12  EMERGENCY CALLS

 

This chapter discusses Victoria’s current emergency call service arrangements, the performance of these services on 7 February, and their interaction. National as well as state systems are reviewed, as both support Victoria during major bushfires. The chapter examines how both can better prepare and provide Victorians with the best possible service when placed under extreme pressure. Considerations for ‘surge’ capacity are given particular focus.

 

12.1     There are two entities involved in answering Triple Zero calls in Victoria — Telstra and the Emergency Services Telecommunications Authority (ESTA). Each provides a vital component of the service.

12.2     Telstra Triple Zero is the ‘front end’ for taking emergency calls. Telstra Triple Zero operators, located in two national call centres (one in Melbourne and the other in Sydney), answer all Triple Zero calls for fire, ambulance or police. When the caller is located in Victoria, Telstra operators transfer those calls to one of three ESTA call centres — Ballarat, Tally Ho (Burwood) or the World Trade Centre (City of Melbourne).1

12.3     ESTA operators are trained as call takers, dispatchers, or both. They provide the essential interface between the public and the emergency services, including the fire services — the Country Fire Authority (CFA) and the Metropolitan Fire and Emergency Services Board (MFB). ESTA staff operate a Computer Aided Dispatch (CAD) system which permits the caller’s request to be translated into immediate dispatch of emergency services.2

12.4     The Triple Zero service suffered significant strain on 7 February. Many calls to the service went unanswered. Telstra staff were often unable to transfer emergency calls through to ESTA. Both the Telstra and ESTA staff on duty operated under extraordinary pressure, dealing with callers who, in many instances, were frightened and distressed.3

12.5     The system for handling Triple Zero calls and their presentation to ESTA involves some complexity. A great deal of the information presented in the hearings was in the form of data and statistical analysis.

12.6     Despite the complexity of the system, the difficulties experienced on 7 February come down to a number of simple propositions:

•    there were insufficient ESTA operators to answer the large number of calls being presented by Telstra Triple Zero operators to ESTA centres

•    Telstra Triple Zero operators were ‘tied up’ waiting on the line trying to put through calls to ESTA centres

•    while occupied, Telstra Triple Zero operators were unable to take other calls from the public

•    thousands of calls (10,768 calls in the national queue over 24 hours and 7824 in the Victorian queue from 2:08pm to 9:00pm) were abandoned before Telstra Triple Zero operators could answer4

•    it is likely that the vast majority of the abandoned calls were made by those affected by the fires in Victoria, though calls from anywhere in Australia relating to life-threatening circumstances might have also been abandoned

•    Telstra’s Triple Zero Service was not staffed to capacity on the day, nor was ESTA. An increase in the number of Telstra Triple Zero operators may have increased the number of calls initially answered. However, it would not have increased the speed of presentation of calls to ESTA, without a commensurate increase in ESTA staff taking calls.

12.7     There are lessons to be learned from these events. Improvements are needed as presently there is insufficient capacity to ‘scale up’ to handle the significantly larger number of calls expected in a large-scale emergency.5

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Telstra’s Emergency Service Answer Point

12.8     Ms Jane Elkington, Manager of Telstra’s Emergency Services Answer Point, explained the role Telstra plays.6 Telstra’s operation of the emergency call service is governed by determinations made by the Australian Communications and Media Authority under Commonwealth telecommunications legislation.7 Telstra is obliged to ensure that each emergency call is ‘received and appropriately handled’ and that it is transferred to the appropriate emergency service organisation.8

12.9     Telstra has responsibility for one aspect of the Triple Zero service as part of its licence conditions and is not remunerated for it.9 Telstra transfers Triple Zero calls to approximately 75 centres of emergency service organisations around Australia.10

12.10  Telstra Triple Zero operators who answer calls use a set script. When the caller is using a fixed land line, their address automatically appears on the operator’s screen, and the Telstra operator will say: ‘Emergency – Police, Fire or Ambulance?’ When the Telstra operator receives a response, they transfer the call to the appropriate emergency services organisation answering point. That point is automatically identified by the computer system that Telstra Triple Zero operators use, and with reference to the caller’s number and phone address.11

12.11  The Telstra Triple Zero operator only hangs up when the call is connected and the caller and the operator at the emergency service organisation are in conversation.12 The ‘overlap’ is usually a matter of three or four words, which the Telstra operator is required to hear before they press ‘disconnect’ and move to their next call.13 The role performed by the Telstra Triple Zero operator usually lasts less than 30 seconds.

12.12  Calls made from mobile phones are handled slightly differently. Because they do not operate from a fixed locality, the Telstra operator needs to establish the state and town where the emergency is. In all other respects, mobile calls are handled in the same way as calls from a fixed line.14

12.13  The Telstra Triple Zero service maintains two key procedures:

•    Operators are required to stay on the line with the caller until emergency service operators answer the call

•    Operators are trained to complete and transfer calls rapidly, engaging in minimal interaction with callers — the involvement of Telstra Triple Zero operators usually lasts less than 30 seconds, and operators use set scripts when speaking with callers.15

12.14  The Telstra Triple Zero service is required to ensure that:

•    85 per cent of calls are answered by a call taker within five seconds of the call reaching Telstra’s answering point

•    95 per cent of calls are answered within ten seconds after the call reaches Telstra’s answering point.16

12.15  Calls to Triple Zero go into a national queue. The queue directs the longest waiting call to the first available Telstra Triple Zero operator at either Melbourne or Sydney. The call centres are staffed 24 hours a day, seven days a week.17

12.16  The Telstra Triple Zero operator presents the incoming call to the first priority number for the emergency service organisation that is automatically selected by the system. The way this works for ESTA is addressed in more detail below.

