Errors led to bushfire tragedy

BLACK SATURDAY – THE REPORT
The royal commission’s review of the Kilmore fire that killed 121 people is damning
A BLIZZARD of mistakes and errors of judgment by many people over many hours contributed to the CFA failure to warn communities about the Kilmore firestorm.
The CFA knew the potential spread of the Kilmore fire by mid-afternoon but failed to issue timely warnings, issued inadequate warnings and failed to identify towns in its likely path, the Bushfire Royal Commission’s interim report concludes.
The commission devotes 23 pages to a micro-analysis of the serial slip-ups that contributed to the disastrous lack of alerts for communities including Strathewen, Kinglake and Kinglake West. The Kilmore fire killed 121 people.
A major problem was that the fire was managed from an incident control centre at Kilmore, where some staff were underqualified and communications systems broke down under pressure.
A nearby control centre at Kangaroo Ground had more qualified staff and better equipment, but protocols forbade its manager from issuing warnings because he was not the manager of the Kilmore fire. For long stretches of the afternoon, Kangaroo Ground could not get through to Kilmore by phone or radio to ask for permission to issue warnings.
This led to incongruities in some of the alerts that were made. Soon after 4pm, power company SP Ausnet was briefed by Kangaroo Ground on the risk of the fire hitting Kinglake and damaging power lines — but Kinglake residents and fire captains received no such warning because it would have breached protocols to post it publicly.
The Kangaroo Ground control centre did issue a “red flag warning” to firefighters on the ground about the dangerous effect of the wind change without asking for Kilmore’s permission, the report said.
Protocols permitted this warning for the sake of firefighter safety. “The same approach should apply to the release of bushfire warnings to the public,” the report said.
It found that an alert message drafted at Kangaroo Ground at 3.02pm warning Kinglake, Kinglake West, Pheasant Creek, Strathewen, Arthurs Creek and St Andrews was accurate and timely. “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.”
But the 3.02pm warning was never released by Kangaroo Ground because Kilmore still had control of the fire.
The commission concluded, “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.”
The commission also criticised the fact that the information officer for the Kilmore fire for much of the afternoon was based in Seymour. He did not have access to those managing the fire, or to fire predictions, and was snowed under by other work, the report said.
The commissioners concluded it had been unreasonable to place the burden of creating and managing an incident management team for a complex, fast-moving fire on unprepared and underqualified CFA personnel at Kilmore.
“Just why the Kilmore ICC was in such a poor state of preparedness has not to date been explained in evidence.”
The commission also found that the practice of assigning an incident controller based on where the fire started — a CFA person if it was on private property, or a DSE controller if it began on Crown land — was flawed.
“On February 7 it led to the appointment of a level two incident controller at the Kangaroo Ground ICC who was inexperienced in the role and not formally qualified over a person highly experienced and qualified.”
Rocky Barca, a DSE staffer and deputy controller at Kangaroo Ground, told the commission of his frustration over the failure to release threat messages and over the way Kangaroo Ground was not given control of the fire even when it moved into the Kangaroo Ground region. He recorded in his log at 4pm, “Kinglake needs threat message ASAP . . . CFA in a mess.”
The commission’s report gave many examples of messages that never made it to air, or were aired briefly and abandoned. An urgent threat message for towns including Kinglake signed off at the Kilmore ICC at 4.10pm could not be sent by fax because of problems with the fax machine. It was emailed to Seymour at 4.24pm. From there it was sent to the Integrated Emergency Control Centre in Melbourne, which received it at 4.35pm, and to the ABC.
But the message was somehow overlooked and never uploaded to the CFA website. It was read over ABC radio at 4.43pm by a CFA officer but not repeated again — possibly because ABC announcers were relying on the CFA website. The fire ripped through the Kinglake ranges between 5 and 6pm.
Warnings that were approved came too late and took too long to be processed. An urgent threat message sent from the Kilmore ICC at 5.20pm was received at the IECC at 5.41 pm. It warned communities from Kinglake to Flowerdale of potential direct impact by fire. It was posted on the CFA website at 5.55pm, by which time many people in the affected areas were already battling flames.
CFA chief officer Russell Rees had told the commission that incident controllers could take concerns to regional managers if there was trouble contacting another ICC. But, the report said, “Even though [Kangaroo Ground’s controllers] were in contact with their respective regional headquarters, the warnings were still not released.”
It also criticised the operation of headquarters on the day, the Integrated Emergency Control Centre, where CFA, DSE and Victoria Police chiefs were stationed together. “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.”
The other serious omission at the state level was that “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.”
It concluded: “On February 7 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 . . . The information for appropriate, timely warnings was available but not delivered to the community.”
Karen Kissane is an Age senior writer.
