RESP.3001.018.0323) at 0324–0325

109    Exhibit 854 – Statement of Beasley (WIT.3004.042.0001) [128.1]; Beasley T17861:21T17863:12

110    Exhibit 82 – Review of the Integrated Emergency Coordination Centre (iECC) Functionality, April 2009 (OESC.001.001.0031) at 0033

111    Exhibit 6 – Revised Statement of Waller (WIT.002.002.0001) [162]

112    Exhibit 82 – Review of the Integrated Emergency Coordination Centre (iECC) Functionality, April 2009 (OESC.001.001.0031); Exhibit 193 – iECC Debriefs (DSE.HDD.0030.0252); Paterson T4322:9T4322:27

113    Exhibit 210 – Statement of Brown (WIT.3024.002.0280) [31]–[46], [69]; Overland T10052:2T10052:14

114    Exhibit 82 – Review of the Integrated Emergency Coordination Centre (iECC) Functionality, April 2009 (OESC.001.001.0031) at 0035, 0039

115    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [21]–[22]

116    Exhibit 853 – Supplementary Statement of Griffiths (WIT.3024.005.0332) [29]–[31], [38]; Exhibit 458 – Statement of Gilmore, Annexure 3 (WIT.3004.019.0043)

117    Exhibit 817 – Victorian Spatial Information Strategy 2008–2010 (TEN.248.001.0001); Exhibit 819 – Statement of Thompson (WIT.3024.005.0317) [7]–[8], [13], [33]; Thompson T16786:24T16787:6, T16789:28T16790:7

118    Exhibit 819 – Statement of Thompson (WIT.3024.005.0317) [9], [13]–[14], [20]–[29]; Thompson T16789:2T16789:4, T16790:8T16790:11

119    Thompson T16792:25T16793:21; Garvey T16842:11T16842:12

120    Exhibit 24 – Statement of Griffiths (WIT.018.001.0001) [10]–[12], [29]; Exhibit 853 – Supplementary Statement of Griffiths (WIT.3024.005.0332) [9]; Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [30]; Griffiths T17713:24T17714:8

121    Exhibit 24 – Statement of Griffiths (WIT.018.001.0001) [28]; Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [33]–[35], [41], Annexure 4 (WIT.3004.034.0189)

122    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [36]; Garvey T16826:17T16827:3

123    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [41]

124    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [42]–[43]; Garvey T16835:6T16835:16; Clelland T17137:30T17138:12; Cowan T3735:22T3736:14

125    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [45]

126    Exhibit 336 – Statement of Rishworth (WIT.098.001.0001_R) [11], [14]–[15]; Attachment 3 (WIT.098.001.0026) at 0026–0027

127    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [70], Annexure 7 (WIT.3004.035.0006); Garvey T16816:25T16816:30

128    Exhibit 820 – Statement of Garvey, Annexure 7 (WIT.3004.035.0006); Garvey T16817:2T16818:30

129    Exhibit 820 – Statement of Garvey, Annexure 7 (WIT.3004.035.0006); Garvey T16821:1T16821:15, T16824:6T16824:14; Griffiths T17718:21T17719:14

130    There are a total of about 58 CFA staff with write access to FireMap, including a number of IT staff who do not do mapping work: Exhibit 24 – Statement of Griffiths (WIT.018.001.0001) [29]; Griffiths T17715:11T17715:16; Garvey T16812:25T16813:19

131    Griffiths T17726:19T17726:31

132    Exhibit 345 – Statement of Steer (WIT.3024.003.0026) [48], Annexure 7 (DSE.HDD.0048.0041); Exhibit 340 – Statement of Lovick (WIT.3024.003.0001) [69], Annexure 7 (DSE.HDD.0052.0215); Exhibit 277 – Statement of Speirs (WIT.3004.014.0001) [165]–[166]; Exhibit 505 – Statement of Murphy (WIT.3004.021.0001) [78]; Murphy T1268:8T1268:16; Steer T8483:7T8485:19, T8493:17T8494:7; Lovick T8379:2T8380:17; Farrell T8509:3T8510:3

133    Exhibit 452 – Statement of Deering (WIT.3004.019.0192) [66]; Exhibit 457 – Statement of Rogasch (WIT.3004.019.0362) [37]; Rogasch T10257:31T10258:3

