9 INCIDENT MANAGEMENT: A CASE STUDY

 

This chapter examines the incident management structure which operated in Victoria on 7 February 2009. It looks at the importance of fire information, and in particular the role of Information Units and fire prediction in that structure. It then considers the practical operation of that structure in one instance on 7 February — the fire that started at Kilmore East. The chapter presents an incomplete account of the emergency response to that fire. However, some conclusions can be drawn on the effectiveness of some of the procedures and systems, and recommendations are made for the 2009–10 fire season.

 

9.1       The Australasian Inter-Service Incident Management System (AIIMS) was developed in Australia in the mid 1980s.1 It was modelled on the United States National Inter-Agency Incident Management System, which in turn was modelled on military operational functions.2 It is used by all Australian fire agencies, and many state emergency services.3 Using the same system allows the exchange of fire managers with the United States and Canada for further experience and support. Victoria Police use a different incident management system and discussions have been ongoing over recent years to integrate the two. However, an integrated system was not in place on 7 February.4

9.2       AIIMS was adopted as the system of incident management for the Country Fire Authority (CFA) and the Department of Sustainability and Environment (DSE) in early 1990.5 AIIMS was introduced in an effort to provide more effective command, control and coordination within and across agencies.6 The introduction of AIIMS recognised that complex, fast moving fire events require more coordinated control arrangements beyond local volunteers at the brigade and group level.7

9.3       Volunteers and career CFA staff may be drawn on to fulfil AIIMS positions, depending on their training.

9.4       The principles of AIIMS, as outlined by Mr Russell Rees, Chief Officer of the CFA, are:8

•    management of incidents by objective

•    one controller of the incident — the Incident Controller

•    delegation of functions depending on complexity of the incident

•    span of control — one person responsible for five people at any one time

•    the development of a plan outlining strategies and tactics to combat the incident.

9.5       The functions of the Incident Management Team (IMT) as outlined by Mr Rees are:

Incident Control: an Incident Controller (IC) will be designated to have overall management of the incident. The IC, in consultation with the other members of the IMT, will determine a control objective that will become the foundation for the development of strategies and the subsequent Incident Action Plan.

Operations: the Operations Section is responsible for the control of operations and the direction of agency resources in accordance with the Incident Action Plan.

Planning: the Planning Section is responsible for collecting and analysing incident information, predicting incident behaviour, recording the location and tasking of resources, and preparation of alternative strategies to control the incident.

9.6       The AIIMS functional structure used on 7 February to manage the Kilmore East fire is depicted in (Figure 9.1).

 

Figure 9.1: Elements of the AIIMS structure referred to in this chapter

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9.7       Mr Rees explained that the Information Unit, which assumes control of all information to the public, has been integrated into the planning section of the IMT. It became a formal part of the AIIMS structure in 2003.12

9.8       Mr Rees also explained that, under AIIMS, incident management is classified into levels 1, 2 or 3.13 In a fire incident:

•    A level 1 fire is a small fire in area, attended by one or two trucks, which is of short duration and is dealt with at the incident. The Incident Controller will be the senior person at the fire exercising control.

•    A level 2 fire is a developing fire incident or one that requires more than the initial responding resources. A level 2 incident may be managed at the incident itself or at an Incident Control Centre (ICC) and involves the Incident Controller delegating some functions to others, thereby forming the IMT.

•    A level 3 fire incident is a large complex fire incident, which may run for days, where a large number of functions are delegated. Such a fire is run from an ICC. The responsible IMT, under the Incident Controller, will directly manage the fire through its operations, planning, and logistics functions.14

9.9       At times in evidence the ICC (the facility) and the IMT (the management team) have been used interchangeably. This is reflected in this chapter.

9.10     In preparation for 7 February, 20 level 3 ICCs were designated and established in pre-determined locations across the State.15 Kilmore fire station was one of the pre-designated ICCs meant to be able to operate with a level 3 IMT ‘virtually immediately’ on the outbreak of fire.16 As evidence referred to later demonstrates, Kilmore was not staffed to operate as a level 3 IMT at the outbreak of the Kilmore East fire.

9.11     Apart from the Kangaroo Ground ICC, which is a permanent facility, the Commission has not examined the state of readiness of other ‘pre-designated ICCs’.

THE IMPORTANCE OF FIRE INFORMATION

9.12     Traditionally firefighters have focused on putting out fires. Evidence before the Commission has highlighted that while extinguishing the fire should be the primary role of firefighters, once this is no longer possible, putting out information to the public is an equally important role.

9.13     The importance of gathering fire information, communicating among agencies and warning the public have been the subject of numerous recommendations in reports, investigations, and Coronial Inquests on Victorian fires over the last 70 years. A selection of some of the previous reports’ comments and recommendations about fire information follows.

9.14     In his report about the 1939 bushfires, Justice Stretton referred to the desirability of early detection of fire and made a number of recommendations including the use of lookout towers and the consolidation of information received concerning fires ‘in a central body devoted to firefighting’.17

9.15     The Report of the Bushfire Review Committee on Bushfire Disaster Preparedness and Response in Victoria, Australia following the Ash Wednesday Fires, noted the important role of communications in fire, the imperative of fire organisations having ‘assured links between them’, and the necessity for timely warnings to communities. The report commented that timely warnings particularly applied ‘to notification of wind changes and forecasts of fire front movement’.18 The issue of warnings is further discussed in Chapter 4.

9.16     The Coroner investigating deaths during the 1997 Dandenong Ranges fires commented that fire information and ‘communication needs to flow to the community in a timely way to assist in the process of early warning and management of risk’. This passage was used in the CFA’s submissions to the 2002–03 bushfire inquiry.19

9.17     The May 2003 Victorian Auditor-General’s report Fire Prevention and Preparedness observed that the most detailed planning may be ineffective if residents do not have access to information that provides the earliest possible warning of fire in their area and indicates the path and intensity of fire.20

9.18     The Report of the Inquiry into the 2002–03 Victorian Bushfires also recommends more emphasis on communication of fire information and warnings. These recommendations highlight the need for timely and effective warnings to potentially fire affected communities:

That in relation to the provision of information to communities affected by fires and other emergencies, DSE and CFA ensure that:

Incident Management Teams understand that one of their primary responsibilities, in co-operation with the Municipal Emergency Response Co-ordinator, is to keep the community informed as to where the fire is and its likely path, what is being done to combat the fire and any preparations the community should undertake;

Community Information Units are effectively integrated into the Incident Management Teams; and

They continue to develop a joint internet-based communications tool to provide information and advice to both affected and broader communities during fires.

Conclusion

Community expectations have changed significantly both in terms of the service communities expect from Government, and in terms of the information they demand from Government during emergencies.

9.19     Mr Chris Carson, CFA Officer, presented a paper to the then Australasian Fire Authorities Council (AFAC) conference in 2004 in which he observed that many people are ill prepared for bushfires and that firefighting agencies can offer two interventions that could assist:

9.20     In 2005 AFAC emphasised that ‘Access to accurate and timely information during periods of high fire danger and fire events is crucial to enable people to make appropriate decisions concerning their safety’. AFAC pointed out that the fire agencies needed to ‘provide the media and the community with information that is accurate, relevant, adequate, consistent, useful and timely’.23

9.21     The report of the July 2006 Joint CFA/DSE Review of Effectiveness of Information Flow to Communities and Media During Fire Incidents observed that:

9.22     To ensure public expectations about warnings were met, the report also stated it would be necessary to review staffing and the physical resources of Information Units.25

9.23     In 2007 Mr Ross Smith, a forester with extensive rural fire management experience, provided the CFA and DSE with a further report, Key Issues Identified from Operational Reviews of Major Fires in Victoria 2006/07.26 This report reviewed the debrief outcomes of firefighters from the 2006–07 bushfire season and again emphasised the importance of providing fire information to communities potentially affected by fire. Its recommendations were accepted by Mr Rees and Mr Ewan Waller, Chief Fire Officer, DSE on behalf of the CFA and DSE respectively.27 The report stated:

^•             The authority must gather reasonable intelligence about the fire location to identify where and in what it is burning (e.g. aerial reconnaissance, remote sensing, on ground investigation, lookout tower observation, verified/verifiable public reports).

^•             The authority must either initiate suppression action against the fire or undertake investigation and/or observation to determine what suppression action is feasible and what an appropriate strategy is.

9.24     By the 2008–09 bushfire season, it was clear that there was a longstanding appreciation and acknowledgement in the fire agencies of the need to gather intelligence about fires and use that information to the benefit of communities threatened by fire, to ensure timely and accurate public advice. This understanding was acknowledged by Mr Rees in his evidence, when he referred to the CFA philosophy that ‘provision of information to the community before and during a major incident was one of its core responsibilities’.29 Providing fire information to the community, Mr Rees stated, ‘plays an important part in achieving safe, self-reliant and resilient communities. Such information enables community members to make informed decisions about their own fire safety’.30 The Commission agrees.

Information Unit — AIIMS

9.25     In an attempt to better manage information flow, Information Units became a formal part of the AIIMS system in 2003. Information Units are responsible for the control of all information disseminated to the public.31 The Information Unit is incorporated into the planning section of the AIIMS structure. Figure 9.2 provides an example of the position of an Information Unit — which sits inside the Planning Section — in a level 3 Incident.

 

Figure 9.2: Information Unit within the AIIMS Structure

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9.26     In 2008 the CFA and DSE published guidelines for the conduct of the Information Unit which provide that:

9.27     The guidelines note that it is ideal to have the Information Unit at the same location as the ICC but envisage that this may not be possible. They refer to the possibility of the Information Officer being located at the Regional Emergency Coordination Centre (RECC) pending establishment of an ICC.34

9.28     The evidence before the Commission is that the Information Officer for the Kilmore ICC was located at the Seymour RECC for some hours after the outbreak of fire on 7 February.35 However, based on the evidence of Mr Rees about the preparedness of pre-designated ICCs, there is no clear reason why an Information Officer and Unit should be located anywhere but at the ICC for a level 3 IMT. Mr Rees referred to the necessity of the Information Unit operating out of the ICC. He stated:

9.29     The Information Unit, through the Information Officer, is responsible for:

•    disseminating information directly to locally identified conduits

•    disseminating information to the integrated Emergency Coordination Centre (iECC) for state level dissemination

•    reporting to the RECC on dissemination networks used and providing to the RECC copies of the information released by the ICC.37

9.30     The Information Unit is required to give priority to providing information to communities that are near a fire incident who are, or may come under, direct threat.38 That requirement carries with it a duty to ensure ‘that accurate up to date incident information is provided to the public, local community, other relevant agencies’.39

9.31     The Planning Section of the IMT, which contains the Information Unit, is referred to as a source of information in the 2008 guidelines:

This information provides a sound understanding of the potential to impact communities, the likely degree of effort required to resolve the incident and consequently a good basis for Information Unit understanding of information needs. The Planning Section is required to undertake the following functions:

Incident Prediction. The document will contain the following information:

^•                       Current and anticipated weather

^•                       Current and anticipated Fire Danger Index

^•                       Fuel loads in the area currently burning and likely to burn

^•                       Description of current and predicted fire behaviour

^•                       A summation of the total distance spread

^•                       A description of any significant issues or priorities likely to face the IMT

^•                       There is likely to be an analysis of a map indicating the likely spread of the fire

Incident Action Plan. This document will contain the following information:

^•                      A statement of the current objective of the suppression strategy including resources

9.32     Information cannot be released by the Information Unit without the authorisation of the Incident Controller irrespective of whether the information is prepared at the ICC or at an alternative location.41 Information created by the Information Unit at the iECC must be authorised by the State Duty Officer.42

9.33     The guidelines clearly set out the responsibility of the IMT through its Information Unit to gather and provide fire information. The guidelines properly prioritise the provision of information to communities near a fire or communities that may come under direct attack by fire. This report returns to the role of the Information Unit and its place in the Incident Control structure later in the chapter after the management of the Kilmore East fire is examined.

FIRE PREDICTION

9.34     The Planning Section also has responsibility for providing incident prediction, which is ‘most likely to be an analysis on a map indicating the likely spread of the fire’.43 Fire analysis and prediction is important to the management of the fire suppression effort and to the provision of timely, accurate advice to communities potentially threatened by fire.44 Fire behaviour analysts provide fire spread predictions for going bushfires and identify human, economic and environmental assets that may be impacted by fire. They also make recommendations about firefighting safety issues relating to fire behaviour and fire weather.45

9.35     Mr Rocky Barca, a qualified level 3 Incident Controller and Deputy Incident Controller at the Kangaroo Ground ICC on 7 February, provided evidence to the Commission on the importance of fire prediction within the ICC.46

               

9.36     Mr John Cowan assisted in the Planning Section at the Kangaroo Ground ICC on 7 February. He has been a volunteer member of the CFA for 31 years and has held senior positions in the organisation.48 Because of his training and experience he has undertaken fire prediction work. He gave evidence of the importance of fire prediction in relation to the management of resources.