TELSTRA’S CAPACITY AND ROSTERS

12.17  The Melbourne and the Sydney call centres each have 25 call taker terminals. As a result, the maximum number of operators who can take Triple Zero calls at any one time across Australia is 50.18

12.18  Telstra’s rosters are generally prepared nine days ahead of time and are based on historical data on the likely number of calls. In each bushfire season, Telstra takes into account the potential for an extreme event that might increase call volume. Telstra’s historical data demonstrate that Friday and Saturday evenings are usually its busiest nights.19

12.19  Ms Elkington said it was extremely rare for the call centres to operate at maximum capacity. Telstra does roster 50 staff to work each New Year’s Eve, as experience has demonstrated that a large number of calls (many of which are not genuine) are received.20

12.20  Telstra is not able to compel staff to work additional shifts or hours.21When preparing rosters Telstra personnel need to ensure that there is sufficient staff available for subsequent shifts.

RECORDED VOICE ANNOUNCEMENTS USED BY TELSTRA

12.21  Recorded voice announcements are used by Telstra in a number of instances.

•    The front-end recorded voice announcement. This announcement is heard by all callers (since December 2008): ‘You have dialled Emergency Triple Zero. Your call is being connected’. This announcement is directed at reducing the high number of inadvertent and non-genuine calls received by Triple Zero.22

•    The ‘short delay’ recorded voice announcement. This is automatically activated if any call to Triple Zero is not answered within 30 seconds. It is activated every 30 seconds thereafter. The caller hears the following message: ‘You have dialled the Emergency Triple Zero Number. Due to an unprecedented high volume of calls being received by Triple Zero, we are experiencing short delays in answering. Please stay on the line and you will be answered by the next available operator’.23

•    The generic ‘extreme event’ recorded voice announcement. This was introduced in 2004 and is used when Telstra experiences high call volumes during an extreme event such a bushfire or major storm. The caller hears the message: ‘You have dialled Emergency Triple Zero. If you require police, fire or ambulance please stay on the line. If you require your local State Emergency Service please hang up and dial 1223 — that’s 1223 — as this service cannot be connected through Triple Zero’.24 When this announcement is activated, it is used in place of the front-end announcement.

•    The ESTA-tailored extreme event recorded voice announcement. When authorised to do so by  ESTA, Telstra uses an announcement tailored to the particular extreme event. In 2006, for example, ESTA authorised Telstra to use an announcement in the following terms: ‘Emergency Triple Zero in Victoria is extremely busy due to bushfires. For emergency assistance please hold. For bushfire information, call 1800 240 667’ (this number is for the Victorian Bushfire Information Line (VBIL)).25

12.22  Ms Elkington explained that the tailored extreme event recorded voice announcement is designed to reduce traffic volumes on Triple Zero by directing callers to VBIL.26 However, the ESTA-tailored extreme event recorded voice announcement was not used on 7 February.27

12.23  It seems likely that even if it had been used, it would have had little impact in reducing the difficulties on the day. Evidence suggests that many callers rang Triple Zero and the VBIL on the day (Chapter 5), and a number of callers rang each number multiple times. The stress on both systems was extreme, with neither able to cope. Cross referrals by each service appear to have simply contributed to the problems.

 

12.24  ESTA is a statutory authority established under the Emergency Services Telecommunications Act 2004 (Vic). ESTA’s central function is to provide emergency telecommunications and other communication services. It operates a call-taking and dispatch service. It is not responsible for early warnings or general information to the public about catastrophic events.28

12.25  ESTA’s operations are governed by administrative arrangements developed in conjunction with the emergency services organisations and the Office of the Emergency Services Commissioner (OESC). The arrangements presently in place were implemented in June 2005 and include performance standards determined by the OESC.29

12.26  ESTA is funded pursuant to an arrangement under which it is paid a fixed fee by each emergency services organisation.30

12.27  Since its inception in July 2005, ESTA has experienced a 28 per cent increase in the number of Triple Zero calls it answers and a 20.8 per cent increase in the total number of all calls it has answered; but the average funding increase has only been 2.5 per cent per year.31 Mr Neil Foster, the Chief Executive Officer of ESTA, confirmed that the increase in call activity has not been matched by increases in funding.32

12.28  An additional $3 million was made available in 2009–10 to support ESTA.33 ESTA has made submissions arguing for a move from a fixed-fee funding arrangement to an activity-based funding arrangement. The Department of Justice has agreed that this review should take place.34

12.29  ESTA is responsible for managing Triple Zero emergency calls, non-Triple Zero emergency calls, non-emergency calls and associated communications for the dispatch of the following emergency services organisations:

•    Victoria Police — only Metropolitan Melbourne, outer suburban area and Geelong

•    Ambulance Victoria — only Metropolitan Melbourne and outer suburban area

•    Country Fire Authority — all designated areas

•    Metropolitan Fire and Emergency Services Board — all designated areas

•    Victorian State Emergency Service — all designated areas.35

12.30  ESTA is not currently responsible for managing calls and communications for Victoria Police beyond metropolitan Melbourne and the outer suburban area and Geelong. Likewise, ESTA is not responsible for managing calls and communications for Ambulance Victoria beyond metropolitan Melbourne.36

12.31  ESTA also answers:

•    emergency calls made directly to the State Emergency Communications Centres (SECCs), not through Triple Zero

•    a number of non-emergency calls on low priority directory numbers.

