The system that failed its bravest

BLACK SATURDAY BLUNDERS
SO MUCH had already gone wrong. They didn’t know the Kilmore fire was in Kinglake. They didn’t know where their second CFA tanker was because the area had so many radio black spots they couldn’t raise it. They had already fled flames that were three times as tall as the trees.
And Karen Barrow’s Black Saturday had only just begun.
In a personal submission to the Bushfires Royal Commission, Miss Barrow, a CFA volunteer and second lieutenant with the Kinglake West brigade, has told the story of one woman’s fire and the bureaucratic bungles that bedevilled it.
Miss Barrow was a driver on a tanker that responded to emergency calls. By 5pm, she and the crew were back at Kinglake West CFA station, readying hoses to protect more than 200 people sheltering there. Meanwhile, CFA pagers began beeping with emergency calls. “One message stated something like ’40-50 people trapped’. I did not look at my pager again after this – the guilt at not being able to assist was too much.”
Later, as they went to answer a call, a woman waved them down and said a man in her backyard had burns to 70 per cent of his body. The woman had called several times for an ambulance but none had arrived. “I asked the crew to stay with the truck while I checked out the patient. I did not want the crew to see a burns patient if they did not need to.”
Miss Barrow assessed his burns as third degree, but the crew was trying to answer a call from people trapped by fire. She radioed through to VicFire, the CFA’s dispatchers, who told her an ambulance was on its way.
After visits to two other properties, Miss Barrow returned to the burnt man. VicFire told her the ambulance service had spoken to the patient, but those caring for him said there had been no contact. She radioed VicFire again and was told she would have to take the man 20 kilometres to Whittlesea.
“We used the ladder as a stretcher and folded up the blankets to use as some kind of mattress,” she wrote. “We lifted him on to the rear deck of Kinglake West Tanker 1 . . . Each end of the ladder was protruding from either side of the truck.
“Progress was painfully slow as we still had to navigate around trees across the road and at times had to drive on the shoulder of the road.”
At last she was able to tell him: “We are almost there. Only a few hundred metres to go.” Then she grinned and said: “And this time I actually do mean it.” He managed a chuckle.
Miss Barrow stayed with him until an ambulance arrived around 2am. The man died about 12 days later.
Miss Barrow continued working until 5 o’clock Monday morning, a 45-hour stint. Kinglake West brigade remained operational round-the-clock for the next six weeks, putting out spot fires, clearing roads and organising deliveries of fuel, water and food.
“During this recovery phase, we received no assistance from the Shire of Murrindindi or the army,” she wrote.
The brigade’s fatigue was intense: “If it were not for brigades such as Panton Hill, Research and Kangaroo Ground, we simply would not have coped. These brigades unreservedly sent people and tankers to assist. In doing so, they shunned protocol, as protocol simply was not working.”
She said strike teams sent to help were insufficient and poorly managed, and that officials kept telling the brigade no further people or tankers were available.
First published in The Age.

Lessons still to learn

The Bushfires Royal Commission has exposed tragic policy failures but has not yet confronted many of the hardest questions.
PAUL Delianis vividly remembers the Black Friday fires of 1939. He was 10 years old. He stood with his dad, a Gippsland dairy farmer, and held his ground as a wall of flame roared towards them. “It was just my father and I, and we both had a potato sack each,” he recalls.
They had managed to struggle through the Great Depression by living frugally. They had no electricity and the only water came from a well. “What’s a hose?” he says drily. “There was no tap – no pressure taps.”
They had wet their hessian sacks but the heat dried them in minutes. “I can remember the wind was very strong. It was driving the fire towards us at an enormous pace. There was no CFA and there was no fire brigade. Have you ever heard the expression, ‘You’re on your own?”‘
They were saved by the weather. Just as the fires reached their boundary fence, the wind turned and pushed the flames away from them. The sacks got a pounding putting out small spot fires but the Delianis home, family and cows were safe.
Paul Delianis grew up to head Melbourne’s homicide squad. Now retired, he still remembers reading in 1939 that the fires burned 2 million hectares of land, destroyed 1000 houses and killed 77 people in Victoria and NSW. It seems to him it was worse than the fires in February this year, in which 173 lives and 2000 houses were lost. “The state was less populous then,” is the way he looks at it.