 

9.37     The Kilmore East fire is the only fire that has been considered in any substantial detail so far in evidence before the Commission. That evidence is not complete as only a partial account of the emergency response to the fires has been heard. However, an analysis of the evidence received to date concerning this fire provides a sound basis for conclusions on the effectiveness of some procedures and systems.

THE ICC AT KILMORE

9.38     The Kilmore East fire was reported at 11:49am.50 At 12:05pm the Kilmore CFA volunteer Captain, Gregory Murphy, received a call from regional Operations Officer Peter Creak, Seymour, to indicate that Kilmore fire station should become the ICC for the fire and that Mr Murphy would be the Incident Controller.51 Mr Murphy possessed level 2 Incident Controller qualifications.52 The Kilmore ICC is the nominated level 3 ICC for the Mitchell catchment area, which covers the Seymour and Northern highway groups.53

9.39     Kilmore was one of the 20 pre-designated level 3 ICCs prepared in anticipation of the conditions forecast for 7 February.54 It was supposed to be at a ‘heightened state of readiness’ for the day.55 The pre-designated level 3 ICCs were meant to be ready for a ‘warm start’ — ‘people there, all the facilities, the equipment is up and running and tested’. Mr Rees said he was assured that this was the case with the pre-designated ICCs.56

9.40     The CFA State Duty Officer on 7 February was Mr Gregory Paterson, a career officer in the CFA. He understood the Kilmore ICC was a level 3 ICC and ‘hot’ in the sense that it had in place an Incident Controller, and that Operations, Planning and Logistics Units were ready to operate at the start of a fire.57 According to Mr Paterson, during the morning of 7 February, he requested that Ms Michelle Koehler, CFA State Emergency Coordination Centre (SECC) officer, contact the regional duty officers and area coordinators so that he could be sure of the level of preparedness of the ICCs. He believed as a consequence of this contact that the Kilmore ‘was a hot level 3 ICC.’58

9.41     However, the evidence of Mr Murphy disclosed that the Kilmore ICC was not ‘hot’ (despite efforts having been made on 6 February to prepare it) and certainly not staffed to a level 3 capacity in the manner described by Mr Rees or Mr Paterson. Mr Murphy was tasked as Incident Controller without a level 3 qualification. He had ‘no prior knowledge [he] would be utilised as a level 3 Incident Controller’.59 This is not a criticism of Mr Murphy as he was placed in an invidious position.

9.42     Upon his appointment as Incident Controller, Mr Murphy was required to establish an IMT at the Kilmore fire station from scratch. Mr Tim Tingiri, who had previously been dispatched to the fire as Commander of the Kilmore pumper, was recalled and appointed Situation Officer.60 Mr Tingiri apparently had undertaken some form of incident management training. He appeared to Mr Murphy to be the most suitable person at the time to undertake the role, although Mr Murphy did not believe Mr Tingiri to have a level 3 qualification. Mr Tingiri had no prior knowledge he would be appointed Situation Officer, a position that carries with it the responsibility of bringing together situation reports of the fire and fire prediction.61

9.43     Other appointments were made to make up the team and to enable the ICC to become operational. The Operations, Logistics and Planning Officers, as far as Mr Murphy was aware, were not level 3 IMT qualified.62

9.44     There was no Information Officer at the Kilmore ICC at the time the ICC became operational at approximately 1:05pm. The Information Officer arrived at the ICC at approximately 3:30pm.63

9.45     Mr Murphy was informed that information concerning the Kilmore East fire, including the release of threat messages concerning that fire, would be processed through the RECC at Seymour as opposed to the Kilmore ICC. Mr Murphy did not see any of the threat messages concerning the Kilmore East fire prior to 3:30pm. He was aware of threat messages being issued but because these were issued from the Seymour RECC, he was unaware of the frequency or content of such messages.64

9.46     At the iECC, at least initially, there was no knowledge that the Kilmore ICC was not staffed at all, let alone not staffed as a level 3 ICC. Mr Rees did not find out that the Kilmore ICC was not pre-staffed until after the event in the following days, although he did ask on the afternoon who the Incident Controller was for the fire.65 Mr Paterson said he was surprised when informed at 2:30pm that a level 3 Incident Controller was being transferred from Mansfield to Kilmore.66

9.47     Mr Rees became aware ‘probably within the first hour of the fire’ there was a level 2 Incident Controller, but said that at the initial stages of the fire this was appropriate and that he knew ‘the fundamentals were there’ but that he didn’t know ‘that we weren’t at the level of readiness that I would have – well I knew was the case at other incidential control centres’.67

9.48     Mr Murphy stated the line scan of the Kilmore East fire which was requested at 12:33pm did not arrive at the Kilmore ICC whilst he was Incident Controller, nor was he aware, or made aware, of any services that could have been offered by the iECC concerning the prediction of fire.68

9.49     The lack of preparedness of the Kilmore ICC meant that systems and protocols were not in place to provide accurate and timely information on the fire.69 It was unreasonable to place the burden of creating and then managing an IMT for a complex, fast-moving fire on unprepared and underqualified CFA personnel. The lack of preparedness, in so far as it affected the provision of information on fire to the public, meant that threat messages and warnings concerning this fire were not issued in a timely manner and failed to contain relevant details and information. Just why the Kilmore ICC was in such a poor state of preparedness has not to date been explained in evidence, and cannot therefore be the subject of a specific recommendation.

9.50     The Commission will pursue in future hearings the following issues:

•    why the Kilmore ICC was not prepared to operate as a level 3 ICC

•    the procedures the CFA considers should be established to ensure pre-designated level 3 ICCs are adequately prepared.

 

The State ensure that State Duty Officers of the CFA and DSE be given direct responsibility for ensuring pre-designated level 3 Incident Control Centres within their respective control are properly staffed and equipped to enable immediate operation in the case of a fire on high fire risk days.

 

The ICC AT KANGAROO GROUND

9.51     The Kangaroo Ground ICC is approximately 50 kilometres south of Kilmore. It is a permanent ICC facility and as such is equipped with desks and prearranged allocations of space for the ICC team. It also has computer and IT facilities, although the fit out at Kangaroo Ground is not as up to date as other permanent ICCs across Victoria.70

9.52     The Kangaroo Ground ICC was set up for a ‘hot’ start as a level 3 ICC on 7 February. Planning, Operations, Deputy Operations and Logistics Officers were in place.71 Other personnel were on site as back up, including support for the Information Unit.72

9.53     While the Kangaroo Ground ICC was a designated level 3 ICC, it was not given responsibility for the Kilmore East fire on 7 February.73 It did become a Divisional Command of the Kilmore ICC and was ‘activated’ as the ICC in control of the Kilmore East fire at 5:42am on Sunday 8 February.74 A Divisional Command normally reports through and takes instructions from the IMT Operations Officer and the Incident Controller of the fire.75

9.54     As a consequence, the Kangaroo Ground ICC was not authorised to issue threat messages or other information concerning the Kilmore East fire on 7 February.76

9.55     Mr Jason Lawrence was the Incident Controller of the IMT at Kangaroo Ground on 7 February. He is a CFA career firefighter, holds the position of Operations Officer, and when asked if he held, and has been trained in, level 3 Incident Controller qualifications Mr Lawrence stated he had ‘undertaken training to that effect’.77 Mr Lawrence had no experience as a level 3 Incident Controller in any previous bushfires.78

9.56     Mr Barca was also rostered to the Kangaroo Ground ICC, where he took the role of Deputy Incident Controller of the IMT. Mr Barca is employed by Parks Victoria and is accredited as a level 3 Planning Officer and level 3 Incident Controller.79 Mr Barca had operational experience as a level 3 Incident Controller at Victorian Bushfires in 2002, 2003 and over the summer of 2005–06. In 2006 he was Incident Controller at the Kangaroo Ground ICC when Kinglake was under fire threat. He has served as Acting Chief Fire Officer for DSE.80

9.57     The practice is that the appointment of Incident Controller is dependent on the location of fire ignition. If the fire starts in land for which DSE has responsibility, a DSE Incident Controller takes charge; if it starts in land where the CFA has responsibility, a CFA Incident Controller takes charge.81

9.58     This method of selection is flawed. On 7 February it led to the appointment of a level 3 Incident Controller at the Kangaroo Ground ICC who was inexperienced in the role and not formally qualified, over a person highly experienced and qualified for the level 3 Incident Controller position.

 

The CFA and DSE agree procedures to ensure the most experienced, qualified and competent person is appointed as Incident Controller for each fire, irrespective of the point of ignition of the fire.

 

on ground reporting

9.59     Examining the information that was available concerning the Kilmore East fire on 7 February provides perspective on the adequacy of the warnings released on the day.

9.60     When reported at 11:49am, the Kilmore East fire was entered on the CFA electronic Incident Management System (IMS).82 Mr Paterson gave the fire, when it first came up on IMS, ‘exceptionally high priority’.83 At 12:10pm Mr Paterson recognised this fire would potentially impact on the Hume Highway and on the Sydney–Melbourne rail link.84 At this time an iECC Situation Officer was dedicated to the Kilmore East fire.85

9.61     At 12:08pm Ms Colleen Keating, Fire Tower Operator at the Kangaroo Ground fire tower, took a bearing on the Kilmore East fire. She spoke with fire tower operators at Mount St. Leonards and Pretty Sally and was informed that the Kilmore East fire was heading towards a Blue Gum plantation and was building fast. That information was conveyed to Mr Lawrence at the Kangaroo Ground ICC.86

9.62     At 12:21pm the Police Forward Command Log recorded a concern about the potential of the Kilmore East fire and at 12:30pm the log noted the fire was a ‘major concern’ of the fire agencies. The log referred to the possible impact on the Melbourne–Sydney rail line and the Hume Highway.87 At approximately 1:00pm the Hume Highway was closed to traffic upon request from Mr Murphy.88 Deputy Commissioner Kieran Walshe, Victoria Police, said that the request was received by police at approximately 12:37pm.89

9.63     Mr Kenneth Williamson, a 30 year volunteer member of the CFA and Whittlesea Fire Brigade Captain, provided evidence concerning the progress of the Kilmore East fire.90 At 1:02pm on 7 February he spoke to Mr David McGahy, volunteer Captain of the Arthurs Creek/Strathewan CFA Brigade. He said that it was more than likely that the fire would jump the Hume Highway and that once it was in the Mount Disappointment area it would have a free run and be hard to pull up. Mr Williamson appreciated that once the fire was in the pine plantation on the western side of the Hume Highway it would be impossible to stop at the Hume Highway.91

9.64     At the time of the conversation with Mr Williamson, Mr McGahy at Arthurs Creek was able to observe that the volume of smoke from the Kilmore East fire had grown enormously.