             The non-Triple Zero emergency calls are typically made directly to ESTA by the emergency services organisations or from high-risk premises like prisons or petrochemical facilities.37

12.32  ESTA also operates the Emergency Alerting System (EAS). This is a dedicated pager messaging system used by the emergency services staff and volunteers of the CFA, the Victorian State Emergency Services (VICSES) and Ambulance Victoria (Rural). It operates over the whole of Victoria by means of 212 radio transmitter sites linked to a message switching centre and a leased satellite service.38

12.33  ESTA’s three SECCs are:

•    the World Trade Centre, which takes calls for Victoria Police for the greater metropolitan area and Geelong, and for VICSES for the metropolitan area

•    Tally Ho, which takes calls for Ambulance Victoria for the greater metropolitan area, for the MFB and for CFA metropolitan area

•    Ballarat, which takes calls for CFA Regional, VICSES Regional and Victoria Police Metropolitan.39

12.34  Mr Foster was asked whether there is any rationale for the manner in which calls for particular emergency services organisations are divided between the three call centres. He said it was partly ‘historical’. He agreed that ‘clearly the ideal position would be to have all emergency communication centres answering and managing all calls for all the centres. In that way you finish up with a much better redundancy option’.40

Esta staffing LEVELS

12.35  As at February 2009 ESTA employed 442 operational staff (excluding administrative and auditing staff) located at its three SECCs.41

12.36  All call takers and dispatchers employed by ESTA must achieve Certificate II or Certificate III in Call Centre Operation (Public Safety) or Certificate II or Certificate III in Emergency Communications.42 All staff have a primary area in which they work (Fire, Police or Ambulance). Only a small proportion of the staff is skilled to operate across multiple areas. To maintain the appropriate skill level, staff are rostered once a fortnight to do a shift in an area other than their primary area.43

PRESENTATION OF EMERGENCY CALLS TO ESTA

12.37  Mr Owen Kiernan, ESTA’s Operations Manager (Support), described the emergency call processes between Telstra Triple Zero and ESTA. Calls are presented by Telstra Triple Zero operators to directory numbers provided by ESTA’s centres. The Triple Zero presentation sequence is an agreed protocol between ESTA and Telstra. It requires that calls be presented by Telstra Triple Zero operators to ESTA using a designated presentation sequence, commencing with the first choice Triple Zero directory number. If that call is not answered within 75 seconds, the Telstra Triple Zero operator withdraws the call from the first choice directory number and re-presents it to ESTA on the second choice directory number. If that call is not answered within a further 75 seconds, the Telstra Triple Zero operator withdraws the call and re-presents it to a third choice directory number. If the call remains unanswered by the time presentation is made to the final choice directory number, the Telstra operator withdraws the call and commences the sequence again.44

12.38  All calls to ESTA’s first choice directory number are assigned a priority of two. The second presentation is given the priority of one. Third and subsequent presentations are assigned the highest priority of zero.45

12.39  In normal circumstances, callers to Triple Zero remain on the line until connected to ESTA, but sometimes the caller may be disconnected. This might be due to the call dropping out, the caller hanging up by choice, or by reason of illness, or the nature of the emergency that is occurring. In such a case, the Telstra operator is trained to stay on the line and announce the Caller Line Identification to the ESTA operator. Where appropriate ESTA will initiate a call back to the caller and/or dispatch assistance in any event. The Telstra Triple Zero operator is sometimes able to supply more information to ESTA, which assists in this process, for example, the last words used by the caller before the call ended.46

12.40  Prior to 7 February, Telstra and ESTA agreed on a new process whereby during periods of extreme call activity, this procedure would be ‘relaxed’ so that the Telstra operator would not remain on the line after a disconnected call, but rather retain the Caller Line Identification data and pass it to an ESTA supervisor via a Telstra supervisor. The intention was to free up the Telstra operator to take more Triple Zero calls.47 Despite this agreement and the intention that it be used on 7 February, it was not deployed uniformly.48

12.41  As noted in paragraph 12.3, ESTA operates a CAD system that enables operators to record call details, nominate and verify incident location, and determine the event type and the emergency responses that should be allocated to that event.49 When an ESTA call taker receives a call about a new fire, they ‘create’ an event in the computer system and record all relevant information provided by the caller. If a subsequent call is determined by the ESTA call taker to be about the same fire, it is added to the information already recorded in the system about that event.50 The CAD system effectively ‘chooses’ the means by which dispatch of emergency resources occurs. The CAD system assigns the resources.51 ESTA is required to dispatch the resources ‘recommended’ by the system.52

 

12.42  ESTA was formally notified of the severe fire risk in the lead up to 7 February. It was provided with Significant Incident Situation Reports from the OESC.53 ESTA’s General Manager attended a meeting of the Victorian Emergency Management Council Coordination Group on 5 February 2009.54 The meeting discussed the forecasts for the weekend and plans, including by ESTA, for the predicted extreme fire danger.55 ESTA made efforts to ensure that additional staff were rostered at Tally Ho and Ballarat, although ultimately its operations are restricted by the number of work stations available.56

12.43  In the week leading to 7 February, Telstra Triple Zero had already experienced increased demand because of the heat wave in South Australia and Victoria, and floods in Queensland.57

12.44  Ms Elkington explained that neither she nor anyone within Telstra’s Triple Zero service was formally notified by the CFA, the Department of Sustainability and Environment or the Bureau of Meteorology of the predicted weather and fire conditions for 7 February. Indeed, there is no formal notification system by which Telstra is alerted to predictions of bad weather or fire risk.58 Telstra staff, including Ms Elkington, monitor the Bureau of Meteorology website to assist with planning.59 She agreed it would be helpful to receive formal notification of fire risk or of Total Fire Ban days.60 It would be beneficial for the OESC to provide significant incident situation reports to Telstra at the same time as it provides them to ESTA. This would assist Telstra with its planning and rosters, and promote closer liaison between ESTA and Telstra in the lead up to predicted days of extreme fire danger. This, in turn, might improve the planning for extreme events.