THE LESSONS
Commission recommendations from the Kilmore failures:
■ State duty officers for CFA and DSE to check that incident control centres are properly staffed and equipped on high-risk days.
■ CFA and DSE to ensure that the most experienced qualified person is appointed incident controller for each fire, regardless of where the fire started.
■ Any level 3 incident controller to be authorised to release a warning when the designated incident controller is temporarily unavailable.
■ The CFA chief officer to be made responsible for issuing public bushfire warnings.
■ This responsibility to be delegated to the DSE chief fire officer when the fire is being managed by DSE.
First published in The Age.

Bushfire blame laid with CFA, Brumby

ROYAL COMMISSION
Agencies told to get tougher on warnings, emphasise ‘go — or risk death’. Black Saturday marked as a failure
FIRE chief Russell Rees and the CFA failed to protect Victorians from the Black Saturday bushfires and should be forced to take greater responsibility to avoid a repeat disaster, the Bushfires Royal Commission has said.
In its interim report, the commission said the Victorian Government should revamp its controversial Stay or Go policy, with the CFA required to tell home owners whether or not their house was defendable.
It said the CFA’s chief officer Rees did not become involved in hands-on management on Black Saturday “even when the disastrous consequences of the fires began to emerge”.
The report said Mr Rees did not check warnings about the Kilmore fire that killed 121, did not speak to controllers at the two centres managing that fire, and did not know of fire behaviour experts or their predictions for the Kilmore blaze.
The commission said all this meant it was “difficult to understand” how the CFA lived up to its responsibility to give local communities information to ensure their safety.
The CFA should have accepted that issuing warnings was part of its job on Black Saturday, even though this was not spelled out in legislation, the report said.
It recommended that the law be changed to make it clear that warnings and advice to relocate were the responsibility of the agency managing a fire.
The report stopped short of suggesting the Stay or Go policy be ditched, but said people should be warned that staying to defend carried many risks, including death. Its 51 recommendations include:
– The re-introduction of community refuges.
– Incident controllers to be given more responsibility for issuing warnings, even when they are not managing the fire concerned.
– Emergency call services including triple-zero be boosted on high-risk days.
The report exposed bungles at the highest level, with the State Emergency Response Plan (SERP) not defining who was responsible for warnings and recommending evacuations.
“In addition, the means by which warnings were issued and evacuations were made on 7 February bore little resemblance to the arrangements in the SERP,” the report said.
“Diffuse or unclear responsibility for warnings and relocation is at best unhelpful and at worst life-threatening.”
The report recommended that whichever agency was responsible for an individual fire — the CFA or the Department of Sustainability and Environment — it should also be responsible for warnings and advice to relocate.
It gave a detailed analysis of what went wrong with management of the Kilmore fire. The commission heard evidence that warnings were drafted but not issued, due to CFA protocol, or authorised but not aired, due to internal communications problems.
The commissioners — chairman Bernard Teague, Susan Pascoe and Ron McLeod — made several recommendations that flowed from this.
They called for all incident control centres to be properly staffed and equipped; for the most experienced controller available to be appointed, regardless of which agency was managing the fire; and for senior controllers to be authorised to issue warnings they believed necessary, even if the warnings related to a fire being managed from another centre.
The Stay or Go policy and bushfire brochures had failed to emphasise adequately the risks of staying and defending, the commission said.
“The risks should be spelt out more plainly, including the risk of death,” the report said. “People should also be encouraged to recognise that not all houses are defendable in all situations and contingencies need to be considered in case the plan to stay and defend fails.”
The CFA should have the authority to give specific advice about the defendability of individual properties and whether residents should leave.
“For those who plan to leave, there should be more explicit advice on triggers that should be used to determine when to do so,” the report said.
People also needed more options than stay or go, because the preferred option might not be possible or might fail. “The availability of local areas of refuge is an important and essential complement to the ‘Stay or Go’ policy.”
The commission welcomed the State Government’s announcement of “neighbourhood safer places” to provide informal shelter but also recommended the setting up of community refuges, which should be defended by the CFA during a fire.
It said the lack of refuges failed people who found themselves in danger when their plans failed, were overwhelmed by circumstances, changed their minds or had no plan.
“The lack of refuges in Victoria also fails to assist people in areas threatened by fire who are away from their homes, such as employees, visitors, tourists, travellers and campers.”
The report recommended that Victoria Police review its guidelines on roadblocks, which were inflexible, and upset people who were already under pressure.
The commission recommended that warnings be clearer, that commercial radio and television stations also be allowed to issue them, and that sirens be played before the broadcasting of serious warnings to alert listeners to pay attention. It said community warning sirens should be re-introduced in towns that wanted them, and it recommended increasing the capacity of the triple-zero service and the Victorian Bushfire Information Line — which failed to answer 80 per cent of calls on February 7 — to handle spikes in volume.