134    Exhibit 277 – Statement of Spiers (WIT.3004.014.0001) [31], [104], [166]; Exhibit 393 – Statement of Pridgeon (WIT.3024.004.0110) [26]–[29]; Pridgeon T9344:1T9357:1; Nugent T12748:26T12749:8

135    Exhibit 245 – Statement of McKenzie (WIT.3024.002.0144) [57]; Slijepcevic T6363:20T6363:28

136    Exhibit 820 – Statement of Garvey (WIT.3004.034.0153) [72], Annexure 8 (WIT.3004.035.0010)

137    Exhibit 820 – Statement of Garvey, Annexure 8 (WIT.3004.035.0010); Garvey T16823:14T16824:14

138    Garvey T16848:6T16848:25, T16849:11T16849:19

139    Garvey T16813:26T16814:15

140    Exhibit 874 – Statement of Corbett (WIT.3004.043.0298) [80], Annexure 11 (WIT.3004.044.0363); Garvey T16809:15T16809:22

141    Garvey T16810:22T16811:5; Corbett T18232:15T18232:31

142    Exhibit 872 – Third Supplementary Statement of Slijepcevic (WIT.3024.006.0113) [46]–[50]; Slijepcevic T18189:29T18190:15

143    Exhibit 869 – Further Statement of Lloyd (WIT.3028.001.0070) [13]–[14], [21]–[23]

144    Griffiths T17729:25T17730:6

145    Exhibit 853 – Supplementary Statement of Griffiths (WIT.3024.005.0332) [29]; Griffiths T17730:23T17731:20

146    Exhibit 853 – Supplementary Statement of Griffiths (WIT.3024.005.0332) [30]–[31], Annexure 3 (DSE.HDD.0152.0008), Annexure 4 (DSE.HDD.0152.0009); Griffiths T17732:8T17732:21

147    Exhibit 192 – Operational Debrief Report 2008/09 Fire Season (DSE.HDD.0030.0102) at 0122, 0130; as to Kilmore and Adam Street ICCs, see, for example, Rogasch T10257:23T10257:26; Hunter T1718:3 T1718:16

148    Exhibit 840 – Statement of Comrie, Annexure 1 (WIT.3031.001.0004) at 0095–0097; Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [200]–[201], Annexure 36 (WIT.3004.027.0393)

149    Exhibit 593 – Statement of Dickson (WIT.4018.001.0001) [50], [60]–[63]

150    Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [52]–[53], [56], [62], Annexure 11 (WIT.3004.024.0321) at 0321–0324

151    Exhibit 202 – Statement of Slijepcevic, Annexure 3 (DSE.HDD.0012.2145); Slijepcevic T12106:13T12106:20

152    Exhibit 551 – Second Supplementary Statement of Slijepcevic (WIT.3024.005.0001) [93]

153    Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [55], [57]

154    Exhibit 547 – Statement of Haynes, Annexure 11 (WIT.3004.024.0321) at 0323

155    Exhibit 547 – Statement of Haynes, Annexure 13 (WIT.3004.024.0333); Haynes T11991:6T11991:12, T11999:17T12000:18

156    Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [54]

157    Haynes T12073:5T12073:9, T12075:7T12075:9

158    Exhibit 551 – Second Supplementary Statement of Slijepcevic, Annexure 17 (DSE.HDD.0074.0284) at 0286

159    Exhibit 547 – SOP J3.08 Appointment of Incident Controller (CFA.001.032.0334)

160    Haynes T12014:25T12015:2; Slijepcevic T12112:13T12112:18

161    Small T12155:14T12155:19

162    Exhibit 553 – Statement of Monti (WIT.7530.001.0001) [23], [37]; Monti T12162:3T12163:2; Haynes T12016:24T12016:27

163    Exhibit 547 – Statement of Haynes (WIT.3004.023.0011) [54], [62]–[64]; Haynes T12001:19T12002:4; Lockwood T9202:15T9202:22

164    Exhibit 551 – Second Supplementary Statement of Slijepcevic (WIT.3024.005.0001) [98], [103], Annexure 20 (DSE.HDD.0074.0348); Exhibit 546 – Linton Report (TEN.132.001.0001) [23.6.16]

165    Exhibit 995 – Report of Van Bruggen (DSE.HDD.0158.0234)

166    Exhibit 995 – Report of Van Bruggen (DSE.HDD.0158.0234) at 0236

167    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [9]