 

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

 

 

ESTA staff levels and resources for 7 February

12.45  As at 7 February, ESTA had ‘on its books’ 62 full-time and 13 part-time operational call takers and dispatchers at the Tally Ho centre. At Ballarat, it had 64 full-time operational call takers and dispatchers, two part-time call takers and four casuals.61 As ESTA operates 24 hours a day, seven days a week, these staff are required to be rostered in a manner that allows for appropriate shifts and breaks.62

12.46  ESTA has a limited number of work stations and equipment for its staff to take and dispatch emergency calls for fire services. On 7 February:

•    at Tally Ho, there were 58 work stations, but only 15 were configured for fire service call-taking and dispatch

•    at Ballarat there were 25 work stations available, but only 13 were configured for fire service call-taking and dispatch.63

12.47  Arrangements were made in the lead up to 7 February for additional staff to work. Additional staff were rostered and staff were contacted and asked to work overtime over the weekend.64

12.48  At Tally Ho during 7 February, there were between eight and 18 fire operators working at all times. Between 2:00pm and 8:00pm, there were between 14 and 18 fire operators working.65 At Ballarat, there were between eight and 19 fire operators working at all times. During the period 2.00pm to 8.00pm, there were between 16 and 19 working.66 However, the numbers of staff who worked on that day ‘in excess’ of the available work stations (namely 15 at Tally Ho and 13 at Ballarat) were unable to take calls and instead performed administrative or support roles.67

12.49  Modelling by ESTA suggests that in order to answer the volume of calls received on 7 February within the benchmark service standards, ESTA would have required 30 staffed call taker positions at Tally Ho centre and 21 staffed call taker positions at Ballarat. This translates (allowing for leave, rostered breaks, etc.) into a requirement for 186 full-time staff at Tally Ho and 130 full-time staff at Ballarat rostered on an ongoing basis — a significant increase on current staff numbers.68

12.50  Mr Kiernan accepted in evidence that it would be possible to keep ‘in reserve’ a body of appropriately trained call-taking staff who might be otherwise engaged (for example, at other centres like VBIL or VICSES) and be made available during fire danger periods to provide for greater surge capacity during extreme events.69 This suggestion was not supported by the State.70

TELSTRA’s Staffing and rosters for 7 February

12.51  Ms Elkington confirmed the total staff numbers who worked over the 24-hour period on 7 February, who were available to take Triple Zero calls were:

•    Melbourne call centre       5071

•    Sydney call centre             4572

12.52  The records produced by Ms Elkington indicate that the highest number of staff working and taking Triple Zero calls at any one time at Melbourne was only 19 (this occurred during three separate 15-minute intervals at 7:15pm; 8:15pm and at 10:30pm).73 Telstra did not operate at maximum capacity for any part of 7 February.

 

12.53  At 12:40pm on 7 February when call volumes were increasing, a decision was made to extend the shifts of Telstra agents to require them to work through breaks. A recall list was activated.74

12.54  At 1:50pm the assistant manager of the Ballarat ESTA call centre contacted Ms Elkington requesting that an ESTA-tailored extreme event recorded announcement be used, but he requested that only callers for the fire service hear the message. Ms Elkington advised him that this was not technically possible, as prior to any call to Triple Zero being answered, it is not known whether the caller is seeking fire, ambulance or police assistance. The assistant manager indicated he would discuss the issue with his own management and advise Telstra if ESTA wished the tailored extreme event announcement to be activated for all calls in Victoria. No such advice was received. As a result Telstra instead activated the generic extreme event announcement from 2:08pm.75

12.55  By 2:00pm the call volume was extreme, and Ms Elkington decided to isolate the Victorian call traffic from the national Triple Zero call queue. Therefore, after 2:08pm all calls originating in Victoria were answered by the Melbourne centre and all calls originating outside Victoria were answered by the Sydney centre. All Victorian callers from that time onwards heard the generic extreme event recorded announcement.76

12.56  At 3:30pm, monitoring of call traffic indicated an unexpectedly high rate in the national queue being handled by Sydney. Investigations revealed that fire services calls originating from Victoria were still coming through. This occurred because the overflow and queue thresholds for the Victorian queue were set at 900 seconds (15 minutes). The threshold for ‘wait time’ in the Victorian queue was adjusted to 30 minutes.77 The need to alter the ‘overflow’ threshold to 30 minute wait time (in relation to a service whose benchmark is a matter of seconds) underscores the extreme delay being experienced.

12.57  Further steps were taken in an attempt to deal with the crisis through a further increase in the number of terminals made available to Victorian fire calls.78 Call volumes in the Victorian queue did not return to ‘close to normal’ until approximately 9:00pm.

Call volume and abandonment rate

12.58  Telstra and ESTA experienced unprecedented demand on 7 February. Telstra experienced (at the peak of the demand on that day) three times the normal call volume.79 Charts produced by Mr Kiernan depicted a large spike in Triple Zero calls on 7 February compared with regular Saturdays during the months of January and February 2009.80 On 7 February ESTA received a total of 6974 Triple Zero calls.81 It answered 6905 Triple Zero calls via its Automatic Call Distribution System.82

12.59  At the peak of demand, ESTA call presentations exceeded 450 calls in a 30 minute period, which translates to a presentation every four seconds. This represented an increase of 450 per cent on typical call activity when compared with the four preceding Saturdays.83 During the height of the activity, ESTA call takers answered a call on average every 12 seconds.84 Fire services normally account for 10 per cent of the Triple Zero calls to ESTA. On 7 February the Triple Zero presentations for fire services accounted for 48 per cent of all Triple Zero emergency calls presented to ESTA.85 For ESTA, the increase in fire call activity for 7 February was about 92 per cent above the next busiest day for ESTA (4202 calls compared with 2185 calls on 22 January 2006).86