It also suggested that a single multi-agency “portal” for bushfires be designed to allow incident control centres to post information and warnings directly. The portal should upload information simultaneously to both CFA and DSE websites.
Premier John Brumby said action was under way on most of the 51 recommendations. The Government would respond to all by August 31.
“The single most important responsibility I have got between now and the rest of the year is to make our state as fire-safe and as fire-ready as possible,” he said. He said the report “is basically endorsing ‘Stay or Go’, but what they are saying is that there needs to be a much stronger focus on leaving early”.
Millions of dollars had already been allocated to new fire-safety initiatives, including an $11.5 million public education campaign on the importance of leaving early, $30 million to upgrade incident control centres, and $167 million to improve emergency services communication systems. On the question of who should take responsibility for system failures on Black Saturday, Mr Brumby said: “There were systems which worked well on the day and systems which didn’t . . . (but) we had more than 600 fires that day.”
Nationals leader Peter Ryan said the report was a damning “catalogue of tragic failures” and showed the Government had failed to fix problems they knew might lead to a tragedy.
“The unfortunate truth is that much of what has led to [the deaths of 173 people] was known to the Government and the agencies before these events transpired,” he said. “There are across many of [the report’s] pages findings that I think are very compelling in terms of a criticism of the Government, its lack of preparation in relation to the day’s events, the fact that for many years — particularly in relation to warnings — they knew or they should have known there were deficiencies there that needed to be accommodated.”
THE CFA SHOULD …
– ADVISE people in bushfire-prone areas the safest option is always to leave rather than stay and defend. Children, the elderly and infirm should not fight fires.
– GIVE chief officer Russell Rees legislated responsibility for issuing warnings to the public.
– ENSURE warnings focus on maximising potential to save lives, and include a level above extreme.
– ISSUE more explicit information about risks and give specific advice about the defendability of individual properties.
– DIRECT firefighting resources, as a priority, to refuges where people are sheltering.
– RECOMMEND residents ‘relocate’ rather than stay and defend.
GOVERNMENT SHOULD…
– IDENTIFY neighbourhood safe areas such as car parks, sporting grounds, amenities blocks and dam walls that could be used as community refuges.
– INVESTIGATE technical possibility of sending warning messages to mobile phones by the 2009-10 bushfire season
– DEVELOP guidelines for use of fire station sirens to alert communities to bushfire threats.
THE MEDIA
– END ABC’S exclusive role as emergency broadcaster and enlist commercial networks in disseminating bushfire warnings.First published in The Age.

Leaders seek to spin their way forward

BLACK SATURDAY – THE REPORT – ANALYSIS
THEY were lined up like war-time generals, but the theme of yesterday’s State Government press conference was more like “Don’t mention the war” — in this case, don’t mention the failures of policies or our emergency systems on Black Saturday.
An historian will one day count the number of times the Premier and CFA chief officer Russell Rees mentioned the key phrase “going forward”. Don’t look back, was the message; look instead at what we are doing for you now.
Whenever the line-up was asked whether anyone would take responsibility for the mistakes that contributed to loss of life that day, the answer was to point out the sheer number of fires (more than 600), or to point out what would have happened if some of the fires that were contained had not been.
The Premier was asked whether the Government and its agencies, in trying to shield themselves from legal liability, had left Victorians exposed to danger.
The commission had heard that the CFA drummed into its volunteers never to tell anyone if their house was defendable or not, partly for fear it could be sued if their assessment proved wrong.
Councils had abandoned refuges for the same reason. Was protecting themselves more important than protecting Victorians?
Mr Brumby said: “I wouldn’t accept that.”
The language of the commission’s report makes it easier for politicians to spin the response to it. It is focused on system failures, which it describes in neutral, non-condemnatory tones. It singles out no individual for blame and shame.
It does not even say that Mr Rees, who it criticises for errors on the day, failed to meet his responsibility, saying only that it was difficult to understand how he lived up to them.
It manages to cast grave doubt on his performance while sliding gracefully away from any direct condemnation of it.
The CFA chief is not yet out of the woods. The commissioners also said they had not yet got to the bottom of several CFA problems that they hope to revisit in future hearings.
These include the inadequacies in incident control centres over the Kilmore fire, and the fact that Mr Rees was out of the loop regarding warnings and predictions.
The report pointed out its findings on this were preliminary because the evidence was not complete.
But even the recommendations the report does contain are valuable. If all the changes it suggests had been in place on Black Saturday — particularly the clear responsibility for warnings, and better equipping of control centres with senior staff and hardware — the devastation of the Kilmore fire might have been largely limited to houses rather than human beings.