9.65     Mr Murphy appreciated that once the fire was in the pine plantation its intensity would increase, the fuel load would be such that ‘all of the requirements for a very large, very difficult fire had been met’.93 At approximately 11:50am, after dispatching the initial response units to the fire, Mr Murphy observed the large column of smoke generated by the fire. The column of smoke he said ‘told a story that — yeah we were going to struggle with that [fire] and we did’.94

9.66     At 1:19pm an entry in IMS recorded the fire near the Hume Highway and noted that spotting over the highway was likely.95 Superintendent Rodney Collins at the iECC reported to the State Emergency Response Coordination Centre that the fire was spreading south at a rapid rate and Wandong may be directly impacted.96

9.67     At around this time, the fire was also in a forested area between Wandong and Clonbinane.97 Mr Williamson described the fire conditions as extreme and measured a slight wind change from north-west to a westerly at 100 kilometres per hour.98 The fire in the forest area was running, he estimated, at 20–30 kilometres per hour, and he said that later in the day the speed of the fire was greater than this, ‘roaring — I’ve never seen anything like it’.99 These observations of the fire made by Mr Williamson were reported back to his group officer Mr Rod Holland. However, it is unclear whether they were passed on to the Kilmore ICC.100 At around 2:00pm Mr Williamson observed the fire behaviour to be erratic and spotting all over the place.101

9.68     At 2:12pm Ms Keating at the Kangaroo Ground tower was provided with information, which she passed onto the Kangaroo Ground ICC, from Mr Peter Coleman, the Pretty Sally tower spotter, to the effect that the fire had crossed the Hume Highway north-east of Wandong. Mr Coleman also stated the fire was heading towards Mount Disappointment and Kinglake West.102 At this time burnt leaves were dropping in the Kangaroo Ground area.103

9.69     At 2:25pm the Strath tower (operated by Melbourne Water) in the Mount Disappointment State Park was evacuated because of the potential threat of fire.104 The evacuation was reported to the Kangaroo Ground ICC at 2:36pm.105

9.70     Spotting of the Kilmore East fire was reported at 2:33pm into the top end of Wandong on 774 ABC Radio and at about 3:00pm around Humevale by the Kangaroo Ground tower. At 3:22pm further heavy spotting was observed in the Humevale area.106

9.71     Deputy Group Officer Lindsey McHugh reported at 3:06pm that the fire had progressed across Mount Disappointment much faster than anticipated and was coming over the top of the mountain into Bruces Creek.107

9.72     Triple Zero calls, presumably concerning spotting of the fire, were received from the Strathewen area from 3:43pm.108

9.73     At approximately 3:30pm information concerning the Kilmore East fire was provided to fire behaviour analysts at the iECC. This information came from a report of an aircraft over the fire. The information demonstrated the fire was further advanced than expected and the rate of spread was faster than predicted.109

9.74     The first callout for the Arthurs Creek Brigade was at 3:43pm. The brigade was dispatched to a spot fire in Eagles Nest Road, Strathewen.110 Other spot fires were breaking out. Within 20 minutes ‘the mountains were starting to spot and the speed of the oncoming fire was something to behold’.111 By 3:55pm Mr Williamson was concerned the fire was such that the whole mountain might be lost.112 At 3:57pm he requested that ‘VicFire’ organise an urgent threat message be made to the residents on Kinglake mountain.113 He believed he also made the same request to the Whittlesea Divisional Command through Mr Holland. In referring to the Kinglake mountain he meant the whole mountain from Mount Disappointment to Kinglake.114

9.75     At 4:05pm the fire was reported at St Andrews.115 Mr David Cooper, a volunteer firefighter and Deputy Group Officer, Lower Yarra Area, who was based at Kangaroo Ground on 7 February, dispatched a tanker to St Andrews at approximately 4:00pm after receiving a report from Mr McGahy that the fire at Arthurs Creek ‘was totally out of control’.116 When Mr Cooper arrived at St Andrews he observed a significant running fire spreading rapidly.117

KANGAROO GROUND ICC information

9.76     At the Kangaroo Ground ICC there was an early understanding about the potency of the fire and the risk of danger to those in its path.118 Mr John Cowan, volunteer CFA member and level 3 Planning Officer, assisted at the Kangaroo Ground ICC.119 He arrived at the ICC at approximately 1:30pm. He understood at that time the fire was about to cross the Hume Highway at Wandong. He took account of the potential of the south-westerly change to impact on the fire ‘because that is drilled into all the CFA firefighters in fire behaviour courses’.120 Soon after arrival he predicted:

9.77     Mr Cowan did not see any line scan of the Kilmore East fire, nor was he provided with any other information concerning aircraft observation of the Kilmore East fire.122

9.78     At 2:40pm Mr Barca was informed by the Kilmore ICC that the fire had passed Wandong and was heading in a south-easterly direction and about to enter Mount Disappointment.123 Mr Barca was concerned. Using his experience and training he determined at that time that the fire would have a forward rate of spread of 20 kilometres per hour, flame height varying from 5 to 30 metres crowning in forest areas, and that spotting would occur up to 20 kilometres away.124 Mr Barca stated:

9.79     Mr Barca attempted to pass this information to Mr Creak at Seymour and Mr Murphy at Kilmore but could not get through on the phone.126

9.80     At 2:59pm an entry was made on the CFA IMS in relation to the Kinglake fire:

9.81     At 3:30pm an entry by the Incident Controller at the Kangaroo Ground ICC, Mr Lawrence, reflected that power/transmission lines in Kinglake (SP Ausnet) ‘were potentially in the path of the fire’.128 This concern for the transmission lines at Kinglake was passed onto the Operations Manager in the Region 13 RECC who indicated to Mr Lawrence he would pass the information onto SP Ausnet.129

9.82     At 4:00pm reports from the CFA radio and the Operational Unit at the Kangaroo Ground ICC informed of ember attack at Kinglake West, Eagles Nest (Arthurs Creek) and Panton Hill.130

9.83     At 4:08pm Mr Lawrence informed Mr Graham Armstrong, Operations Officer at Region 13, that there were ‘a large number of assets in the fire path’ that could not be defended. These included water treatment facilities at Yan Yean and Sugarloaf and transmission lines in the Kinglake area. Mr Lawrence formed the opinion that as strategic infrastructure could not be defended, the focus of attention would be solely on the ‘protection of life and property of potentially affected townships, including Arthurs Creek, Strathewen, St Andrews, Kinglake West and Kinglake and other smaller communities in between’. At this time the Kangaroo Ground ICC predicted without the wind change the fire would run to Diamond Creek.131

9.84     An entry into the IMS at 5:11pm from the Kilmore ICC advised the wind change would arrive sooner than expected, and was now anticipated to impact on the western flank of the Kilmore East fire at 6:30pm.132

iECC information

9.85     At 12:55pm on 7 February the CFA produced an electronic map of the estimated fire location for the Kilmore East fire.133 A line scan of the fire was commenced at 12:46pm and a second line scan was run at approximately 12:55pm.134 Line scans are infra red aerial readings generally collected by a light aircraft flying across the path of the fire.135 Their collection is limited by suitable flying conditions and this restricted flights on 7 February.136

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Figure 9.3: Kilmore East fire line scan 12:46–12:49pm

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Figure 9.4: Kilmore East fire line scan 12:55–12:58pm

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9.86     In the nine minutes between the two line scans, the fire is shown to have developed. The area of active firefront is greater and the plume of the fire is drawn in an easterly direction by upper winds.139 The line scan image shows spot fires ahead of the fire and demonstrates the plume of the fire is drawing the fire together.140 The fire at this stage was incapable of being suppressed.141 Dr Kevin Tolhurst, Senior Lecturer, Fire Ecology and Management, University of Melbourne, was of the opinion that the fire was out of control 20 or 30 minutes after ignition.142 These line scans provided the basis for a later prediction of the path of the Kilmore East fire, which showed the fire going through the Kinglake region.143

9.87     An article published in The Australian on 14 February 2009 reported concerns and statements attributed to Mr Waller, Mr Rees and Mr Bruce Esplin (Emergency Services Commissioner) as follows:

9.88     Mr Rees said the article did not represent his language. He said he had a concern for the Kilmore East fire like a number of other fires burning on the day. Mr Rees said he appreciated that if the fire got across the Hume Highway and into Mount Disappointment, the fire would not be controlled on the day and that it would impact on communities and populated areas.145

9.89     Mr Waller stated in evidence that he did have a sense of dread, early on, concerning the Kilmore East fire because of where the fire was located in the Kilmore Gap, with northerly winds and a history of bad fires in the Mount Disappointment area. In his opinion it was a fire ‘of very high potential’.146 Mr Waller held the opinion on 7 February that once the fire crossed the Hume Highway ‘it was going to run’ and follow a predictable course.147

9.90     Concern about the potential of the Kilmore East fire within the iECC is demonstrated by the evidence of Ms Sarah Henshaw, Information Unit Leader for the CFA at the iECC on 7 February.148

9.91     Ms Henshaw attended a meeting at the iECC at 2:28pm which had been called by CFA State Coordinator, Mr Geoff Conway. At the meeting Mr Conway informed those attending ‘that priority areas for the Kilmore East fire were Whittlesea, Hurstbridge and Kinglake’.149 Also in attendance at the meeting were State Duty Officers of the CFA and DSE and Ms Jennifer O’Beirne from the DSE Information Unit.150

9.92     Ms Henshaw said that Mr Conway wanted priority given to Whittlesea, Hurstbridge and Kinglake in terms of provision of information to those areas — to warn these communities. She was informed with others attending the meeting that messaging needed to come from the ICCs that addressed those priority areas.151

9.93     As a consequence of the meeting with Mr Conway, Ms Henshaw spoke with Mr Alex Caughey who was the Information Officer for the Kilmore East fire at the time. To the best of her recollection she raised Whittlesea, Hurstbridge, Kinglake for the purpose of having the Information Unit prepare messaging for those areas.152 Despite this, the first time Kinglake received a warning by reference to the CFA website was at 5:55pm.153

9.94     Between 3:11pm and 3:30pm fire behaviour analysts at the iECC produced a hand drawn prediction map of the Kilmore East fire.154 The map incorporated information from the aircraft surveillance unit at 3:30pm that the fire was spreading faster than anticipated.155 The prediction map indicated the fire potentially spreading to Hurstbridge and close to Kinglake, with spotting extending considerably further as far as Flowerdale and Toolangi. The hand drawn map is reproduced below.

 

Figure 9.5: Hand drawn map created at 3:11pm

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9.95     The prediction map was distributed at approximately 4:30pm.157 It was not produced in its electronic form until 5:43pm.158

9.96     The potential effect of the south-westerly change on fires was appreciated at the iECC. Ms Henshaw described a conversation with Mr Conway at 5:49pm during which he informed her that Mr Rees and Mr Waller were concerned that the wind change had the potential to impact on fires in south, eastern and central Victoria and Gippsland. Mr Conway expressed the need to get information to the public about the wind change.159

9.97     Ms Henshaw drafted a web article concerning the fires and the wind changes that was signed by Mr Rees.160 It was then decided that the article should be redrafted as an urgent media release. The information went to the Media Officers to prepare a media release. Ms Henshaw was not sure if it was ever issued.161

9.98     The web article prepared by Ms Henshaw (which was ultimately never released) was signed by Mr Rees at 6:09pm. It referred to erratic winds accompanying the change and the potential for unpredictable fire behaviour.162

9.99     The Commission, as yet, has not received evidence from Mr Conway.

 

Kilmore EAST fire information conclusions

9.100  Not all the evidence describing the information and intelligence that was available concerning the Kilmore East fire on 7 February received to date has been referred to in this report. However, the evidence referred to establishes the following significant matters:

•    Within 20 to 30 minutes of the time of ignition of the Kilmore East fire (11:49am) it was a fire out of control with no prospect of being contained. It could not be fought.

•    By 1:00pm, when the Hume Highway was closed to traffic and the fire had entered the pine plantation on the western side of the Highway, there was an appreciation that the fire would likely cross the Hume Highway and enter the Mount Disappointment area. This carried with it the high risk that the fire would impact on populated areas.

•    When the fire crossed over the Hume Highway just prior to 2:00pm, those experienced in fire behaviour must have anticipated its potential for destruction.

•    Between 2:00pm and 2:30pm the fire had been reported as running at speeds of between 20 and 30 kilometres per hour, with erratic fire behaviour and heavy spotting.

•    Fire prediction undertaken at various locations between 1:30pm and 2:45pm showed that residents in and surrounding Flowerdale, Kinglake West, Kinglake, St Andrews, Strathewen, Steels Creek, Humevale, Christmas Hills, Toolangi and Whittlesea were at risk.

•    In addition to running at great speed, the fire was expected to crown in forested areas, spot long distances (up to 20 kilometres), and have flame heights up to 30 metres.

•    The cold front approaching from the south-west would have a major impact on the Kilmore East fire, converting the eastern flank of the fire to a much broadened firefront, adding significantly to the fire’s activity and potential devastation.

•    By at least 2:28pm, there was an appreciation at the iECC amongst senior officers of both fire agencies, of the grave potential of the Kilmore East fire to impact on communities and townships including Whittlesea, Hurstbridge and Kinglake.