12.60  There were very high rates of abandoned calls on 7 February. Abandoned calls are those calls which are abandoned or terminated by the caller before the call can be answered by a Telstra operator.87 There are two important features of the data for 7 February:

n      The analysis proceeds on the basis that the Victorian calls were only isolated from the national queue at 2:08pm.88 Thus, there are two relevant sets of figures: national figures for the entire 24-hour period, and figures for the Victorian queue from 2:08pm (Tables 12.1 and 12.2).

n      Care must be taken in analysing the data for abandoned calls, as each abandoned call does not necessarily represent a different caller. It is likely that many callers rang Triple Zero a number of times on 7 February, perhaps hanging up and dialling again in the erroneous hope that they might increase their chances of getting through.89

 

Table 12.1: National queue 24-hour call data, 7 February

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Table 12.2: Victorian queue, 2:08pm to 9:00pm, 7 February

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12.61  More detailed statistics (broken down into 15 minute intervals) demonstrate that the ‘peak’ in abandonment rates occurred at approximately 5:00pm, as is illustrated in Figures 12.1 and 12.2.

 

Figure 12.1: National Triple Zero emergency call data by 15 minute intervals — 7 February

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Note: this graph shows calls abandoned and calls answered. The sum of these figures equals calls presented in Ms Elkington’s statement for all periods except for between 5:45pm and 6:00pm, where an additional 18 calls have been listed.

 

Figure 12.2: Victorian Triple Zero emergency call data by 15 minute intervals — 7 February

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Note: this graph shows calls abandoned and calls answered. The calls answered figures were obtained by adding together the figures contained in WIT.5003.001.0424 and WIT.5003.001.0431. The calls abandoned figures were obtained by summing together the figures contained in WIT.5003.001.0438 and WIT.5003.001.0445.

 

12.62  These statistics are disturbing. Nearly 73 per cent of calls in the Victorian queue were abandoned during the afternoon and evening of 7 February.100 It is not known why these calls were abandoned. The reasons might include a decision by a caller that the call was not urgent; a caller needing to flee from danger; and the caller being overwhelmed or even injured. There is every likelihood that during this period many callers were in fear for their lives when they abandoned their call. Further, while many of the abandoned calls no doubt related to the bushfires in Victoria, it is not known, nor is it now possible to ever know, how many in that group (particularly in the national queue) may have been calling Triple Zero for other serious personal circumstances, including life-threatening illness.101

12.63  Much lower rates of disconnection occurred after Telstra Triple Zero operators answered the calls. Mr Trevor Ives, Manager, Management Information Services, explained that 6974 Triple Zero calls were answered by ESTA and 368 were disconnected after the call was answered by Telstra, but before it was answered by ESTA. This tends to suggest that the overwhelming majority of callers who got through to Telstra waited on the line and spoke to an ESTA call taker.102

Wait times

12.64  All Triple Zero calls are recorded. During the hearings, examples were played of two standard or typical calls to Triple Zero that were made on 7 February. These were calls during which the caller requested a fire service and the Telstra Triple Zero operator transferred the call within 12 to 20 seconds.103

12.65  The Commission heard a harrowing recording of a caller from Kinglake. The call was answered by a Telstra operator at 8:15pm on the evening of 7 February. In that call, the Telstra operator was on the line with the caller for 3 minutes and 55 seconds waiting for ESTA to answer.104 The distress and mounting panic of the caller was evident. Telstra operators received many calls like this on 7 February.

12.66  The statistics set out below in Table 12.3 were supplied by Telstra. Mr Ives explained that the ‘wait time’ does not always indicate that a member of the public was also waiting on the line. The caller may have disconnected for some reason; however, the Telstra Triple Zero operator was waiting on the line to convey the caller’s Caller Line Identification details to ESTA. The final figures in the table (wait times of 20 minutes for 12 calls) are an example of this and need to be treated with caution. For 11 of these 12 calls, the Telstra operator waited on the line after a caller had disconnected in order to pass on the Caller Line Identification details to ESTA. Only in one instance was a caller waiting on the line for in excess of 20 minutes.105

12.67  With that caveat in mind, the statistics still illustrate the long wait times experienced on the day.

 

Table 12.3: Triple Zero call transfer data, time delays

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12.68  ESTA reported non-compliance with its call answer speed benchmark. Only 24.5 per cent of calls were answered within five seconds and a further 32.2 per cent were answered within 30 seconds.108 The applicable benchmarks are 90 per cent and 95 per cent.

12.69  Mr Kiernan conceded that ESTA did not have the staff or work stations to handle the unprecedented call activity on 7 February.109

Triple Zero Calls presented to ESTA for fire services

12.70  Of the 4202 fire-related calls, 3310 were emergency calls from Telstra Triple Zero. Of these 3310 emergency calls:

•    660 were presented to MFB (640 of which were answered by ESTA)

•    1249 were presented to CFA Regional (1238 of which were answered by ESTA)

•    1401 were presented to CFA Metropolitan (1368 of which were answered by ESTA).

             These figures come to a total of 3246 calls answered (of the 3310 calls presented).

 

bottleneck IN EMERGENCY calls Presented to esta

12.71  Telstra’s data indicate that it presented 3299 calls to Victorian fire services on 7 February.110 Of these, approximately 46 per cent (1534 calls) had to be re-presented to alternative directory numbers at ESTA before an operator was available to take the call.111

 

Table 12.4: Triple Zero call referrals for fire services, 7 February

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12.72  There was a ‘bottleneck’ created as a result of Telstra operators being unable to put through calls to an emergency service organisation. Ms Elkington emphasised that Telstra Triple Zero is ‘absolutely reliant’ on the emergency services picking up the calls being presented.117 She said:

12.73  Ms Elkington also said that although it is possible for Telstra to respond to predictions of high fire danger, they would not respond by staffing to the maximum level for two reasons: first, there are many days of high danger in Australia; and second, Telstra is able to turn around calls quickly, due to its short handling times, but is restricted by the fact that it cannot connect those calls if the emergency service organisation is unable to take the call.