First published in The Age.

Release reopens scarred wounds

BLACK SATURDAY – THE REPORT – THE FAMILY
“TODAY is a devastating day for families who have lost loved ones,” says Joan Davey. “Today confirmed what we already know. They perished because a terrible situation was badly managed.”
She and her husband Leon lost their son Rob, daughter-in-law Natasha Halls Davey and two grandchildren, Jorja and Alexis, in the Black Saturday fires in Kinglake.
Mrs Davey said yesterday the commission’s interim report had stirred up trauma for grieving families, but she hoped its recommendations would protect lives in future.
“We feel anguish when our future has been lost. We lost a beautiful son, his beautiful wife Natasha. We will never see the bright future that was to be theirs. My darling Jorja, three years old, she will never run into Granny’s arms again. Baby Alexis, so beautiful, will never get to walk.”
Mrs Davey agrees that Black Saturday was unprecedented: “It was a terrible, terrible day, but there were so many points in that day when a better outcome was possible and nothing was done to ensure a better outcome. It was like they shut their eyes and turned away and hoped it would turn out, but it didn’t turn out for us.”
But she wanted to express the family’s gratitude to firefighting volunteers: “There are lots of people who did their best.”
Natasha’s father, Michael Halls, said he was pleased with the commission’s process, although he criticised the idea that people should simply be warned that death could result from a decision to stay and defend.
“It shouldn’t just be a matter of saying, ‘You could die’. That will just frighten you. If you want people to make rational, considered decisions, they have to have objective information.”
He said people needed to know details such as the fire danger index for a given day and what it meant for the intensity of any fire: “That beyond 75, any fire cannot be stopped. Once it’s 150, it’s far beyond any chance of control and all the CFA’s efforts should be put into warning about a catastrophic firestorm.
“The CFA seems to think that is their information, but the public has paid for it and they have a right to it.”
First publsihed in The Age.

CFA blamed, told to take charge

ROYAL COMMISSION – Agencies told to get tougher on warnings, emphasise ‘go — or risk death’
FIRE chief Russell Rees and the CFA failed to protect Victorians from the Black Saturday bushfires and should be forced to take greater responsibility to avoid a repeat disaster, the Bushfires Royal Commission has said.
In its interim report, the commission said the Victorian Government should revamp its controversial stay-or-go policy, with the CFA required to tell home owners whether or not their house was defendable.
It said the CFA’s chief officer Rees did not become involved in hands-on management on Black Saturday “even when the disastrous consequences of the fires began to emerge”.
The report said Mr Rees did not check warnings about the Kilmore fire that killed 121, did not speak to controllers at the two centres managing that fire, and did not know of fire behaviour experts or their predictions for the Kilmore blaze.
The commission said all this meant it was difficult to understand how the CFA lived up to its responsibility to give local communities information to ensure their safety.
The CFA should have accepted that issuing warnings was part of its job, even though this was not spelt out in legislation, the report said. It recommended the law be changed to make it clear that warnings and advice to relocate were the responsibility of the agency managing a fire.
The report stopped short of suggesting the stay-or-go policy be ditched, but said people should be warned that staying to defend carried many risks, including death. Its 51 recommendations include:
■The re-introduction of community refuges.
■Incident controllers to be given more responsibility for issuing warnings, even when they are not managing the fire concerned.
■Emergency call services including triple-zero be boosted on high-risk days.
The report exposed bungles at the highest level, with the State Emergency Response Plan not defining who was responsible for warnings and recommending evacuations. “Diffuse or unclear responsibility for warnings and relocation is at best unhelpful and at worst life-threatening,” it said.
Mr Rees, who this month was reappointed for two more years, said Black Saturday exposed weaknesses in the CFA and he welcomed the report. He said it had clarified his role “by looking to provide further power to the chief officer in respect of warnings”.
“The interim report and CFA positions are completely lined up,” he said. “I stick to the fact I did my very best that I could in the circumstances on Black Saturday.”
The report recommended that whichever agency was responsible for an individual fire — the CFA or the Department of Sustainability and Environment — it should also be responsible for warnings and advice to relocate.
It gave a detailed analysis of what went wrong with management of the Kilmore fire. The commission heard evidence that warnings were drafted but not issued, due to CFA protocol, or authorised but not aired, due to internal communications problems.
The commissioners — chairman Bernard Teague, Susan Pascoe and Ian McLeod — made several recommendations that flowed from this. They called for all incident control centres to be properly staffed and equipped; for the most experienced controller available to be appointed, regardless of which agency was managing the fire; and for senior controllers to be authorised to issue warnings they believed necessary, even if the warnings related to a fire being managed from another centre.