Kilmore ICC warnings

9.101  Mr Caughey from the Seymour RECC acted as Information Officer for the Kilmore East fire until approximately 4:00pm. He had not previously allocated the Kilmore ICC its own Information Officer because he was not aware it would be activated as a level 3 ICC.163 It was an unusual situation for him, as an Information Officer, to be remote from the ICC and the immediate information concerning the fire coming into the ICC.164

9.102  After being appointed Information Officer to the Kilmore ICC, Mr Caughey remained under pressure due to responsibilities of his other pre-arranged tasks. He was supervising three untrained administrative officers at the Seymour RECC who were inundated with calls from people seeking fire information, and he personally was overwhelmed with calls over the course of the afternoon.165

9.103  Mr Caughey maintained the role of Information Officer, working from Seymour, until Ms Leonie Hunter, a CFA volunteer officer, arrived at the Kilmore ICC at approximately 4:00pm.166 Up until that time he had responsibility for preparing messages and warnings concerning the Kilmore East fire. The messages and warnings were issued from the Seymour RECC. They were not seen or signed by the Incident Controller at Kilmore.167 There was a Media Officer at Kilmore providing information to Mr Caughey concerning the fire. On a number of occasions Mr Caughey spoke to the Incident Controller.168

9.104  An awareness message timed at 12:30pm was posted to the CFA website at approximately 12:40pm. The message was prepared at the iECC and advised that the fire was burning in a south-easterly direction and the communities of Wandong and Clonbinane should be ‘aware of this fire’. The message was authorised by the CFA State Duty Officer, Mr Paterson.169

9.105  Mr Caughey partially prepared an ‘awareness message — initial advice’ concerning the Kilmore East fire at or about 12:50pm. The message described a wildfire burning in a southerly direction. The advice stated the fire was not currently posing a threat to communities but provided a smoke and ember warning for the communities of Wandong, Heathcote Junction and Upper Plenty. This warning was not released because Mr Caughey said he was answering telephone calls at the Seymour RECC and with the passing of time the fire information contained in the message became out of date.170

9.106  Mr Caughey prepared an alert message at 1:10pm. This message was authorised by the Regional Coordinator at Seymour, Mr Creak. The message stated the fire was ‘not posing a threat’ to communities of Wandong, Heathcote Junction and Upper Plenty but those communities ‘should be aware that fire activity in the area has increased’. This alert message was not posted to the CFA website (release 1). Mr Caughey said he had ‘real problems’ sending this message out particularly to ABC Radio.171

9.107  An urgent threat message was prepared by Mr Caughey at 1:50pm. The message advised that ‘the communities of Wandong may be directly impacted by the fire within ten minutes’. This urgent threat message was authorised by Mr Creak.172 This release was not uploaded on the CFA website until 2:40pm (release 2). Mr Caughey commented in his statement ‘The fire’s behaviour was such that our messages were really chasing the fire instead of the fire chasing our messages’.173

9.108  Mr Caughey prepared a further urgent threat message nominally timed at 2:05pm, which he believed was distributed within ten minutes of its preparation to ABC local radio and to the iECC for uploading. This release authorised by Mr Creak, advised communities of Heathcote Junction and Upper Plenty they ‘may be directly impacted by the fire within 30 minutes’.174 This was designated as release number 3 of the Kilmore East fire messages. This message was not uploaded to the CFA website.175

9.109  Ms Henshaw, the CFA Information Unit Leader at the iECC, stated that a facsimile had been received at the iECC at 1:53pm from the Seymour RECC (Mr Caughey) which included releases 1 to 3 for the Kilmore East fire. However, it was not received by the Information Unit at the iECC until sometime after 2:21pm, taking at least 28 minutes to be distributed within the iECC’s Information Unit.176

9.110  From 12:40pm, no information was posted to the CFA website concerning the Kilmore East fire, until 2.25pm, when a message was initiated at the iECC, authorised by Mr Paterson.177 The message stated that the fire was ‘not currently posing a threat to communities, however, the communities of Kilmore East, Wandong and Clonbinane need to be aware of this fire’. It went on to state that the fire had jumped the Hume Highway, was significantly spotting and that it was ‘impacting on the outskirts of the Wandong township’. This confusing message was issued at the iECC because it was considered important to upgrade the information from an awareness message to an alert message and because the iECC Information Unit had at that stage not received any information from the RECC or ICC.178 At 1:53pm the iECC had received information that Wandong, Heathcote Junction and Upper Plenty were under imminent threat. It is difficult to understand why this was not put in the iECC drafted warning or why the message did not carry the importance of an urgent threat message, (further analysis of this message is in Chapter 4).

9.111  At 2:40pm, release 2 (prepared by Mr Caughey at 1:50pm) stating that ‘Wandong may be directly impacted by the fire within ten minutes’ was uploaded onto the CFA website.179 The information was redundant and conflicted with the earlier posted message concerning Wandong.

9.112  Mr Caughey prepared an urgent threat message at 2:45pm (release 4). This message advised the community of Hidden Valley that they ‘may be directly impacted upon by the fire within 60 minutes’.180 This message was uploaded to the CFA website at 3:05pm.181

9.113  No updated information concerning the Kilmore East fire was uploaded to the CFA website between 3:05pm and 3:52pm.182 At 3:30pm Mr Caughey prepared an urgent threat message authorised by Mr Creak, which advised that ‘the community of Whittlesea may be directly impacted upon by this fire within two hours’.183 This message was emailed to the iECC at approximately 3:45pm and was uploaded to the website at 3:53pm.184

9.114  At 4:05pm an urgent threat message for Hidden Valley was updated by the iECC to include the words ‘urgent threat messages for Wandong, Heathcote Junction and Upper Plenty remain current’.185 Ms Henshaw informed the Commission that the reason for this update was that Kilmore release 3, the 2:05pm message, which warned these communities, had not been uploaded to the website, and therefore the urgent threat message on the website did not include Wandong, Heathcote Junction or Upper Plenty.186

9.115  Due to his location and the pressure of his work commitments it was not possible for Mr Caughey to properly perform the responsibilities of Information Officer for the Kilmore East fire. He did not have access to the Planning or Situation Officers. He had no direct access to any fire prediction or analysis taking place at the Kilmore ICC. He had no direct opportunity of interacting with the Planning Unit or other key members of the IMT to obtain an ‘understanding of the potential [of the fire] to impact on communities’ or for obtaining ‘information needs’ concerning the fire.187

9.116  Earlier, at about 2:00pm, Ms Hunter was tasked to take over the responsibility of Information Officer from Mr Caughey and be located physically at the Kilmore ICC.188 She had to travel to Kilmore from the Alexandra CFA group headquarters.189 She took over Information Officer duties at the Kilmore ICC at approximately 4.00pm.190

9.117  Information release 6 for the Kilmore East fire was prepared by Ms Hunter at 4:10pm. This release was signed by the Incident Controller, Mr Murphy.191 The urgent threat message stated in part:

9.118  This warning is the first acknowledgement in an information release of the potential of the fire to impact as far as Kinglake. The evidence discloses the following course of events in relation to this warning:

•    It took ten minutes (after 4:10pm) to be signed off at the Kilmore ICC because the Incident Controller was very busy.193

•    There was a problem with the fax machine at the Kilmore ICC. The urgent threat message could not be sent so arrangements were made to email it to Mr Caughey at Seymour RECC. This was done at 4:24pm.194

•    Mr Caughey then emailed or faxed the urgent threat message to three email addresses at the iECC, (the CFA and DSE information desks and the Victorian Bushfire Information Line), to 774 ABC Radio and to local radio stations (Star and UGFM).195

•    The urgent threat message was received at the iECC at 4:35pm.196

•    The message was not uploaded to the CFA website. Upon investigation by Ms Henshaw after 7 February it was noted the email was not flagged as having been actioned by iECC staff responsible for uploading information to the website.197

9.119  The 4:10pm threat message was read over 774 ABC Radio at 4:43pm by Mr John Haynes, Deputy Chief Officer of the CFA.198 However, the 4:10pm message was not repeated on ABC Radio. This may have been because the announcers were relying on information available on the CFA website.199 The next occasion on 774 ABC Radio when the Kilmore East fire was mentioned, was at approximately 5:10pm. The announcer, Mr Steve Martin, referred to a grass and scrub fire burning four kilometres east of Kilmore. He referred to Hidden Valley as the community that may be directly impacted by this fire.200

9.120  Mr Martin at this time referred to a ‘Whittlesea’ fire. This was a reference to an urgent threat message (described in the next paragraph) that was prepared at the iECC and confusingly nominated the fire as a Whittlesea fire.

9.121  An urgent threat message referring to Whittlesea, nominally authorised by Mr Creak but authored at the iECC, was uploaded to the CFA website at 4:35pm (bearing a time stamp of 4:40pm).201 This message referred to a bushfire burning in the Mount Disappointment area and noted that the communities of Whittlesea, Humevale, Arthurs Creek, Nutfield, Eden Park and Doreen may be directly impacted by the fire.

9.122  At 5:41pm an urgent threat message from the Kilmore ICC bearing the time of 5:20pm was received at the iECC. This message gave an urgent threat warning to communities from Kinglake to Flowerdale informing them of the potential of direct impact by the fire. This was posted to the CFA website at 5:55pm, but contained a review time of 5:50pm.202

9.123  The above examination of the information and warnings prepared for communities in the path of the Kilmore East fire between 12.00noon and 6.00pm reveals that the information and warnings were not timely and did not accurately reflect the fire information that was available.

KANGAROO GROUND ICC Warnings

9.124  At the Kangaroo Ground ICC staff were concerned about the potential of the Kilmore East fire. Ms Serafina Munns, an experienced volunteer member of the CFA, had been rostered to work in the Information Unit on 7 February. Ms Munns had never worked in an ICC Information Unit prior to 7 February.203 As early as 12:17pm she recorded in her log a report from a Kinglake West CFA member who could see the smoke column of the fire over Mount Disappointment. At that stage the fire was most likely in the Wallan area.204

9.125  In preparation for information releases from the Kangaroo Ground ICC, Ms Munns used templates for releases and gathered information from the CFA radio, telephone calls and discussions with the ICC personnel, particularly the Information Unit and the Planning and Mapping Departments concerning the predicted path of the Kilmore East fire.205 The Kangaroo Ground Fire Tower Operator, Ms Keating, also frequently reported matters concerning the fire to Ms Munns.206

9.126  At 1:30pm Ms Munns recorded in her log a concern that the fire could burn into and around Mount Disappointment and burn towards Kangaroo Ground.207 The Information Unit prepared an awareness message for release concerning this potentiality. The Information Unit was informed that it was inappropriate to release this message because the fire was not in the Kangaroo Ground ICC area of responsibility.208

9.127  Mr Lawrence, Kangaroo Ground ICC Incident Controller, did not initiate direct contact with the local brigades in areas mentioned in the urgent threat messages that were not released, and was unaware of any attempt within the Kangaroo Ground ICC to do so.209

9.128  At 2:19pm there was a briefing of Kangaroo Ground ICC staff addressed by Mr Lawrence and Mr Barca, Deputy Incident Controller, concerning the Kilmore East fire. The meeting was informed that the fire was burning one kilometre from Wandong, and heading towards Kangaroo Ground, although there was an understanding this information might have been out of date. Members of the Information Unit again asked if fire information could be released from Kangaroo Ground. Mr Lawrence informed them this could not occur because ‘it was not our fire’, meaning the Kilmore ICC had responsibility for issuing such information.210

9.129  At 2:40pm, despite prior phone calls and investigations, the Kangaroo Ground ICC could not ascertain who was the Incident Controller at Kilmore. It appears there was some confusion amongst the Kilmore IMT as to who had this role. Mr Barca spoke to a person at the Kilmore ICC at 2:46pm who informed Mr Barca that the Incident Controller at Kilmore was either Mr Greg Murphy or Mr Peter Creak. Mr Barca was unable to contact either individual.211

9.130  A phone call was received by Mr Barca at the Kangaroo Ground ICC at 2:40pm from the Kilmore ICC. Mr Barca was informed of the south-easterly spread of the fire. He then undertook an exercise of predicting the fire spread. Mr Barca predicted that the fire could potentially impact on Kinglake, Kinglake West, Strathewen, St Andrews, Steels Creek, Flowerdale, Humevale and surrounding towns and areas.212

9.131  Following this analysis, at around 3:00pm, Mr Barca spoke with Mr Lawrence about the need to draft a threat message.213 Mr Barca asked the Information Unit to draft a message for Kinglake and surrounding communities.214

9.132  At 3:02pm an alert message was drafted.215 The information contained in the message was that the fire was estimated to be over 1000 hectares and that it was near Wandong heading in a south-easterly direction. It further stated:

9.133  The 3:02pm alert message represents an accurate and timely warning concerning the potential of the Kilmore East fire. It was the combined work of the Planning Unit and the Information Unit at the Kangaroo Ground ICC.217 It demonstrates what could have been achieved by way of information and warning to those who were in the path of the Kilmore East fire. It also demonstrates the time at which information could have been released to the community.

9.134  However, the draft alert message of 3:02pm was not released. According to Mr Lawrence it was not released because ‘the fire was being controlled by the Kilmore ICC and it was their responsibility to issue information messages be they urgent messages or otherwise’.218 This message was not released by the Kangaroo Ground ICC because the Kilmore ICC, not the Kangaroo Ground ICC, continued to have control of the fire.219

9.135  Mr Lawrence stated in evidence that he attempted to contact the Kilmore ICC to pass the information on, without success. He did not know whether the Kilmore ICC was releasing this type of information.220 Mr Lawrence was not monitoring the CFA website to see what information was being released but, in any event, he reiterated: ‘not being the controlling ICC for that fire at that time, I was not able to issue those information releases regardless’.221

9.136  Mr Barca stated that the unauthorised release of fire information may have caused confusion. He understood the draft threat message was forwarded to the Kilmore ICC for approval and release.222 It is apparent that personnel at the Kangaroo Ground ICC were not aware that the Information Officer for the Kilmore ICC at that time was based at the Seymour RECC, not at Kilmore.