168    The Coroners Act 2008 (Vic) replaced the Coroners Act 1985 (Vic) on 1 November 2009. Similar provisions enabling the restriction of access to a fire affected area are also contained in the new Coroners Act 2008

169     B Teague, R McLeod, S Pascoe, 2009 Victorian Bushfires Royal Commission: Interim Report, Parliament of Victoria, Melbourne, August 2009, Recommendation 10.5

170    Exhibit 273 – Statement of Arthur, Annexure 6 (WIT.3010.004.0648); Exhibit 540 – Statement of Walshe (WIT.3010.009.0027) at 0030, Attachment 8 (WIT.3010.009.0361)

171    Country Fire Authority Act 1958, ss. 30(1), 44A(1)

172    Country Fire Authority Act 1958, s. 31(3)(a); Coroners Act 2008, ss. 37–38

173    Exhibit 542 – Record of Investigation into Death – Case No. 289/06 (SUMM.022.038.0059); Exhibit 542 – Western Australia – Record of Investigation into Death – Ref. No. 27/09 (TEN.142.001.0001)

174    Walshe T682:22T682:26

175    Exhibit 542 – Record of Investigation into Death – Case No. 289/06 (SUMM.022.038.0059) at 0072

176    Exhibit 273 – Statement of Arthur, Annexure 6 (WIT.3010.004.0642)

177    Exhibit 542 – Record of Investigation into Death – Ref. No. 27/09 (TEN.142.001.0001) at 0053

178    Exhibit 542 – Record of Investigation into Death – Ref. No. 27/09 (TEN.142.001.0001) at 0062

179    Exhibit 542 – Findings and Actions from Inquiries Conducted by the Department of Environment and Conservation into the Boorabbin Fire (TEN.144.001.0001) at 0009

180    Exhibit 542 – Findings and Actions from Inquiries Conducted by the Department of Environment and Conservation into the Boorabbin Fire (TEN.144.001.0001) at 0009–0010, 0024–0035

181    Exhibit 273 – Statement of Arthur, Annexure 6 (WIT.3010.004.0648) at 0649; Exhibit 19 – Revised Statement of Walshe (WIT.003.002.0001) [150]

182    Exhibit 273 – Statement of Arthur, Annexure 6 (WIT.3010.004.0648) at 0649; Walshe T683:16T683:23

183    Exhibit 19 – Revised Statement of Walshe (WIT.003.002.0001) [151]; Walshe T683:28T684:2

184    Exhibit 273 – Statement of Arthur, Annexure 6 (WIT.3010.004.0648); Exhibit 19 – Revised Statement of Walshe (WIT.003.002.0001) [149]

185    Exhibit 269 – Statement of Russell, Annexure 23 (WIT.3004.013.0299); Walshe T683:3T683:10

186    Exhibit 273 – Statement of Arthur (WIT.3010.004.0483) [84]; Exhibit 275 – Statement of Salter (WIT.3010.004.0726_M) [29]; Exhibit 654 – Statement of Humberstone (WIT.3010.002.0108) [33], [35]

187    Exhibit 275 – Statement of Salter (WIT.3010.004.0726_M) [35]

188    Exhibit 369 – Statement of Brown (WIT.108.001.0001_R) [32]; Exhibit 385 – Statement of Cherry (WIT.107.001.0001_R) [37]; Exhibit 362 – Statement of Glenn (WIT.066.001.0001_R) [38]–[40]; Exhibit 349 – Statement of Kennedy (WIT.102.001.0001_R) [33], [35]–[36]; Exhibit 77 – Statement of Walter (WIT.041.001.0001_R) [74]–[79]; Exhibit 903 – Statement of Clements (WIT.162.001.0001_R) [21], [30]–[31]; Exhibit 67 – Statement of Harvey (WIT.036.001.0001_R) [34]–[36]; Exhibit 898 – Statement of Nowak (WIT.159.001.0001_R) [51]–[52]

189    Exhibit 361 – Statement of Anderson (WIT.3032.001.0001) [33]

190    Exhibit 28 – Statement of Sigmund, Attachment 3 (WIT.020.001.0015) at 0025–0027; Exhibit 272 – Statement of McGennisken (WIT.089.001.0001_R) [32]–[39], [41]–[45]; Exhibit 125 – Statement of Williams (WIT.055.001.0001_R) [70]–[72]; Exhibit 522 – Statement of Mortimer (WIT.118.001.0001_R) [63]; Sigmund T913:11T913:22; McGennisken T7485:3T7487:27, T7489:1T7489:19; Williams T4231:11T4231:24