The stay-or-go policy and bushfire brochures had failed to emphasise adequately the risks of staying and defending, the commission said. “The risks should be spelt out more plainly, including the risk of death,” the report said.
“People should also be encouraged to recognise that not all houses are defendable in all situations and contingencies need to be considered in case the plan to stay and defend fails.”
The CFA should have the authority to give specific advice about the defendability of individual properties and whether residents should leave.
“For those who plan to leave, there should be more explicit advice on triggers that should be used to determine when to do so,” the report said.
People also needed more options than stay or go, because the preferred option might not be possible or might fail. “The availability of local areas of refuge is an important and essential complement to the stay-or-go policy.”
The commission welcomed the State Government’s announcement of “neighbourhood safer places” to provide informal shelter but also recommended the setting up of community refuges, which should be defended by the CFA in a fire. It said the lack of refuges failed people who found themselves in danger when their plans failed, were overwhelmed, changed their minds or had no plan.
“The lack of refuges in Victoria also fails to assist people in areas threatened by fire who are away from their homes, such as employees, visitors, tourists, travellers and campers.”
The report recommended that Victoria Police review its guidelines on roadblocks, which were inflexible, and upset people who were already under pressure.
The commission recommended that warnings be clearer, that commercial radio and television stations also be allowed to issue them, and that sirens be played before the broadcasting of serious warnings to alert listeners to pay attention. It said community warning sirens should be re-introduced in towns that wanted them, and it recommended increasing the capacity of the triple-zero service and the Victorian Bushfire Information Line — which failed to answer 80 per cent of calls on February 7 — to handle spikes in volume.
It also suggested that a single multi-agency “portal” for bushfires be designed to allow incident control centres to post information and warnings directly. The portal should upload information simultaneously to both CFA and DSE websites.
Premier John Brumby said action was under way on most of the 51 recommendations. The Government would respond to all by August 31.
“The single most important responsibility I have got between now and the rest of the year is to make our state as fire-safe and as fire-ready as possible,” he said. He said the report “is basically endorsing stay or go, but what they are saying is that there needs to be a much stronger focus on leaving early”.
Mr Brumby had already backed Mr Rees, saying last month that “I don’t believe we could have asked for more from Russell Rees” and his team.
Millions of dollars had already been allocated to new fire-safety initiatives, including an $11.5 million public education campaign on the importance of leaving early, $30 million to upgrade incident control centres, and $167 million to improve emergency services communication systems.
On the question of who should take responsibility for system failures on Black Saturday, Mr Brumby said: “There were systems which worked well on the day and systems which didn’t . . . (but) we had more than 600 fires that day.”
Nationals leader Peter Ryan said the report was a damning “catalogue of tragic failures” and showed the Government had failed to fix problems they knew might lead to a tragedy.
“The unfortunate truth is that much of what has led to [the deaths of 173 people] was known to the Government and the agencies before these events transpired,” he said. “There are across many of [the report’s] pages findings that I think are very compelling in terms of a criticism of the Government, its lack of preparation in relation to the day’s events, the fact that for many years — particularly in relation to warnings — they knew or they should have known there were deficiencies there that needed to be accommodated.” — With AAP
THE CFA SHOULD …
– ADVISE people in bushfire-prone areas the safest option is always to leave rather than stay and defend. Children, the elderly and infirm should not fight fires.
– GIVE chief officer Russell Rees legislated responsibility for issuing warnings to the public.
– ENSURE warnings focus on maximising potential to save lives, and include a level above extreme.
– ISSUE more explicit information about risks and give specific advice about the defendability of individual properties.
– DIRECT firefighting resources, as a priority, to refuges where people are sheltering.
– RECOMMEND residents ‘relocate’ rather than stay and defend.
GOVERNMENT SHOULD…
– IDENTIFY neighbourhood safe areas such as car parks, sporting grounds, amenities blocks and dam walls that could be used as community refuges.
– INVESTIGATE technical possibility of sending warning messages to mobile phones by the 2009-10 bushfire season
– DEVELOP guidelines for use of fire station sirens to alert communities to bushfire threats.
THE MEDIA
– END ABC’S exclusive role as emergency broadcaster and enlist commercial networks in disseminating bushfire warnings.
First published in The Age.

BLACK SATURDAY – CFA CHIEF SPEAKS OUT

‘I gave it everything I possibly could. In my view, I gave it everything, to the best of my ability’ BLACK
Soul-searching, yes. But Russell Rees has no plans to walk away.
IT’S an ugly question but it has to be asked. With 173 people dead in the Black Saturday bushfires, has CFA chief Russell Rees found himself wrestling with a distressing sense of personal responsibility?