There is another way to look at it. In 1939, it was man and his hessian sack against the elements. Today, Victoria’s Country Fire Authority has 30,000 volunteer firefighters, 400 career firefighters and 1200 fire trucks. The Department of Sustainability and Environment, which looks after fires on public land, has its own fleet of tankers. Planes and helicopters chart the spread of fires from the sky, and satellites film them from space. Meteorologists warn days in advance that catastrophe might be looming and, with television, radio, mobile phones and the internet, it has never been easier to warn large numbers of people that catastrophe is actually upon them. Millions of dollars have been spent educating the community about bushfires, and vast bureaucracies have been set up to manage them.
So what went so horribly wrong on Saturday, February 7 – Black Saturday?
The royal commission into the fires set up by a stunned State Government finishes its first eight weeks of hearings on Monday. Over 34 days, with the evidence of more than 80 witnesses, it has unearthed many problems that contributed to the disaster. These included: the speed and ferocity of the two main fires that day; multiple bureaucratic bungles over warnings, communications and lines of command; and the failure of the state’s bushfire policy, “stay or go”, in the face of a fatal confluence of factors including urban sprawl, climate change and lack of public awareness.
Comments by the three commissioners during the hearings (chaired by former Supreme Court judge Bernard Teague) and submissions by lawyers assisting the inquiry suggest that sweeping changes will be recommended in the interim report due on August 17. But exposing problems is easier than fixing them. Some recommendations of previous bushfire inquiries are still dangling in limbo because of a defensive, slow-moving, Yes Minister mindset in parts of the public service that has been exposed at the inquiry – the kind of mindset that led to some of the deadly outcomes on Black Saturday.
Commissioner Susan Pascoe told one witness that when the commissioners had spoken at community consultations to people struck by the fires, they found “there was a perception . . . that there was no one in control on the day”.
In fact, it turns out that no official or agency is responsible for warning communities of approaching bushfires. In that sense, no one was in control on the day.
Fire behaviour expert Dr Kevin Tolhurst told the inquiry the blazes were so fierce they produced the energy equivalent of 1500 of the atomic bombs used on Hiroshima, enough to power Victoria for a year. The winds they created snapped tree trunks and some fires created their own weather, with clouds and lightning.
In the face of this, the system of predictions and warnings about where the fires would spread was often chaotic. Grieving relatives, some who lost whole families, have wept quietly in the hearing room as they listened to tales of one mishap after another. CFA officials have told the inquiry of warnings typed up but never released, of predictions made but never acted upon, and of a tussle for control between two centres over the Kilmore East fire that killed 121 people.
CFA fire brigade captains in Arthurs Creek and Kinglake said they received no alerts that their towns were about to be attacked. Important information was lost inside the CFA, between the CFA and the DSE, and between the emergency agencies and the public.
Piecing together the causes has been difficult. Lawyers assisting the commission who have tried to press public servants on how an emergency process is supposed to work have often found themselves wading through treacle in search of a direct answer.
Observed Commissioner Pascoe: “One of the issues that . . . is hard to glean is whether the scale of activity on the day meant that people were overwhelmed or whether there were not the systems in place to enable that kind of communication.”
CFA chief Russell Rees pointed out there was a torrent of information to deal with on Black Saturday, with 1368 calls to bushfires and at least 47 fires that might have grown to threaten communities. “Hindsight as a way of knowing is a wonderful thing,” he said.
Rees said the CFA had no statutory responsibility to issue warnings other than notifications of Total Fire Ban days, a stance he later softened when he said, of the lack of warnings, “we deeply regret it”.
Police Superintendent Rod Collins was the state emergency response officer on Black Saturday, a role that carries a responsibility to ensure “consideration” is given to warnings and to recommending evacuations. But he told the inquiry that fire agencies should be responsible for warnings, and that it was not his job to assess the content or timing of warnings or to know the details of fires.
What actions did he personally take to ensure the adequacy of warnings on the day? “I don’t do everything.”
In his recommendations to the commission this week, senior counsel assisting, Jack Rush, QC, said: “No person or authority in Victoria is charged with a responsibility of issuing warnings to the community as to the risk of bushfire.” He said the role of co-ordinator that Rees had adopted on Black Saturday was divorced from his fundamental responsibilities, including overseeing fire prediction, providing warnings and protecting life.
Superintendent Collins told the inquiry that even if asked, he would not have advised the Emergency Services Minister to evacuate communities. Apart from the fact that evacuation holds its own risks, he said, under current laws and policies, “you have a right to make a decision about staying and dying”.
It was a brutally frank assessment of the “stay and defend or leave early” policy. The policy is based around two options: leave home well before a fire approaches, or learn how to stay and defend your home against a blaze. It is built on the idea that “people protect houses and houses protect people”. But on Black Saturday, the bodies of 113 people – two-thirds of those who died – were found sheltering inside houses. Some were entire families of young parents with small children.