12.74  Given the high abandonment rate of calls (prior to them being answered by Telstra), it is possible that if more emergency calls had been answered by Telstra operators, it may have served to reduce the phenomenon of callers hanging up and making multiple calls. Further, the ‘comfort’ of a caller being connected, even if waiting, may be beneficial.

12.75  The Commission acknowledges, however, that there is a tension and difficult balance, between providing additional call takers for very occasional high volume days, and having many more staff than are required. It is anticipated that if bushfire information and warnings are better prepared, disseminated and understood, the demand on Telstra Triple Zero and ESTA call takers will be less on extreme bushfire days.120 Regrettably, there are always likely to be some delays when call volumes peak on some occasions and the Commission is hopeful that if other measures that are recommended in this interim report are actioned, this will mitigate the impact of any delays.

 

Lay evidence

12.76  A number of witnesses described being unable to get through on Triple Zero, and noted the distress this caused. Mr Denis Spooner spoke of his wife and son trying Triple Zero without success while trapped in their home at Strathewen.121 Ms Jill Kane tried to reach Triple Zero after her brother was overcome and collapsed near his home in Bendigo.122 Similarly, Mr David Brown’s son tried calling Triple Zero three times from Strathewen when the family was threatened by fire and sheltering in their home. He could not get through.123 Ms Anastasia Scott attempted to call Triple Zero from Marysville around 7:00pm and could not get through.124

12.77  Mrs Carol Matthews tried to call Triple Zero to obtain aid for her son who was trapped in his home at St Andrews as fire approached. Mrs Matthews could not get through, which was a source of great distress. A friend kept trying for her, and eventually got through but received incorrect information about the attendance of appliances near the Matthews’ home.125

EMERGENCY ALERT SYSTEM

12.78  As noted in paragraph 12.32, ESTA operates a dedicated pager messaging system (the EAS) used by emergency services staff and volunteers of the CFA, VICSES and Ambulance Victoria (Rural). It operates over the whole of Victoria by means of 212 radio transmitter sites linked to a message switching centre and a leased satellite service.

12.79  EAS also experienced unprecedented demand. The total number of pager messages recorded in the emergency pager system log for 7 February is 13,899 messages. By comparison, the system usually transmits between 2000 and 3000 messages a day.126

12.80  A total of 12,111 messages were sent from 11:50am to midnight. This equates to one message every 3.5 seconds.127 4349 of these were emergency messages; 93.2 per cent of which were delivered within 30 seconds. There were 7649 non-emergency messages and 1901 administrative messages transmitted.128

Cross referrals

12.81  The Standard Operating Procedures that apply to ESTA staff provide that if a caller is making an inquiry about (rather than reporting) a fire, or is seeking incident information, the caller is advised to ring VBIL. VBIL staff who receive calls from members of the public who are reporting new fires and/or are in life-threatening circumstances advise them to call Triple Zero (Chapter 5).

12.82  On 7 February, ESTA did not have any information about the capacity of VBIL to take calls referred to it, or any information about the volume of calls being experienced at VBIL’s call centre.129 These cross-referrals no doubt contributed to the difficulties the VBIL call centre experienced. Mr Kiernan agreed that having information about the impact on VBIL may be helpful in reviewing ESTA’s procedures.130

 

IMPLICATIONS OF The 2008 windstorm report

12.83  ESTA’s performance during extreme events was the subject of a review by the OESC in August 2008. The OESC investigated the operational response to the extreme storm which occurred on 2 April 2008, including aspects of ESTA’s operations. The report, Review of the April 2008 Windstorm Melbourne (the 2008 Windstorm Report), identified areas for improvement.131

12.84  During the storm in April 2008, Telstra experienced a surge in demand to its Triple Zero service. As ocurred on 7 February, Telstra implemented a recorded voice announcement and isolated Victorian traffic from the national queue during the afternoon.132 Large numbers of calls went unanswered.133

12.85  A number of the recommendations made in the 2008 Windstorm Report refer to:

•    streamlining the Telstra–ESTA handover process

•    reviewing the interface between the CFA Brigade communication systems and the ESTA CAD system

•    reviewing and improving call queue arrangements and paging systems.134

             These recommendations appear to focus directly on the shortfalls that became apparent (again) on 7 February 2009.

12.86  A draft of the report was supplied to ESTA in October 2008, but the report and the Government’s response were not released publicly until April 2009, after the Royal Commission was established.135 The Government’s response to the 35 recommendations indicates that for some matters it is ‘currently implementing the recommendation … to be further considered in light of any findings of the Royal Commission’. For others it ‘intends’ to implement the recommendations but notes ‘it will need to be further considered in light of any findings of the Royal Commission’.

12.87  It is a matter of concern to the Commission that as recently as August 2008 issues pertaining to the system’s capacity to cope with extreme events was the subject of a detailed review by the OESC, yet a number of the failings evident in the operational response to the windstorm in August 2008 were replayed during 7 February.

12.88  It has also emerged that although aspects of the 2008 Windstorm Report directly concerned arrangements between Telstra and ESTA, the report was not brought to the attention of Ms Elkington until it was released publicly.136 She accepted it was possible the report had been supplied to other sections within Telstra, but she had not been consulted.137 More frequent liaison between Telstra Triple Zero and ESTA might contribute to a more organised response by both entities to extreme events.

telstra and the triple zero service

12.89  Telstra has been investigating alternatives to the requirement that its Triple Zero operators stay on the line in all circumstances until a three-way conference is established. This is being considered because of the desire to ‘free up’ operators more quickly during major events. Thus far, Telstra’s capacity to implement change has been constrained by the technical limitations of some emergency service organisations not having queuing facilities. As a result, the strict requirement has been maintained.138

12.90  This matter will require dedicated effort and resources from all jurisdictions, including the Commonwealth, if change is to be implemented in a way that preserves the integrity of the Triple Zero service and its important Caller Line Identification information. The Commission encourages all governments to work together to progress these options.