The Bushfires Royal Commission has heard of bungles over warnings that were never released. Lawyers assisting the commission have accused Mr Rees of being out of touch with his basic responsibilities that day, including the oversight of warnings and the protection of life.
Yesterday, in his first interview since the commission began, the man who has been with the CFA since he was a boy defended himself. Adamantly.
“I think every single person who’s involved in this questions how and what they did, before, during, after,” he said. “There’s that introspectivity that you go through.
“Hindsight’s a bloody wonderful thing . . . You always look back and say, ‘Well, could I have done better? Could I have done this, or could I have done that?’ ”
But he concluded that, for him, the answer was no.
“I gave it everything I possibly could. In my view, I gave it everything, to the best of my ability. And all I can do is say, ‘If there are things I have to improve on, if there’s things that we as an organisation have to improve on, then we just take it on board and go forward.’ ”
There have been calls for his resignation. Mr Rees said he had not considered it.
“That’s never entered my head. I knew that I needed to commit towards the future . . . We can’t walk away from the fact that this is Victoria’s — sorry, Australia’s — worst natural disaster. And for me to walk away, I don’t think I could live with myself. It’s pretty simple. And people are saying they want me.”
Had Premier John Brumby discussed his future with him?
“No. I’ve never discussed my future with the Premier . . . All I know is that I was told the Premier is supportive of me, and that happened while I was [recently] on leave.”
Russell James Rees, 53, joined a CFA junior brigade in his home town of Moe when he was 11.
He had loved the agency long before that, barrelling along on his bike to local fires to watch the battle to extinguish them.
The family of six kids — Mr Rees the youngest — didn’t have much and it was free entertainment.
He trained as a primary school teacher, but the CFA offered him a job when he graduated. He became chief officer eight years ago.
He has a ponderous way of speaking, with methodical blocks of ideas laid out in steady order.
At the commission he walked with an increasingly heavy tread as the days progressed, but on his own turf he seems somehow lighter.
When he went home around 10.30pm on Black Saturday he knew that dozens had died. He also knew the toll would rise. On the Sunday morning, he heard of the razing of Marysville.
“I don’t know if there’s a difference between disbelief and unbelief, you know? You don’t want to believe it, but you know it’s true . . . you think, ‘Heaven forbid, this is real true, this is real true.’ ”
Any questions about how the CFA’s processes failed on the day draw from him reassurances that lessons have been learnt.
The commission has heard of turf being defended against common sense and of a choice to obey protocols rather than release much-needed warnings. But Mr Rees has not reviewed the performances of key people.
There has been no “tackling individuals”, he says. “If you chase the individual down, in environments like this, individuals will actually cease to want to participate, and when they do, they’ll participate in a total risk-averse way which, in the end, is detrimental to your outcome.
“Because emergency service management is not a perfect environment. No matter where you are, you don’t know everything.”
But wasn’t risk-averse behaviour actually one of the problems, with a reluctance by some to break rules?
“Yeah.” He pauses. “But I wasn’t there and neither were you . . . It’s all so easy to point the bone at individuals who gave it everything and made errors. The reality is, for many of those, the person who feels the most pain is actually the individual themselves.”
He says it has been argued that Black Saturday was just a natural disaster, “that it’s not about systems at all”.
He would not put that forward but he has this to say about bushfire.
“It’s almost like layers of a cake, where the suppression is almost the last layer of the cake. It’s how we choose to live, where we choose to live, how we manage our vegetation, how we mange our regulatory control in terms of building . . . and how we manage what I call fire prevention, which is stopping fires in the first place.”
Victoria’s climate has deteriorated seriously and the future seems to hold little promise of improvement, he says.
This is why he rejects the idea that it was bad luck for him that such a disaster happened on his watch.
“I don’t think it’s bad luck. I don’t look at it as luck at all. This is what’s happening in our environment. This is what we’re now dealing with. Would you have thought that the chief of the New York Fire Department would have had to deal with the collapse of the twin towers?”
First published in The Age.

Earth, wind and fire

THE Black Saturday fires created 120 km/h winds, snapping trees in half. They created their own weather, triggering storm clouds and lightning strikes that started more fires. They fuelled flames that leaped 100 metres into the air and fireballs that barrelled ahead of a front and landed with explosive force in farmers’ paddocks.
And they fed on their own fury and destructiveness. The fiercer they became, the more strength they drew from the heat, wind and energy they had spawned.
The science behind them has been explained by fire behaviour expert Kevin Tolhurst in evidence to the Bushfires Royal Commission and in a report he produced for the inquiry on the physical nature of the fires that day.
Dr Tolhurst is senior lecturer in fire ecology and management at Melbourne University. He says the Black Saturday fires were unique in three ways: the speed of ignition, the intensity of the flames and the way they spread in ”pulses”, with prolific spotting up to 35 kilometres ahead of a front.