9.137  Mr Barca spoke with Mr Bernard Barbetti, the DSE Regional Duty Officer at Box Hill, at approximately 2:50pm. Mr Barca told Mr Barbetti of his concerns for the potential of the Kilmore East fire and the threat to Kinglake and surrounding areas. He raised the need for a threat message and Mr Barbetti said he would check with the iECC about the status of issuing messages. Mr Barbetti phoned back at 3:13pm to advise no threat messages had been issued.223

9.138  Mr Barca stated that continuing attempts were made by Kangaroo Ground personnel to contact the Kilmore ICC to check on the issuing of threat messages for the fire.224 Requests were made by the Kangaroo Ground ICC to take control of the fire as fire was burning rapidly into the Kangaroo Ground ICC area. Mr Barca recorded in his log at approximately 4:00pm:

9.139  Mr Barca made this entry because of his frustration concerning the failure to release threat messages and because Kangaroo Ground had not been made ICC for the fire.226

9.140  Even though Kangaroo Ground was not the controlling ICC, Mr Lawrence had a conversation with Mr Armstrong, CFA Region 13 Operations Manager, at 4:00pm to discuss what firefighting resources could be allocated to the protection of SP Ausnet power transmission lines at Kinglake.227 At 4:08pm Mr Lawrence advised Mr Armstrong that Kangaroo Ground did not have sufficient resources to defend the Kinglake power assets. Mr Armstrong advised he would liaise with SP Ausnet.228

9.141  There is an incongruity in this situation. SP Ausnet, responsible for power line infrastructure in and around Kinglake, was advised of the threat and the inability of the CFA to defend that infrastructure. The township and residents of the same area received no warning information posted to the website, because of a perceived necessity to comply with the Chief Officer’s Standard Operating Procedure (January 2005).

9.142  At 5:20pm Mr Lawrence, against CFA procedure, did authorise an urgent threat message concerning the Kilmore East fire to be released from the Kangaroo Ground ICC. It featured the same communities that were the subject of the 3:02pm threat message that was never released.229 The release of this message occurred despite Kangaroo Ground not being the ICC for the fire. The reason given for the release was the continuing inability to make contact with the Kilmore ICC and a recognition that it was ‘a priority to issue those messages’.230 Mr Barca was not aware that Mr Lawrence had unilaterally issued this message.231

9.143  Evidence indicates Mr Lawrence did make contact with the Kilmore ICC during the course of the afternoon. He spoke with Mr Murphy at 3:50pm and at 4:50pm he spoke with Mr Peter Hayes, Operations Officer at the Kilmore ICC.232 This conversation with Mr Hayes occurred only 14 minutes after Ms Munns had spoken with Mr Lawrence about issuing an urgent threat message. Ms Munns had raised the need to issue an urgent threat message at the Kangaroo Ground ICC with Mr Lawrence yet again because she, ‘didn’t believe that our communities at the southern end of the fire were being warned while we knew the fire was coming into the area’.233 There is no evidence that Mr Lawrence raised the issue of the release of the warnings during his conversations with Kilmore IMT members.

9.144  In the context of this contact with senior officers of the IMT at the Kilmore ICC, it is difficult to accept that Mr Lawrence was in fact giving priority to the issuing of threat messages from the Kangaroo Ground ICC. At this stage, the Commission recognises that the evidence is incomplete. The CFA should investigate whether there are any lessons to be learned, in light of comments made about communication problems at the Kilmore ICC.

9.145  It is an unsatisfactory situation that only the Incident Controller in control of the fire authorises information releases and that a firefighting officer can be in possession of information that could save lives but not release such information because of rigid divisions of responsibility.

9.146  It is noted that the Kangaroo Ground Divisional Command issued a red flag warning for firefighting personnel without authorisation of the Kilmore ICC.234 Authorisation for release of a red flag warning by the Incident Controller is not required, because it is an urgent message aimed at ensuring that fireground personnel ‘receive timely and accurate information relevant to their safety’.235 The same approach should apply to the release of bushfire warnings to the public.

9.147  Mr Rees indicated in evidence that AIIMS as a system is ‘immature’ and he thought this may explain the rigid approach to its operation.236While this may be the case within the CFA, the Commission notes the system was adopted by them almost 20 years ago.237 Concerning the issue of the Kangaroo Ground ICC being prevented from releasing warnings, Mr Rees went on to say that there was a need for flexibility and ‘we … weren’t as flexible as what we should have been’.238 Mr Rees said you have to give people ‘the capability to break through [the system] when it is not working’.239 The Commission strongly supports this approach.

9.148  Mr Rees indicated that there was an ability to work through to the regional level when the Kangaroo Ground ICC was incapable of contacting the Kilmore ICC.240 Yet even though both Mr Lawrence and Mr Barca were in contact with their respective regional headquarters, the warnings were still not released.

9.149  On 7 February for communities in the path of the Kilmore East fire, the core responsibility of the CFA of providing accurate and timely fire information was not met. Supporting and promoting ‘safe, self-reliant and resilient communities’ able ‘to make informed decisions about their own safety’, was not achieved.241 The information for appropriate, timely warnings was available but not delivered to the community.

 

The CFA and DSE ensure that where a level 3 Incident Controller or officer of equivalent ranking is satisfied that a bushfire warning is required, then such Incident Controller is authorised to release a warning where the designated Incident Controller is temporarily unavailable

 

iECC warnings

9.150  The evidence presented to date highlights the inadequacy of the warnings provided to threatened communities in the path of the Kilmore East fire. The process of monitoring warnings was also deficient.

9.151  The evidence discloses a widespread appreciation of the need for timely and accurate community warnings in bushfire events, discussed in Chapter 4. Ensuring that this widespread appreciation is matched by practice is another matter. There is a void in the responsibility for the issuing of bushfire warnings in Victoria, with no legal obligation falling on any person to issue warnings. As indicated by Mr Rees in his evidence, no person or authority in Victoria is charged with a legal or formal procedural responsibility for issuing warnings to the community concerning the risk of bushfire.242

9.152  The Commission acknowledges this. The CFA has, in practice, provided information and warnings to communities for many years. The creation, jointly with DSE, of the Victorian Bushfire Information Line acknowledges this.

9.153  The CFA and DSE have participated with AFAC in the evolution of AIIMS over the last 20 years.243 They have seen the role and responsibilities for information and warnings gain importance and consequence within the AIIMS structure.244 The CFA and DSE have been aware that fire information is required by Incident Controllers, both to manage and protect their own firefighting resources and to warn and protect communities under threat.

9.154  The provision of advice and warnings to the community has been a basic role of the fire authorities for many years and a fundamental expectation of the community.

9.155  To put the issue beyond doubt, the Commission considers it desirable to specify in legislation, a person who must shoulder direct responsibility for ensuring appropriate warnings during bushfire incidents. The Chief Officer of the CFA already possesses statutory power and authority concerning fires and, more particularly, for the protection of life, and is the largest fire agency in relation to bushfire in Victoria.

9.156  However, as some fires are under the control of a DSE Incident Controller, without any involvement of the CFA, it is appropriate that there also be a standing delegation allocating responsibility to the DSE Chief Fire Officer for providing information and issuing warnings.

 

The State amend the Country Fire Authority Act 1958 to provide that the Chief Officer has responsibility to issue warnings and provide information to the community concerning the risk of bushfires.

 

 

The CFA effect a standing delegation of the responsibility for providing information and issuing warnings to the DSE Chief Fire Officer where a fire is directed to be under the control of a DSE Incident Controller.

 

WARNINGS — CONCLUSIONS

9.157  By 2:00pm on 7 February the fire agencies understood that the Kilmore East fire was burning out of control with high potential to endanger life and property. Observations and reports made of the fire by experienced CFA personnel amply demonstrated its severity and its great potential to cause substantial damage, although it is unclear to the Commission at this time if all of these were received at the ICCs. The subsequent threat messages failed to convey this information, failed to communicate warnings in a timely fashion and failed to identify towns and communities in the likely path of the fire.

9.158  The Commission awaits an explanation as to why the Kilmore ICC was without any ICC personnel at the outbreak of this fire. In particular, the fact that the Information Officer was located at the Seymour RECC and distracted from his duties created a void in information. As indicated in evidence by Mr Rees, such an arrangement negatively impacts on the flow of information to the community from the ICC.245 This occurred on 7 February.

9.159  Despite knowledge held by senior personnel at the iECC as to the potential danger of the Kilmore East fire, there was an absence of timely and accurate warnings and oversight of the ICC. The meeting attended by Ms Henshaw at 2:28pm with the State Coordinator of the CFA and the State Duty Officers of the CFA and DSE identified areas including Whittlesea and Kinglake as priority areas for information. The identification of these particular towns at that time reflects the high degree of concern of senior officers in both agencies that this fire, following a predictable course, would impact on communities and populated areas. That information sent by the Kilmore ICC for uploading onto the website at the iECC was not uploaded is indicative of the level of breakdown on the day.

9.160  No warning concerning the Kilmore East fire included information as to the anticipated impact of the south-westerly change on the fire. Fires in the Western Districts had already demonstrated to the iECC the well known impact of the change on a smaller scale. The wind change did create the expected ‘horror’ situation with the Kilmore East fire.246

9.161  The consideration given by Mr Rees and Mr Waller at the iECC at approximately 6:00pm to the south-westerly change’s impact on the fires was consideration after the event. The impact of the change was always an eventuality that needed to be carefully monitored and should have been taken into consideration earlier.

control of the kilmore east fire

9.162  Over the course of the afternoon of 7 February the firefront of the Kilmore East fire moved south into the area of the Kangaroo Ground ICC footprint. It was the strategic assessment of Mr Lawrence and the IMT at Kangaroo Ground, by mid afternoon, that the fire would be more efficiently managed by Kangaroo Ground.247

9.163  Mr Barca raised the issue of the most appropriate ICC to control the Kilmore East fire with Mr Barbetti, DSE Coordinator Box Hill, at around 2:50pm. Mr Barbetti indicated he would contact the iECC on this matter and also concerning the issuing of threat messages about the Kilmore East fire.248 At 3:45pm Mr Barbetti informed Mr Barca it was still a Kilmore ICC controlled fire.249

9.164  The appropriateness of the ICC continuing at Kilmore was raised a number of times over the course of the afternoon of 7 February with Mr Graham Armstrong, Operations Manager Region 13, by both Mr Barca and Mr Lawrence. On all occasions they were informed that the fire would continue to be managed by the Kilmore ICC.250

9.165  At 4:30pm Mr Stewart Kreltszheim, a career firefighter with the CFA since 1993 and Operations Manager Region 23 based in Benalla, ‘instructed’ Mr Lawrence and Mr Barca that the Kangaroo Ground ICC was to be officially set up as a Divisional Command under the control of the Kilmore ICC.251 In large fires, areas of the fire are identified as Divisions with a ‘Divisional Commander’ to assist with span of control. The Divisional Commander (in this instance Mr Lawrence) normally reports through the Operations Officer of the IMT to the Incident Controller and receives advice regarding operational objectives.252

9.166  At 5:45pm Mr Armstrong advised Mr Lawrence he would confer with the State Duty Officer, CFA, as to whether Kilmore or Kangaroo Ground should run the fire.253 At 6:32pm Mr Armstrong advised Mr Lawrence no decision had been made. In this conversation Mr Lawrence informed Mr Armstrong he was unable to contact the Kilmore ICC.254

9.167  At 10:00pm, at a command meeting at the Kangaroo Ground ICC, Mr Lawrence indicated that Mr Armstrong had stated Kangaroo Ground was to assume command of part of the fire.255 The Kilmore ICC was telephoned, but there was a new Incident Controller on duty who indicated he knew nothing of any such transfer.256

9.168  It was not until between 5:00am and 6:00am on 8 February that Kangaroo Ground was in fact given control of the fire.257

9.169  The Chief Officer’s Standard Operating Procedure 8.04 (January 2005), provides a procedure for the transfer of incident control or command.258 The Incident Controller, a more senior Brigade Officer, an Operations Manager or State Coordinator may initiate a transfer of Incident Controller. The Standard Operating Procedure provides that, where appropriate, the transfer should have the agreement of the incumbent Incident Controller.259

9.170  The Commission will not speculate as to why the transfer did not occur earlier. It acknowledges the challenges of transferring incident control in the midst of rapidly moving fire operations. The communication issues raised in evidence are summarised below.