191    Walshe T685:18T686:13

192    Exhibit 541 – Statement of Lanyon (WIT.3010.002.0001) [16]–[17]; Exhibit 13 – Statement of Newman (WIT.009.001.0001_R) [19]; Collery T8424:6T8425:11; Barton T8876:22T8877:11

193    Exhibit 272 – Statement of McGennisken (WIT.089.001.0001_R) [36]–[45]; Exhibit 253 – Statement of Ryan (WIT.3010.004.0408) [40]; Exhibit 649 – Statement of Scully (WIT.3010.001.0418) [16], [26]–[27]; Exhibit 657 – Statement of Murphy (WIT.3010.001.0362) [24], [34]; Exhibit 473 – Statement of Brundell (WIT.3010.006.0215) [20]–[22]; McGennisken T7487:1T7487:27; Gaffee T10345:27T10346:3; Moore T13082:19T13083:7, T13084:13T13086:3

194    Exhibit 275 – Statement of Salter (WIT.3010.004.0726_M) [35]. The location of the roadblocks for the Horsham fire is set out in: Exhibit 269 – Statement of Russell, Annexure 22 (WIT.3004.013.0297); Exhibit 273 – Traffic Management Points – Suggested Options for Improvements to Enhance Fire Fighting Capabilities (WIT.3010.004.0722); Exhibit 272 – Statement of McGennisken (WIT.089.001.0001_R) [38]–[50]; Exhibit 28 – Statement of Sigmund, Attachment 3 (WIT.020.001.0015) at 0025; Exhibit 277 – Statement of Speirs (WIT.3004.014.0001) [169]; Exhibit 283 – Statement of New (WIT.3010.004.0062) [51]; McGennisken T7485:3T7487:27, T7489:1T7489:19; Sigmund T913:11T913:22

195    Exhibit 272 – Statement of McGennisken (WIT.089.001.0001_R) [40]

196    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [36]–[40]; Exhibit 398 – Statement of Wilson (WIT.3010.009.0147) [41]–[47], Attachment 3 (WIT.3010.009.0183). For the response to Sergeant Wilson’s recommendations: Exhibit 542 – Letter from VGSO – TMP Report of Sergeant Wilson (CORR.1001.0011) Walshe T11781:1T11781:12

197    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [41]–[48], Attachment 3 (WIT.3010.009.0336), Attachment 8 (WIT.3010.009.0361); Exhibit 840 – Statement of Comrie, Annexure 1 (WIT.3031.001.0004) at 0113; Walshe T11781:15T11782:11

198    Exhibit 542 – Standard Operating Procedure J3.10 – Traffic Management During Bushfires (RESP.3001.018.0332) at 0335

199    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [52]–[55]

200    Exhibit 540 – Statement of Walshe, Attachment 8 (WIT.3010.009.0361) at 0364–0366; Walshe T11788:31T11796:22

201    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [64]–[76], Attachment 8 (WIT.3010.009.0361) at 0364–0366; Walshe T11788:31T11796:22

202    Exhibit 540 – Statement of Walshe, Attachment 8 (WIT.3010.009.0361) at 0363

203    Exhibit 540 – Statement of Walshe (WIT.3010.009.0300) [60], Attachment 7 (WIT.3010.009.0357)

204    Exhibit 540 – Statement of Walshe, Attachment 7 (WIT.3010.009.0357) at 0358; Walshe T11804:30T11805:1, T11808:2T11809:16

205    Exhibit 540 – Statement of Walshe, Attachment 8 (WIT.3010.009.0361) at 0367

206     Exhibit 542 – Standard Operating Procedure J3.10 – Traffic Management During Bushfires (RESP.3001.018.0332); SOP J3.10 also implements Recommendation 10.6 of the Commission’s interim report; B Teague, R McLeod, S Pascoe, 2009 Victorian Bushfires Royal Commission: Interim Report, Parliament of Victoria, Melbourne, August 2009

207    Walshe T11803:15T11804:1, T11814:17T11814:22

208    Walshe T11789:31T11790:25

209    Haynes T12044:9T12044:23

210    Walshe T11817:5T11817:18; Billing T8918:29T8919:19

211    Exhibit 540 – Statement of Walshe, Attachment 8 (WIT.3010.009.0361) at 0366

212    Walshe T11801:9T11801:19