The Black Saturday fires were similar to previous Victorian fires in that they were at their worst following the cool change late in the day. The drop in temperature brings relief to baking cities but the associated change in wind direction can mean horror in country areas.
Cool changes ”turn the flank (side) of a long and narrow, cigar-shaped fire, driven by strong northerly winds, into a fire front several kilometres wide”, Dr Tolhurst says. ”Typically, about 80 per cent of the total area burnt occurs after this wind change.”
When five firefighters died at Linton in 1998 it was because a cold front turned a seemingly benign fire with flames less than half a metre high into a blaze with flames 10 metres high, he says.
On Black Saturday much of the bush was dried out from more than a decade of drought and 11 days of temperatures over 30 degrees. This meant it was easier for embers to bring fuel, such as bark or leaves, to kindling temperature of about 300 degrees.
They did not have to smoulder for long periods to dry the fuel because the fuel was already desiccated. Dr Tolhurst says the speed with which embers ignited spot fires was unique to February 7.
Even mountain ash and rainforest areas, usually moist, had been dried out.
”Normally you wouldn’t have a chance of trying to ignite or burn those areas . . . (but they) are the areas where the greatest fuel accumulation occurs so when they do burn, they burn with great intensity.”
A fire burning fiercely interacts with fuel, air, its own spot fires and the energy it produces to create a self-sustaining system. The more it consumes, the more it can consume.
The fires that day also set a record for spotting distance, due to the prevailing winds and the winds and heat the fires created.
The Kilmore fire on Black Saturday developed a smoke plume about 5200 metres from the ground and a huge white pyrocumulus cloud 8500 metres off the ground.
The plume acts like someone sucking on a straw, Dr Tolhurst says. As air rises into the plume, more air is drawn into its base. This vacuuming effect pulls on the thousands of surrounding spot fires, encouraging the burning areas to come together and form a whole, and drives the direction of the fire front. The formation of the pyrocumulus cloud adds further heat to the smoke column and reinforces the updraft of air.
If the atmosphere is unstable, it is easier for a parcel of warm air to rise. Thunderstorms develop in unstable atmospheres because warm moist air rises readily and forms thunderclouds.
Late on Black Saturday, pyrocumulus clouds developed into a fire-induced thunderstorm that produced lightning strikes and small fires in Melbourne’s water catchment forests, including the Upper Yarra and Britannia Creek catchments.
Bushfires create their own winds when air is whipped into the convection column at ground level.
”In the 2003 fires in Canberra, we saw the fire tornado that was a result of that convective effect,” Dr Tolhurst says. ”In the fires here on February 7 we saw trees snapped off – down at the Bunyip Ridge fire, for example, where the winds would have had to have been in the vicinity of 120 km/h or more.”
Fire whirls, balls, flares and willy-willies of flame are moving air filled with combustible gases, ”and the quickest way for these to rise is to actually spin in the same way as a tornado or willy-willy would rise by spinning. When it has got combustible gases in it, we get a fire whirl.”
A lot of people on Black Saturday saw ”fair dinkum fire flares or fire balls”, he says.
”The fuels were so dry and the temperatures were so high, the rate at which the volatile gases were given off was much quicker than normal, if you like, and so the likelihood of getting black smoke and these parcels of unburnt volatiles moving through the air is much greater.”
Those parcels of gases need to mix with air to ignite and often travel long distances through the fire zone before igniting when they hit fresh air at the edge of it. ”You only need to go down to Southbank to see the gas flares in front of the casino there. It is the same phenomenon. We see it separated from the source, and it won’t last, but it is there.”
Many people have described the noise of the fires that day as being like the rumble of dozens of freight trains or the roar of hundreds of jet engines.
That noise is not heard until the front is upon you, says Dr Tolhurst. Video of Marysville just before the fire showed it still and quiet, with hardly a flutter of leaves in the trees, because prevailing winds and the winds of the bushfire cancelled each other out. ”Often as the fire is approaching things will go calm,” he says.
Many things make up the roar of the fire front: ”One is just the strong winds associated with the fire, with updraughts and so on, so that you get the thrashing of leaves and twigs and branches and other material. You don’t even need much wind. The fire actually bursts the cells of the plants . . . the crackling of the cells as they explode with the heat from the fire is quite deafening.”
The Black Saturday fires burnt out 300,000 hectares and produced flames that leaped 100 metres in the air and had temperatures of up to 1200 degrees . ”The energy of the fires was equivalent to more than 1500 atomic bombs the size of the one used at Hiroshima . . . but bushfires release their energy in a ‘storm’, not a ‘blast’,” he says.