9.171  Mr Lawrence and Mr Barca maintained there were continual difficulties in making contact with the Kilmore ICC on 7 February.260 Evidence set out earlier indicates this was the reason why urgent threat messages prepared at Kangaroo Ground were not released — they could not be authorised by the Kilmore ICC.

9.172  Mr Barca stated that after Kangaroo Ground was appointed as a Divisional Command Centre, it received no instructions. Indeed ‘after numerous attempts to contact the Kilmore ICC by telephone (the phone rang out or was not answered)’ he said that Kangaroo Ground was unable to obtain instructions.261 Mr Barca stated after the 4:30pm communication with Mr Kreltszheim, he was unable to make contact with the Kilmore ICC again until 11:45pm.262

9.173  The Kilmore ICC received an ‘unbelievable amount of phone calls … and a large amount of radio traffic as well’.263 Mr Kreltszheim described communications as being stretched on the day. However, he was not aware of any problem with the communication system or the faxing or sending of urgent threat messages.264 He said there was a link with Mr Lawrence established by a Liaison Officer at the Kilmore ICC using a mobile phone.265

9.174  The evidence of Mr Lawrence indicates he did communicate with the Kilmore ICC at 3:50pm, 4:30pm and 4:50pm.266

9.175  Ms Hunter, Kilmore ICC Information Officer, stated that she had no difficulty communicating by telephone with the Kangaroo Ground ICC although she acknowledged that there were problems with getting threat messages through.267

9.176  The Kilmore fire station is not a permanent ICC and the telecommunications infrastructure did not match that of the Kangaroo Ground ICC. An area of the multipurpose room in the Kilmore fire station was partitioned off, in preparation for use as an IMT work centre on the night of 6 February.268 However, when Ms Hunter arrived at the Kilmore ICC on the afternoon of 7 February, she was allocated a room away from where the rest of the IMT were working and eventually was forced into the reception centre of the fire station.269 There was initially no computer or printer for her to use; she used her own notebook computer.270 There was a problem with the fax machine and an urgent threat message had to be phoned through to the Seymour RECC.271

9.177  Other evidence indicates a lack of communication and understanding between firefighting personnel in the field and the ICCs at Kilmore and Kangaroo Ground:

•    Mr Williamson, the CFA Captain at Whittlesea who made important observations of the fire at around 2:00pm, commented: ‘we couldn’t talk to them [Kilmore] on the day’, the lack of communication had ‘a major impact’.272

•    Mr McGahy, Captain of the Arthurs Creek/Strathewen Brigade, had no communication with the Kilmore ICC at all on the day.273

•    Mr Hendrie, Captain of the Kinglake Brigade, had no communication with the Kilmore ICC. He believed Kangaroo Ground was ICC for the fire.274

•    Mr Cooper, Deputy Group Officer at Kangaroo Ground, was involved in operational aspects of the management of fires at St Andrews and then involved in relief activities in Kinglake. All his observations concerning the fire were related to the Kangaroo Ground Divisional Command — he thought they would be managing the fire as the ICC.275

9.178  The Report of the Inquiry into the 2002–03 Victorian Bushfires recommended ‘a single state-of-the-art all hazards State Emergency Operations Centre be established for Victoria’.276 The recommendation accepted that the implementation of the centre may need to develop in stages incorporating initially the CFA, DSE,the Metropolitan Fire and Emergency Services Board (MFB) and the State Emergency Aircraft Unit.277

9.179  A preliminary trial of one week was undertaken in February 2008 where the SECC functions of the CFA were relocated to the DSE Fire Emergency Coordination Centre at Nicholson Street, East Melbourne. This trial was apparently successful and in August 2008 a full scale trial, to run until 30 June 2009, was commenced with all the CFA State coordination functions transferring to the iECC.278

9.180  The CFA left ‘well developed SECC facilities and operational capacity at Burwood’.279 Lack of facilities at the Nicholson Street iECC meant some CFA support capacity was left behind but, in the main, Mr Rees said the operational capacity all went to Nicholson Street.280

9.181  The objective in moving to the iECC was to integrate the CFA and DSE firefighting structures. When asked what was integrated during this trial period, Mr Rees referred to the Information Desk, the Situation Unit and the Mapping Section having both CFA and DSE people working side by side.281 Mr Rees said that information collection was ‘as integrated as possible’, but noted that integration was made harder by the fact that the CFA and DSE run different systems.282 Significantly each agency took their own command and control structures to the iECC ‘what we call the command function or the command cell are separate functions of the agencies’.283

9.182  Mr Rees indicated that the duplication of command structures at the iECC did not sit well with integration. He stated that ‘we need to understand that we can make better use of the key people and avoid the current parallel we are running’.284 The CFA and DSE ran separate websites providing different fire information from different sources.285 The CFA and DSE have different mapping tools or systems. There was an attempt to share capability but ‘the mapping systems … are not the same simply because the CFA is not DSE. We are not the same’.286

9.183  Mr Rees stated that the move to the iECC worked well and was a success.287 On the other hand, the CFA’s State Duty Officer on 7 February, Mr Paterson, pointed to a significant drop in the CFA’s operational capacity. He stated:

9.184  As Mr Paterson stated, the function of the Situation Unit is ‘vitally important’ to maintaining regular and up to date information about fires.289

9.185  There were no operating procedures for the functions, role or work of the agencies at the iECC.290 A two page iECC Guideline was produced on 6 February 2009 and endorsed by officers of Victoria Police, the CFA and DSE, in consultation with the MFB and State Emergency Services.291 The guideline has little detail. It describes the role of the iECC as follows:

9.186  At the iECC there was no one person in charge. Neither the Chief Officer of the CFA nor the Chief Fire Officer of DSE filled such a position. Mr Rees stated that control of the iECC was a partnership between the CFA and DSE State Duty Officers: ‘they sit side by side and work together’.293

9.187  Importantly, there is no procedure or protocol that allocates responsibility for issuing or monitoring community warnings in the event of fire to someone in the iECC. The events and circumstances of 7 February discussed above show this is a significant omission. While the Commission recognises the attempt at integrating the ‘different systems’, at this stage the evidence supports a conclusion that the main function of the iECC was limited to ‘where the two fire agencies have come together to work together in the coordination of the fires as two agencies with like outcomes’. Mr Rees stated that the iECC is not ‘a state coordinative centre for the management of disasters’.294 Just how the CFA move to the iECC impacted on operational capacity of the CFA on 7 February is not clear on the limited evidence the Commission has received. To date, however, the iECC appears more like co-location rather than integration.

9.188  Later hearings of the Commission will examine aspects of the organisation and structure of the CFA and DSE and the use of AIIMS, along with the cultural issues that inevitably impact on such co-locations.

Preliminary observations — Key iECC roles

9.189  The CFA Chief Officer possesses authority and power that may be exercised for the purpose of ‘extinguishing or restricting the spread of the fire’ or ‘protecting life or property’.295 The Chief Officer may delegate, by written instrument, powers and authorities conferred upon him under the Country Fire Authority Act 1958.296 The statutory role of Chief Officer is an operational role. Mr Rees described himself as the senior operations commander of the CFA.297 Mr Rees described his overall responsibilities as follows:

9.190  It is an onerous role, as shown on 7 February. To fulfil this role, particularly as it concerns the ‘communication of the current fire situation’, the Chief Officer would need to be kept informed by the most up to date fire intelligence and recognise the potential of major fires.

9.191  At the iECC Mr Rees did not appear to become actively involved in operational issues, even when the disastrous consequences of the fires began to emerge.299 His responsibilities on 7 February included ensuring an IMT was in place for major fires and that he was kept informed of the fire situation so he could inform those above him of the fires in a strategic sense.300

9.192  According to Mr Rees, his responsibilities also included coordination at a ‘State strategic level’.301 Mr Rees described this role as requiring strategic decisions as to the priority of resources on a statewide basis.302

9.193  By 3:30pm Mr Rees was aware the fire was in the Mount Disappointment area, that it was spotting significantly, and that there was fire spotting in the Strathewen area a long way ahead of itself.303 Mr Rees recognised the potential with this type of spotting that a range of communities could be the subject of such fire activity but he could not say if he turned his mind specifically to that.304

9.194  Mr Rees did not look specifically at warnings concerning the Kilmore East fire nor did he, given his knowledge of the spotting potential of that fire, ask anybody to check whether the Kilmore ICC was producing timely warnings.305 He did not do this because he said his ‘approach was state-wide. It was a strategic approach. It was not specifically related to one fire’.306 On 7 February, Mr Rees did not have any personal contact with either the Kilmore or the Kangaroo Ground ICC.307

9.195  Mr Rees was not aware specifically of the presence of Dr Tolhurst in the iECC on 7 February, although he knew fire behaviouralists were there, and had met with fire behaviouralists to be briefed as to the potential impact of the Bunyip fire and the damage it might cause to surrounding areas on 6 February.308

9.196  Mr Rees did not see any prediction maps concerning the Kilmore East fire on 7 February.309 Again, the reason given why he did not inspect prediction maps was the need for a state overview.310

9.197  Mr Waller stated in evidence that in prioritising fires of state significance the potential or prediction for those fires was very important.311 He said that senior management at the iECC, including himself and Mr Rees, were discussing the fires over the course of the day. He agreed that it was not possible to coordinate resources without having some understanding of the potential of the fires.312 The methodology of working out fires, Mr Waller said, involved:

9.198  According to Mr Waller, he and Mr Rees discussed both CFA and DSE fires equally.314

9.199  In relation to the Kilmore East fire, Mr Waller knew there was a problem in the containment of the fire very soon after ignition.315 Once the fire had crossed the Hume Highway, Mr Waller had the opinion on the day it would not be able to be pulled up; it would be uncontrollable and factors including the impact of the south-westerly change and its impact on the fires had to be taken into account.316

9.200  Mr Waller also agreed that the evidence before the Commission on the warnings issued on the day for the Kilmore East fire demonstrated that the warnings did not properly address the potential for the fire or the impact of the south-westerly change.317 Mr Waller stated he would have expected (for a DSE fire) that the DSE State Duty Officer would monitor the performance of the ICC in issuing warnings and inform him if he thought things were going wrong.318

9.201  Mr Paterson was the CFA State Duty Officer at the iECC on 7 February. The State Duty Officer is the next most senior CFA Officer to the State Coordinator, who is responsible to the Chief Officer. Mr Conway was the State Coordinator. The Commission has not yet heard evidence from Mr Conway and will examine the role of State Coordinator further in future hearings.

9.202  The functions of the CFA State Duty Officer, effectively transferred to the iECC on 7 February, are set out in Standard Operating Procedures concerning the State Emergency Coordination Centre (November 2007).319 The CFA State Duty Officer ‘will be the first point of contact for Regional Duty Officers for all operational matters requiring State notification or action in relation to incidents at which CFA personnel are engaged, or where state coordination of resources may be required’.320

9.203  The CFA Standard Operating Procedures concerning the SECC (iECC on 7 February) described without prioritisation the various roles of the SECC, including:

     …

^•             provide support to Incident Management Teams in regions

     …

9.204  However, Mr Paterson stated to the Commission that:

•    he did not see it as one of his tasks in coordinating resources to make an assessment of a fire’s capacity to cause substantial damage or loss of life322

•    fire spread prediction was not important to him at a state level in terms of ‘resources strategy’323

•    he did not see any fire prediction maps in relation to the spread of the Kilmore East fire and he did not discuss fire prediction at all with the State Coordinator or the Chief Officer. He saw no information on the day as to the likely area in which the Kilmore East fire would burn324

•    he did not form a belief as to whether the Kilmore East fire was capable of suppression, nor did he discuss that issue with the State Coordinator or Chief Officer325

•    he did not prioritise the major fires on the day in terms of coordination326

•    he was not aware on 7 February there was any difficulty communicating with the Kilmore ICC.327

9.205  The evidence discloses that the most senior and third most senior CFA officers on 7 February made no reference to prediction maps and did not use the services of fire behaviour analysts located at the iECC.328 How the CFA’s responsibility in relation to ‘ensuring that suitable information is received by local communities to enable them to take appropriate actions to increase their safety’ was achieved is difficult to understand.329

9.206  On the basis of the evidence set out above, it is also difficult to understand how Mr Rees could properly carry out a strategic statewide coordination responsibility or how Mr Paterson could carry out the responsibilities of State Duty Officer and the coordination tasks he described.