12.91  In this context, Telstra has also promoted the introduction of national technological solutions. Telstra has made representations to the Commonwealth Attorney-General, calling for a ‘holistic, coordinated approach to emergency response policy development’.139 Ms Elkington said in her evidence that Telstra is concerned that there is no single authority that manages the end-to-end emergency call service. Telstra would like to see ‘an overarching review of the emergency call service so that there is some accountability on an authority that will lead the strategic direction, the operational direction of the end-to-end service’.140 The Commission welcomes this approach and notes Ms Elkington’s words in relation to the importance of the Triple Zero service:

12.92  In its written submissions Telstra called for the Commonwealth Government, in consultation with the state and territory governments, to ‘set the agenda for the emergency call service, by taking strategic and operational responsibility’.142

12.93  There are obvious practical barriers to the Commonwealth setting ‘the agenda’, as each state and territory has its own emergency services to which Triple Zero calls are presented, each with its own operational demands and capabilities. However, the Commission does support Telstra’s suggestion that the Commonwealth and the State of Victoria work together to improve the end-to-end Triple Zero process (including resourcing and infrastructure). The aim ought to be to reduce the ‘bottlenecks’ which occur at emergency service organisations’ answering points.143

ESTA RESOURCES AND FUNDING

12.94  The State accepted, in its written submissions to the Commission, that there should be a recommendation to increase ESTA staff. However, it did not accept that there ought to be any related recommendation on funding. It noted that additional funding had already been provided to ESTA in the 2009–10 Budget. The State said the following:

Options in addition to increasing staff are being pursued by the State to address the delays experienced on 7 February, such as training more staff to be ‘multi-skilled’. For example, there would be an effective increase in numbers of staff available to take calls for fire, if police call takers at the Ballarat centre could handle the fire related calls on busy days. To this end ESTA has already commenced the cross training of existing police staff at Ballarat.

The State also considers that long term goals and business models must be implemented such as:

(a) a revision of ESTA’s infrastructure, staffing arrangements and operating procedures so as to allow its call takers to answer calls for multiple emergency services organisations regardless of which State Emergency Communications Centre they were located in;

12.95  The question of broader reform in the nature of ‘splitting’ ESTA’s functions between its emergency and non-emergency functions is a matter for the State to explore in the longer term. The Commission welcomes the indication that steps will be taken immediately to tackle the question of staffing levels and increased multi-skilling prior to the coming fire season.

12.96  Although it accepted the need for increased staffing levels, the State rejected a proposed recommendation to the effect that there be established a pool of reserve staff available to work in ESTA centres. In so doing, it emphasised the specialised training provided to ESTA staff and the need to maintain standards.145 The Commission accepts this, and proposes increasing the work stations available at ESTA centres.

 

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

 

 

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

 

 

[1]     Exhibit 62 – Statement of Foster (WIT.012.001.0001) [29]–[30]

[2]     Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14]; Foster T1963:10–T1963:15; Walshe T1215:10–T1215:13; Edwards T2863:30–T2864:2

[3]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [115]; Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [144.e]; Kiernan T2025:17–T2025:26

[4]     The reference is to calls, rather than callers, as it appears likely many callers hung up and redialled Triple Zero a number of times when they were unable to get through.

[5]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [57]–[58]; Kiernan T2021:28–T2022:10

[6]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001)

[7]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [27]–[28]; Attachment 2 (WIT.5003.001.0105), Attachment 3 (WIT.5003.001.0109)

[8]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [32]

[9]     Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [34]

[10]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [11]

[11]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5], [24]

[12]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [25]

[13]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [61]

[14]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5]

[15]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [64]; Attachment 6 (WIT.5003.001.0180)

[16]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [33]

[17]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [57]–[58]

[18]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [88]

[19]   Elkington T3821:9–T3821:29

[20]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [88]

[21]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [96]

[22]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [51]

[23]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [46]–[47]

[24]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [49]

[25]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [55]

[26]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [56]

[27]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [100]

[28]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [7]–[9]

[29]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [33]–[34]; Attachment 5 (WIT.012.001.0032)

[30]   Foster T1956:3–T1956:6

[31]   Exhibit 62 – Foster (WIT.012.001.0001) [38], [40]; Exhibit 62 – Statement of Foster (WIT.012.001.0001) [35]–[38]

[32]   Foster T1960:12–T1960:18; Foster T1957:5–T1957:6

[33]   Foster T1957:29–T1958:4

[34]   Foster T1957:5–T1957:6

[35]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14]

[36]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [14]–[15]

[37]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [19]

[38]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [26]–[27]

[39]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [30]

[40]   Foster T1950:5–T1950:15

[41]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [50]

[42]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [55]

[43]   Exhibit 62 – Statement of Foster (WIT.012.001.0001) [57]

[44]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [14]–[15]

[45]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [16]

[46]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [21]–[22]

[47]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [23]

[48]   Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [41], [43] and [44]

[49]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [20], [65]–[66]; Exhibit 62 – Statement of Foster, Attachment 4 (WIT.012.001.0030)

[50]   Exhibit 63– Statement of Kiernan (WIT.3000.001.0001) [41]–[42]

[51]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [43]–[48]; Attachment 4 (WIT.012.001.0030)

[52]   Foster T1955:1–T1955:10

[53]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [72]–[86]

[54]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [83]; Attachment 10 (WIT.3000.001.0118)