Fire reached the homes of people who were never going to be able to defend their houses and who had never even thought to have a fire plan because they saw themselves as townies. One was disabled man Mick Kane, who caught alight and died in his own driveway in an outer suburb of Bendigo. Commissioners Susan Pascoe and Ron McLeod have questioned whether Victoria’s bushfire brochures are too coy about the risks of staying to defend. Chairman Bernard Teague was struck by the use of a family photograph in one brochure, suggesting it was safe to have young children in the house while fighting a fire.
Some of the policy off-shoots of “stay or go” defy common sense. CFA sirens cannot be used to warn communities of approaching fire. Even if asked, CFA and community fireguard staff cannot tell home owners if their houses are not defendable. Victorians cannot legally be made to evacuate in the face of fire danger if they have a pecuniary interest in the land or the building under threat.
Emergency Services Commissioner Bruce Esplin pointed out that mass evacuations on a day of high risk could involve hundreds of thousands of people, and that “the road network in Victoria certainly wouldn’t support such a huge-scale leaving”. Evacuations would also be opposed by many in country areas. “stay or go” is a policy that plays to the bushman’s image of himself as tough and self-reliant.
John O’Neill of Steels Creek said: “A cop came down to me the next day and he said something about, ‘Maybe you should have been evacuated.’
“I said, ‘You’d want a bigger gun than that, mate . . .’ I don’t care (about) breaking the law if it comes to looking after my house. I will send them out; I will hide in the bush and I will wait. There are a lot of other guys who would do the same.”
Bushfire expert David Packham told the inquiry that many rural people were reluctant to give up their autonomy to officials: “A lot of people in the country, the real farming people, know how to handle themselves in these situations, certainly much better than perhaps a newly appointed city-based member of the police force.”
But many homes in country areas are now owned by “tree-changers” who have little background in fighting fires. The policy also does not take into account holidaymakers, in particular campers, who might find themselves caught in the open.
Rush said “stay or go” should be examined as to whether it “pays insufficient attention to the reality that education will not reach all community members, that not all will be prepared, and that taking responsibility can require resources that may in given circumstances be beyond the reach of many”.
Lawyers for the commission have also recommended the reintroduction of community refuges, which were put in place after Ash Wednesday in 1983 but have been all but abandoned in the decades since. Councils feared legal liability, and there were concerns that they might encourage last-minute evacuations or turn into communal death traps. Primarily, though, the reluctance seems to be about cost, with the Municipal Association of Victoria insisting that State Government funding would be essential.
If there are to be substantial changes as a result of this inquiry, it will be crucial that officials know whose rear end will be kicked for delays or failures.
Norman Free is manager of the state fire management planning support team. He told of struggling to get up just one project, an integrated fire management plan for the state. The process began in 2003 and moved achingly slowly. It is expected to be up and running in 2012. He told the inquiry the project needed work from many departments and agencies over whom he had no authority: “Committees are difficult structures and one point of authority . . . would have made my job a lot easier.”
Rush has recommended a bushfire royal commissions ombudsman be established to monitor the implementation of changes.
Many issues that contributed to the disaster that day have yet to be examined by the commission. They include the environmental stand-off between greenies, who want the bush preserved, and other residents who want trees cut from roadsides and burn-offs to reduce fuel loads. Then there is the politically sensitive question of whether people should be forbidden to live in some extreme-risk areas. But the biggest question will concern climate change, which is affecting the number and severity of bushfires not just in south-eastern Australia but in the US, Canada, Greece and Spain.
Following Black Saturday, Melbourne University professor of meteorology David Karoly said a CSIRO study had found climate change was starting to increase the number of bushfires by causing hotter, drier conditions. By 2020, extreme fire-risk days were tipped to increase by 65 per cent. “By 2050, there will be between a doubling and a quadrupling of extreme fire-risk days.”
In the end there might be one scenario Premier John Brumby and the emergency services cannot resolve. If world leaders continue to fiddle over carbon emissions, Victoria burns.
Karen Kissane is an Age senior writer.
A BETTER WAY?
Recommendations by counsel assisting the commission
– CFA chief officer be made responsible for warning communities that might be hit by fire. Warnings should give a time-frame and the highest level warnings should be preceded by alert siren.
– Establish community refuges to shelter people whose plans to stay and defend fail, who change their mind, or who have no plan. CFA crews would defend refuges.
– CFA staff to advise households, communities or locations that their best option is to leave early, and incident controllers should consider whether to recommend evacuation. People who want to stay should not be compelled to leave.
– There be only one website where both fire agencies give bushfire information.
First published in The Age.