9.207  The Commission made comment earlier in this chapter on the responsibilities and expectations for the provision of warnings and information. These are preliminary observations because the evidence is not complete and the Commission has not heard from the CFA State Coordinator or the DSE State Duty Officer.

FIRE PREDICTION AND ANALYSIS

9.208  DSE, with the support of various fire agencies Australia-wide, has in recent years conducted a course to train fire behaviour analysts.330 The placement of trained fire behaviour analysts at a state level and in ICCs would enhance timely and accurate warnings to the community.331

9.209  Fire behaviour analysts were located at the iECC during the 2008–09 bushfire season. They were involved in morning briefings at the iECC and prepared prediction maps as tasked.332 On 7 February they were not well positioned within the iECC.333 The flow of information concerning fires was slow and in some cases nonexistent.334 The analyst who was requested to undertake fire prediction for the Kilmore East fire was not provided with the line scans of 12:45pm until sometime after 2:00pm.335 Mr Williamson’s observations about the extreme fire scenario he observed north of Wandong at 2:00pm were not conveyed to the fire behaviour analyst at all.336

9.210  At the iECC on 7 February both the CFA and DSE were undertaking fire prediction and analysis. The communication between the two organisations at this level was not good.337

9.211  Overall the evidence points to fire behaviour analysis and fire prediction at the iECC on 7 February being a secondary consideration not referred to by Mr Rees or Mr Paterson. The flow of information to fire behaviour analysts at the iECC needs to be improved. It could be greatly assisted by locating fire behaviour analysts in a better position at the iECC, where they can readily access fire information as it is received at the iECC.

9.212  At the ICC level, fire prediction in a Situation Unit should be a priority for the Situation Officer. Threat messages need to be based on fire prediction and the Information Officer needs to be aware of fire prediction in the ICC as soon as it is available.

9.213  The Commission acknowledges the desirability of locating trained fire behaviour analysts in Situation Units of ICCs across the State. However, as the evidence of Mr Barca at Kangaroo Ground indicates, incident prediction in the early stages of a bushfire does not require enormous sophistication. The Commission accepts the submission of the Volunteer Fire Brigades of Victoria that it is a relatively straightforward undertaking in the preliminary stages of a bushfire to calculate speed, flame height, spotting distances and present the Incident Controller with ‘likely threats downwind’.338

 

9.214  As the evidence in this chapter reveals, the fire agencies were in possession of information early in the afternoon of 7 February that demonstrated the extreme nature of the Kilmore East fire and its potential. Despite this knowledge, warnings were not released in a timely manner.

9.215  There are a number of factors to explain this failure, some of which have been addressed. The release of information and warnings to the community needs to be made a priority in the ICC and effectively monitored at the iECC. The evidence before the Commission indicates insufficient priority was given to this.

9.216  The evidence the Commission has received to date does not enable it to make a definitive recommendation as to whether the Information Unit should have a separate and more significant identity within the AIIMS structure. The evidence concerning the Kilmore East fire demonstrates that warnings to the community need to be given a higher priority and this necessarily means that, for the 2009–10 bushfire season, the role and status of the Information Unit needs to be elevated.

9.217  Increasing this priority requires scrutiny of the function and the role of the Information Officer. In his evidence, Mr Rees raised the potential of expanding the Information Unit within the IMT by making it a separate function and therefore providing more direct access to the Incident Controller. This change in structure may highlight the function and prioritisation of information to the community.339

9.218  The Deputy Incident Controller is an optional appointment to a level 3 IMT, but in Victoria Deputy Incident Controllers are appointed where DSE and the CFA share responsibility for fire management (such as Kangaroo Ground IMT). A possibility identified by the Commission is to give the Deputy Incident Controller the responsibility in the IMT of authorising and releasing warnings to the community.

9.219  A further option is to make the Deputy Incident Controller responsible for all planning functions within the existing AIIMS structure, including information. Such an adjusted structure would better emphasise the increased priority given to information.

9.220  Alternatively, the information function could be established as a separate and equal function to operations. The Deputy Incident Controller could be delegated responsibility for ‘information’, ensuring information is collected and analysed, predictions are made, and warning advice is disseminated in a timely fashion.

9.221  These options are raised now, in this interim report, in an effort to promote the provision of timely and accurate information to the community. The CFA and DSE may choose to explore and trial such options over the 2009–10 bushfire season.

9.222  The Commission intends to examine this and other matters when it considers organisational aspects of the CFA and DSE in later hearings.

 

CLICK FOR IMAGE

 

[1]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [65]

[2]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [65]

[3]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [71]

[4]     Pearce T1401:3–T1403:9; Walshe T704:3–T704:25

[5]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [67]

[6]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [69]

[7]     Individual CFA brigades led by Captains are grouped for administrative purposes into CFA ‘groups’, usually centred on a local area and led by a senior volunteer Group Officer. Captains and Group Officers are elected to their positions by other volunteers. A number of CFA Groups are managed by a CFA Region.

[8]     Exhibit 3 – Statement of Rees (WIT.004.001.0001) [72]

[9]     ICS refers to Incident Control System. It is an additional reference to AIIMS that is not used by the Commission and is not used in the AFAC reference text — AFAC, The Australasian Inter-service Incident Management System, Third Edition, East Melbourne, 2005.

[10]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [73]

[11]   Adapted from Exhibit 131 – Mapping Information Flow During Critical Incidents (TEN.033.001.0001) at 0024

[12]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [183]; Rees T2427:28–T2427:29

[13]   Rees T25:13–T25:16

[14]   Statement of Rees (WIT.004.001.0001) at [127]–[129]; Rees T25:23–T26:17

[15]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0082

[16]   Rees T2415:1–T2415:13

[17]   Exhibit 81 (TEN.028.001.0001) at 0029

[18]   Exhibit 141 (TEN.038.001.0001) [141], [154]

[19]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [167]

[20]   Exhibit 9 (TEN.001.001.0183) at 0194

[21]   Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1270

[22]   Exhibit 76 – Rees Tender (SUMM.036.002.0257) at 0257

[23]   Exhibit 85 – Statement of Gledhill, Attachment 1 – (WIT.025.002.0027) at 0035

[24]   Exhibit 137 (SUMM.022.002.0297) at 0298

[25]   Exhibit 137 (SUMM.022.002.0297) at 0303

[26]   Exhibit 74 (SUMM.022.069.0086)

[27]   Exhibit 74 (SUMM.022.069.0086) at 0089

[28]   Exhibit (SUMM.022.069.0086) at 0115

[29]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [167]; Rees T31:23–T32:14

[30]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [166]

[31]   Statement of Rees (WIT.004.001.0001) [183]

[32]   Exhibit 131 — Mapping Information Flow During Critical Incidents (TEN.033.001.0001) at 0024

[33]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0263

[34]   Exhibit 3 – Statement of Rees (WIT.004.001.0246) at 0263

[35]   Caughey T1687:5–T1687:25

[36]   Rees T2420:18–T2420:21

[37]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0263

[38]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0270

[39]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0255

[40]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0272–0273

[41]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281

[42]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281

[43]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0272–0273

[44]   Exhibit 38 – Tolhurst article (SUMM.035.002.0006) at 0007

[45]   Exhibit 38 – Tolhurst article (SUMM.035.002.0006) at 0008–0009

[46]   Exhibit 107 – Statement of Barca (WIT.3026.001.0001)

[47]   Barca T3469:11–T3469:21

[48]   Exhibit 115 – Statement of Cowan (WIT.3004.009.0001) [2], [4]; Cowan T3726:25–T3726:31

[49]   Cowan T3727:31–T3728:9

[50]   Exhibit 4 – Supplementary statement of Rees (WIT.004.002.0001) [14]; Exhibit 2, Rees Tender (WIT.004.002.1459) at 1466

[51]   Murphy T1262:24; Murphy T1262:20–T1262:23

[52]   Murphy T1262:26

[53]   Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [5]

[54]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) at 0082

[55]   Exhibit 3 – Statement of Rees (WIT.004.001.0001) [112]; Rees T2415:5–T2415:27

[56]   Rees T2415:18–T2415:27

[57]   Paterson T4261:10–T4261:27

[58]   Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [28]–[29]

[59]   Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [23], [25]; Murphy T1263:1–T1263:19

[60]   Murphy T1264:3–T1264:6

[61]   Murphy T1264:8–T1264:25

[62]   Murphy T1265:4–T1266:10

[63]   Murphy T1266:12–T1266:29

[64]   Murphy T1267:1–T1267:15

[65]   Rees T2416:15–T2416:31

[66]   Paterson T4262:4–T4262:8

[67]   Rees T2416:22–T2417:3

[68]   Murphy T1268:8–T1268:16

[69]   During a discussion with Commissioner McLeod, Mr Rees agreed that these were inadequacies that contributed to the difficulties on the day. See T2430–T2432:9

[70]   Barca T3466:17–T3467:4

[71]   Barca T3465:29–T3466:16

[72]   Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [3]–[4]; Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [14]

[73]   Lawrence T1571:1–T1571:8

[74]   Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [26], [36]

[75]   Barca T3478:28–T3479:2

[76]   Exhibit 3 – Statement of Rees, Attachment 7 (WIT.004.001.0246) at 0281; see also Exhibit 127 – Statement of Paterson, Attachment 3 (WIT.3004.010.0281) at 0445

[77]   Lawrence T1570:30–T1571:17

[78]   Lawrence T1571:13–T1571:15

[79]   Barca T3463:7–T3463:11; T3464:6–T3464:25

[80]   Barca T3463:20–T3464:5

[81]   Barca T3465:4–T3465:25

[82]   Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1466

[83]   Paterson T4267:27–T4267:28

[84]   Paterson T4268:24–T4268:31

[85]   Paterson T4268:31–T4269:2

[86]   Keating T3224:3–T3224:15

[87]   Exhibit 21 (TEN.003.001.0001) at entries 20–21

[88]   T1280:11–T1280:15

[89]   Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [157]; Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [30]

[90]   Exhibit 132 – Statement of Williamson (WIT.3004.009.0029)

[91]   Williamson T4435:30–T4437:1

[92]   McGahy T2247:26–T2248:4

[93]   Murphy T1269:23–T1269:31

[94]   Exhibit 41 – Statement of Murphy (WIT.3004.001.0001) [22]; Murphy T1261:10–T1261:17

[95]   Exhibit 2 – Statement of Rees, Attachment (WIT.004.002.1459) at 1466

[96]   Exhibit 21 – Walshe Tender (TEN.003.001.0001) at 0002

[97]   Williamson T4438:10–T4438:16; T4440:1–T4440:6

[98]   Williamson T4440:7–T4440:31

[99]   Williamson T4441:9–T4441:13

[100]  Williamson T4441:4–T4441:19

[101]  Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [40]

[102]  Keating T3226:30–T3227:1

[103]  Exhibit 98 – Statement of Keating, Attachment (VPO.001.002.0237_002_R) at 0003_R

[104]  Sholl T4347:14–T4348:24

[105]  Exhibit 98 – Statement of Keating, Attachment (VPO.001.002.0237_002_R) at 0003_R

[106]  Exhibit 7 – ABC Radio transcript (SUMM.001.002.0001) at 0245; Keating T3230:14–T3240:19; Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [53]

[107]  Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [44]–[48]

[108]  Exhibit 30 – Google Star Tool as at 13 May 2009 (WIT.010.002.0001)

[109]  Exhibit 122 – Statement of Sutton (WIT.3024.001.0008) [66]

[110]  McGahy T2248:27–T2249:5

[111]  McGahy T2249:10–T2249:27

[112]  Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [56]

[113]  Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [58]–[59]

[114]  Exhibit 132 – Statement of Williamson (WIT.3004.009.0029) [59]; Williamson T4450:6–T4450:19

[115]  Exhibit 98 – Statement of Keating (VPO.001.002.0237_R) at 0243

[116]  Cooper T3255:17–T3255:29

[117]  Cooper T3257:7–T3257:10

[118]  Cowan T373:1–T3731:2

[119]  Exhibit 115 – Statement of Cowan (WIT.3004.009.0001) [1], [4]

[120]  Cowan T3730:18–T3731:18

[121]  Cowan T3731:22–T3731:28

[122]  Cowan T3736:19–T3736:28

[123]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [33]

[124]  Barca T3470:18–T3470:25

[125]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [35]

[126]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [37]

[127]  Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1466

[128]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) at 0212; Lawrence T1588:9–T1588:12

[129]  Lawrence T1588:18–T1588:19

[130]  Exhibit 7 – Statement of Barca (WIT.3026.001.0001) [50]

[131]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [25]

[132]  Exhibit 2 – Rees Tender (WIT.004.002.1459) at 1467

[133]  Exhibit 4 – Statement of Rees, Attachment (WIT.004.002.0343) at 0390. Map was produced using the Emergency Information Management System