[55]   Exhibit 63 – Statement of Kiernan, Attachment 10 (WIT.3000.001.0118) at 0122

[56]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [92]–[127], Exhibit 62 – Statement of Foster (WIT.012.001.0001) [65]

[57]   Elkington T3832:10–T3832:20

[58]   Elkington T3831:1–T3831:27

[59]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [87]

[60]   Elkington T3831:17–T3832:3

[61]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [87]

[62]   Kiernan T2021:28–T2022:10

[63]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [107]–[115], [120]–[127], T2019:1–T2021:22; Foster T1966:4–T1966:8

[64]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [101]–[102], [126]–[127]

[65]   Exhibit 63 – Statement of Kiernan, Attachment 16 (WIT.3000.001.0135)

[66]   Exhibit 63 – Statement of Kiernan, Attachment 18 (WIT.3000.001.0137)

[67]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [107]–[115], [120]–[127]; Kiernan T2019:1–T2021:22

[68]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [147]; T2023:3–T2023:7

[69]   Kiernan T2024:30–T2025:16

[70]   State of Victoria (SUBM.100.005.0001) [150]

[71]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [94]

[72]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [94]

[73]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001); T3835:1–T3835:11

[74]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [98]

[75]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [100]

[76]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [101]–[103]

[77]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [107]

[78]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [114]

[79]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118], [121]

[80]   Exhibit 63 – Statement of Kiernan, Attachment 19 (WIT.3000.001.0138)

[81]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [134]

[82]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [135]

[83]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [137]

[84]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [146]

[85]   Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [140]

[86]   Foster T1977:26–T1978:2

[87]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]

[88]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]

[89]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [124]; T3844:17–T3844:30

[90]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]

[91]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]

[92]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]

[93]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [118]–[119]

[94]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]

[95]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]

[96]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]

[97]   Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [123]; Elkington tender (TEN.044.001.0001)

[98]   Graph based on data at Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [119]

[99]   Graph based on data at Exhibit 117 – Statement of Elkington, Attachment 22 (WIT.5003.001.0424); (WIT.5003.001.0431); (WIT.5003.001.0438)

[100]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [122]

[101]  Elkington T3835:23–T3835:29

[102]  Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [41]–[42]

[103]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5]–[6]; Attachment 1 (WIT.5003.001.0102); (WIT.5003.001.0103); Elkington T3819:3–T3820:3

[104]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [5]–[8], [25]–[26], [59]–[63]; Attachment 1 (WIT.5003.001.0104); Elkington T3819:3–T3820:12

[105]  Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [43]–[44]

[106]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [7], [116]; Exhibit 117 – Elkington tender (TEN.044.001.0001)

[107]  Elkington T3859:27–T3860:29; Exhibit 152 – Statement of Ives (WIT.3005.001.0001) [43]–[44]

[108]  Exhibit 63 – Statement of Kiernan (WIT.3000.001.0001) [139]–[144]; Attachment 20 (WIT.3000.001.0154) at 0159; Tender (EXH.063.0004) at 0005

[109]  Kiernan T2035:29–T2036:4

[110]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [116]

[111]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [126]

[112]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [116], [126]

[113]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [126]

[114]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [127]

[115]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [127]

[116]  Exhibit 117 – Elkington tender (TEN.044.001.0001)

[117]  Elkington T3837:9–T3837:26

[118]  Elkington T3838:1–T3838:5

[119]  Elkington T3841:11–T3841:27

[120]  Kiernan T2048:23–T2048:31

[121]  Exhibit 10 – Statement of Spooner (WIT.011.001.0001_R) [24]; Spooner T484:23–T484:24

[122]  Kane T1050:27–T1051:6

[123]  Exhibit 48 – Statement of D Brown (WIT.029.001.0001_R) [9]; D Brown T1642:13–T1642:31; see also Exhibit 119 – Supplementary Statement of Jennings (WIT.5004.002.0001) [7]

[124]  Exhibit 91 – Statement of Scott (WIT.045.001.0001_R) [27]; Scott T2925:26–T2925:30

[125]  Exhibit 116 – Statement of Matthews (WIT.057.001.0001_R) [30]-[31]; Matthews T3784:5-T3784:31

[126]  Exhibit 62 – Statement of Foster (WIT.012.001.0001) [73]

[127]  Exhibit 62 – Statement of Foster (WIT.012.001.0001) [74]

[128]  Exhibit 62 – Statement of Foster (WIT.012.001.0001) [75]–[77]

[129]  Kiernan T2005:23–T2005:25

[130]  Kiernan T2006:15–T2006:18

[131]  Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517)

[132]  Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1564

[133]  Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1565

[134]  Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1565, 1567, 1569, 1571

[135]  Exhibit 62 – Statement of Foster (WIT.012.001.0001) [66]–[71]; Exhibit 11 – Statement of Esplin, Attachment 15 (WIT.005.001.1517) at 1561–1577, Esplin Tender (TEN.002.001.0366); Foster T1966:23–T1968:13

[136]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [82]

[137]  Elkington T3862:10–T3862:26; Foster T1966:23–T1968:13; T1968:29–T1969:2; T1979:8–T1979:20

[138]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [66]–[76]

[139]  Exhibit 117 – Statement of Elkington (WIT.5003.001.0001) [77]–[80], Attachment 13 (WIT.5003.001.0332); (WIT.5003.001.0335)

[140]  Elkington T3850:20–T3851:7

[141]  Elkington T3845:13–T3846:3

[142]  Telstra (SUBM.100.010.0001) [27]

[143]  Telstra (SUBM.100.010.0001) [27]

[144]  State of Victoria (SUBM.100.005.0001) [147]–[149]

[145]  State of Victoria (SUBM.100.005.0001) [150]; Myers T5046:23–T5046:26