[134]  Rees T2673:6–T2673:8

[135]  Rees T70:14–T70:28

[136]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [342]; Tolhurst T1144:1–T1144:16

[137]  Exhibit 157 – (EXP.003.006.0002)

[138]  Exhibit 157 – (EXP.003.006.0003)

[139]  Tolhurst T1736:24–T1737:23

[140]  Tolhurst T1738:6–T1738:16

[141]  Tolhurst T1739:7–T1739:11

[142]  Tolhurst T1058:16–T1058:18

[143]  Exhibit 38 – Statement of Tolhurst, Attachment (SUMM.035.002.0131); Tolhurst T1121:12–T1121:18

[144]  Exhibit 72 (WIT.004.003.0001) at 0002–0003

[145]  Rees T2400:9–T2401:2

[146]  Waller T4358:12–T4358:16

[147]  Waller T4359:7–T4359:19

[148]  Henshaw T4778:26–T4779:13

[149]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [57]

[150]  Henshaw T4803:7–T4803:9

[151]  Henshaw T4803:12–T4803:25

[152]  Henshaw T4803:31–T4804:26

[153]  Exhibit 3 – Statement of Rees, Attachment 31 (WIT.004.001.0509) at 0577

[154]  Exhibit 122 – Statement of Sutton, Attachment 9 (DSE.CD03.0001.0035); Sutton T4068:26–T4069:28

[155]  Sutton T4065:6–T4066:19

[156]  Exhibit 122 – Statement of Sutton, Attachment 9 (DSE.CD03.0001.0035)

[157]  Exhibit 122 – Statement of Sutton (WIT.3024.001.0008) [68]

[158]  Exhibit 4 – Statement of Rees, Attachment (WIT.004.002.0343) at 0399

[159]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [65]

[160]  Henshaw T4784:31–T4785:4

[161]  Henshaw T4785:5–T4785:17

[162]  Exhibit 149 (EXH.149.0001); Henshaw T4799:24–T4800:16

[163]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [17]; Caughey T1689:6–T1689:9

[164]  Caughey T1687:5–T1687:17

[165]  Caughey T1689:26–T1690:11

[166]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [33]; Caughey T1687:18–T1687:25

[167]  Caughey T1688:12–T1688:22

[168]  Caughey T1688:30–T1689:3

[169]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [69]; Annexure 9 (WIT.3004.009.0193)

[170]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [19]; Annexure 5 (WIT.3004.001.0154) at 0179

[171]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [20], [22]; Annexure 6 (DSE.HDD.0017.0470); Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509); Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [72]

[172]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [23]; Annexure 7 (WIT.3004.001.0154) at 0183

[173]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [23]; Exhibit 3 – Statement of Rees, Attachment 3 (WIT.004.001.0509) at 0533

[174]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [25]; Annexure 8 (WIT.3004.001.0154) at 0185

[175]  Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509)

[176]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [71]; Annexure 10 (WIT.3004.009.0195); Henshaw T4805:28–T4806:4

[177]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [72]; Annexure 11 (WIT.3004.009.0199)

[178]  Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0530

[179]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [73]

[180]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [27]; Attachment 9 (WIT.3004.001.0154) at 0188

[181]  Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509) at 0537

[182]  Exhibit 3 – Statement of Rees, Annexure 31 (WIT.004.001.0509)

[183]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [31]; Annexure 10 (WIT.3004.001.0154) at 0190

[184]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [78]

[185]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [80]; Annexure 17 (WIT.3004.009.0218)

[186]  Henshaw T4807:18–T4807:29

[187]  The benefits of this type of co-location are promoted in the AIIMS Information Unit Guidelines. See Exhibit 3 – Statement of Rees, Annexure 7 (WIT.004.001.0246) at 0272

[188]  Caughey T1688:5–T1688:7

[189]  Caughey T1687:22–T1687:30

[190]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [33]

[191]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [35]

[192]  Exhibit 52 – Statement of Caughey, Annexure 6 (WIT.3004.001.0154) at 0192

[193]  Hunter T1720:16–T1720:27

[194]  Hunter T1721:8–T1721:22

[195]  Exhibit 52 – Statement of Caughey (WIT.3004.001.0154) [22], [36]; Caughey T1694:10–T1694:11; T1698:17–T1698:20; T1701:13–T1702:3

[196]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [81]

[197]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [81]; Henshaw T4808:7–T4808:9

[198]  Exhibit 7 – ABC transcript (SUMM.001.002.0001) at 0319

[199]  Exhibit 7 – ABC transcript (SUMM.001.002.0001); Henshaw T4808:27–T4809:11

[200]  Exhibit 7 – ABC transcript (SUMM.001.002.0001) at 0337

[201]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [82]; Annexure 19 (WIT.3004.009.0224)

[202]  Exhibit 149 – Statement of Henshaw (WIT.3004.009.0096) [83]; Annexure 20 (WIT.3004.009.0227)

[203]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [2], [18]

[204]  Munns T1354:28–T1355:10

[205]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [22]

[206]  Exhibit 44 – Statement of Munns, Annexure 1 (WIT.3004.001.0065) at 0081–0100; Munns T1355:7–T1355:28

[207]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [26]; Annexure 1.4 (WIT.3004.001.0065) at 0099

[208]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [26]; Munns T1357:14–T1357:26

[209]  Lawrence T1624:17–T1624:31

[210]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [27]

[211]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [36]–[37]; Barca T3467:28–T3468:25

[212]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [33]–[35]; Barca T3468:26–T3471:16

[213]  Barca T3473:29–T3473:6

[214]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [39]

[215]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [32]; Munns T1361:8–T1361:27

[216]  Exhibit 44 – Statement of Munns, Annexure 4.4 (WIT.3004.001.0065) at 0112

[217]  Munns T1361:28–T1362:6

[218]  Lawrence T1588:27–T1589:26

[219]  Lawrence T1589:21–T1589:26

[220]  Lawrence T1589:12–T1590:10

[221]  Lawrence T1589:31–T1590:10

[222]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [41]–[42]

[223]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [38]; Barca T3473:6–T3473:21

[224]  Barca T3477:26–T3478:3

[225]  Exhibit 107 – Statement of Barca, Annexure 1 (DSE.0088.0879.0041) at 0046; Barca T3477:21–T3477:23

[226]  Barca T3477:24–T3477:31

[227]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [24]; Annexure 1.1 (WIT.3004.001.0197) at 0212; Lawrence T1590:11–T1590:22

[228]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [25]; Annexure 1.1 (WIT.3004.001.0197) at 0213

[229]  Exhibit 44 – Statement of Munns (WIT.3004.001.0065) [40]; Annexure 4.6 (WIT.3004.001.0065) at 0116; Lawrence T1577:29–T1577:30

[230]  Lawrence T1577:29–T1578:11

[231]  Barca T3482:10–T3482:13

[232]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [23], [27]

[233]  Munns T1366:13–T1366:24

[234]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [56]

[235]  Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0771–0776; Lawrence T1616:9–T1616:13

[236]  Rees T1845:3–T1845:11

[237]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [67]

[238]  Rees T1924:24–T1924:30

[239]  Rees T1926:1–T1926:4

[240]  Rees T2500:24–T2501:26

[241]  Quoted remarks are to be found in Exhibit 3 – Statement of Rees (WIT.004.001.0001) [166] –[167]

[242]  Rees T41:21–T41:24

[243]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [80]–[82]

[244]  Rees T1924:18–T1924:22; T2420:8–T2420:28

[245]  Rees T2420:18–T2460:21

[246]  Tolhurst T1004:13–T1004:25

[247]  Lawrence T1597:24–T1597:28; T1613:17–T1613:24

[248]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [38]

[249]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [47]

[250]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [48]

[251]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [51]

[252]  Barca T3478:28–T3479:2

[253]  Lawrence T1625:8–T1625:11

[254]  Lawrence T1613:26–T1613:31

[255]  Barca T3480:27–T3480:31

[256]  Barca T3481:1–T3481:6

[257]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [36]

[258]  Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0437–0440

[259]  Exhibit 127 – Statement of Paterson, Annexure 3 (WIT.3004.010.0281) at 0438

[260]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [20]; Barca T3477:26–T3477:28

[261]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [22]

[262]  Exhibit 107 – Statement of Barca (WIT.3026.001.0001) [52]

[263]  Kreltszheim T1288:23-T1289:3

[264]  Kreltszheim T1289:1–T1289:30

[265]  Kreltszheim T1289:23–T1289:26

[266]  Exhibit 50 – Statement of Lawrence (WIT.3004.001.0197) [23], [26]–[28]

[267]  Hunter T1728:3–T1729:7

[268]  Murphy T1257:5–T1257:20

[269]  Hunter T1719:16

[270]  Hunter T1718:1–T1718:16

[271]  Hunter T1721:6–T1721:18

[272]  Williamson T4474:24–T4475:7

[273]  McGahy T2246:14–T2246:24

[274]  Hendrie T863:16–T863:19

[275]  Cooper T3270:1–T3270:8

[276]  Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1240

[277]  Exhibit 11 – Statement of Esplin, Attachment 11 (WIT.005.001.0951) at 1240

[278]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [96]

[279]  Statement of Rees (WIT.004.001.0001) [98]

[280]  Rees T2369:31–T370:14

[281]  Rees T2370:21–T2370:30

[282]  Rees T2370:30–T2371:2

[283]  Rees T2371:5–T2371:7

[284]  Rees T2386:26–T2387:6

[285]  Rees T2372:17–T2372:24

[286]  Rees T2373:29–T2374:10

[287]  Rees T1848:10–T1848:14, T2388:9–T2388:17

[288]  Exhibit 127 – Statement of Paterson (WIT.3004.010.0001) [48]; Paterson T4241:6–T4241:25

[289]  Paterson T4246:28–T4247:13

[290]  Rees T2369:11–T2369:31

[291]  Exhibit 19 – Statement of Walshe (WIT.003.002.0001) [65]; Annexure 7 (WIT.003.002.0061)

[292]  Exhibit 19 – Statement of Walshe, Annexure 7 (WIT.003.002.0061)

[293]  Rees T2555:2–T2555:15

[294]  Rees T2555:25–T2555:31

[295]  Country Fire Authority Act 1958 s30(1)

[296]  Country Fire Authority Act 1958 s28(1)

[297]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [33]

[298]  Exhibit 3 – Statement of Rees (WIT.004.001.0001) [105]

[299]  Rees T21:22–T22:18; T2382:20–T2383:12

[300]  Rees T21:4–T22:19

[301]  Rees T2514:18

[302]  Rees T21:24–T22:8

[303]  Rees T2533:4–T2535:8

[304]  Rees T2535:25–T2535:30

[305]  Rees T2536:20–T2537:5

[306]  Rees T2537:13–T2537:21

[307]  Rees T2538:9–T2538:11

[308]  Rees T2403:23–T2403:27; Sutton T4056:30–T4057:6

[309]  Rees T2405:30–T2405:31

[310]  Rees T2406:4–T2406:10

[311]  Waller T4354:4–T4354:26

[312]  Waller T4354:10–T4355:8

[313]  Waller T4355:9–T4355:15

[314]  Waller T4355:26–T4356:2

[315]  Waller T4358:22–T4358:30

[316]  Waller T4359:7–T4360:31

[317]  Waller T4360:31–T4361:9

[318]  Waller T4361:20–T4361:28

[319]  Exhibit 71 – Rees Tender (CFA.001.001.0001)

[320]  Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0001

[321]  Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0002–0003

[322]  Paterson T4247:23–T4247:29

[323]  Paterson T4248:6–T4248:7

[324]  Paterson T4268:6–T4268:23

[325]  Paterson T4282:8–T4282:27

[326]  Paterson T4267:26–T4267:31

[327]  Paterson T4275:11–T4275:16

[328]  Rees T2405:30; Paterson T4268:6–T4268:23

[329]  For further information about where this responsibility derives from, see Exhibit 71 – Rees Tender (CFA.001.001.0001) at 0003

[330]  Tolhurst T1077:29–T1078:8

[331]  Tolhurst T1078:9–T1078:25; Waller T123:16–T123:20

[332]  Tolhurst T1084:15–T1085:1

[333]  Waller T123:24–T123:27

[334]  Tolhurst T1085:26–T1086:4

[335]  Tolhurst T1111:31–T1112:5

[336]  Sutton T4072:12–T4073:19

[337]  Sutton T4062:31–T4063:6

[338]  Volunteer Fire Brigades Victoria Inc (SUBM.100.004.0001) at [129], [137]

[339]  Rees T2564:7–T2564:15