”The total amount of heat released from the fires on Black Saturday would have been sufficient to provide the total energy needs for all Victorian domestic and industrial use for a year. This energy was released in just a few hours.”
Dr Tolhurst told the commission the fires that day showed up holes in scientific knowledge and, therefore, in the advice given to the community.
Video around one fire observation tower showed severe flames for an hour and strong radiant heat for five hours in total. Dr Tolhurst says this phenomenon of ”areas of fire” that burn for long periods has not been studied adequately and is not reflected in fire advice that tells people they can shelter briefly in houses while a fire front passes quickly over.
Areas of massive spot fires that can burn for hours, rather than a passing front, are not captured well in scientific models or in training, he says.
”If a fire is only travelling at a maximum of five or 12 km/h per hour, why do so many kangaroos get killed, because they can travel much quicker than five or 10 kilometres an hour? It’s because they basically get surrounded by fire; they get engulfed in an area of fire. So we need to actually change our conceptual framework and follow that up with research that fits that pattern.”
THE RED STORM THE THREE STAGES OF FIRE
1 Directly under the smoke plume and driven by a northerly wind: This is the fastest and most intense phase. The fire burns out relatively quickly but could still last for an hour. This kind of blaze destroyed Humevale and Strathewen.
2 To the left (or east) of the left-hand flank: This kind of fire will affect an area for a long period of time. The area could be struck by firebrands coming from high up in the air and travelling long distances. Running fires could go on for two hours or more but the process is more gradual, and its intermittent nature may leave people confused or disoriented. This kind of fire attacked Kinglake and Pheasant Creek.
3 After the wind change: The long flank (side) of the fire turns and becomes the front. There is a massive release of embers and spotting is prolific.
Areas that were previously in clear air will fill with smoke with little warning. Spotting may occur five kilometres ahead of a front that is now 20 kilometres long. The danger of getting caught, surrounded by fire, is very high. This happened in Marysville, Buxton and Flowerdale.
SOURCE: DR KEVIN TOLHURST, MELBOURNE UNIVERSITY
EFFECTS OF SMOKE INHALATION
A million microscopic particles can enter your body in a single breath. The tinier the particles, the greater the threat they pose. A human hair is 70 microns wide.
15 MICRONS AND LARGER Half of particulates inhaled lodge in the mouth, nose and throat.
Possible effects Dryness, irritation, inflammation, chronic runny nose, nasal and throat cancers.
5-15 MICRONS Particles are deposited in trachea, pharynx and air passages in lungs.
Possible effects Breathing difficulties, cough, aggravation of existing heart and lung disease, influenza, bronchitis, lesions and lung cancer.
5 MICRONS AND LESS Tiniest particles penetrate the alveoli where lungs perform gas exchange. Some are removed by cells called macrophages; many will remain permanently.
Possible effects Pneumonia, emphysema, reduced blood and oxygen flow, loss of macrophages and alveoli.
COUNTDOWN TO A CATASTROPHE
THE MURRINDINDI FIRE/ FEBRUARY 7 2009
2.57pm DSE spotter Colin Hind at Mt Despair tower sees start of fire at Murrindindi mill. Phones regional district officer at Broadford DSE.
3.06pm Operations manager and crews arrive about 3.30pm.
3.30pm Mt Gordon spotter Andy Willans tries to call Marysville CFA captain Glen Fiske to warn him town under threat. Cannot get through.
Calls local Pauline Harrow instead.
3.45pm Alert message issued that fire burning in Murrindindi area and moving S/E direction.
4.30pm Andy Willans reports spotting in Narbethong.
4.45pm First urgent threat message for Narbethong issued by DSE (crossposted on CFA website 10 minutes later.
4.47pmWarning announced on ABC.
5pm DSE air observer flies over blaze and says there is fire “all around Narbethong”.
5.27pm Urgent threat message issued for Marysville. “The communities of Narbethong, Marysville and Buxton can expect to come under direct attack from this fire. Healesville residents are advised to remain on high alert.”
5.34pm ABC broadcasts threat message for Marysville.
5.45pm – 6pm Map predicting fire would hit Marysville produced in the IECC.
6.20pm Spot fire in Marysville (before main fire).
6.30pm South-westerly wind change hits, Narbethong and Marysville spot fires merge.
7pm DSE office on fire (partially destroyed).
Fire contained by 6pm, March 5 2009
KILMORE EAST FIRE/FEBRUARY 7 2009
11.49am Kilmore East fire reported to CFA.
12.33pm Infrared “linescan” of fire area taken by aircraft.
12.40pm Awareness warning for Wandong and Clonbinane.
2.25pm Alert message for Wandong.
2.40pm Urgent threat message for Wandong.
3.05pm Urgent threat messsage for Hidden Valley 3.18pm First time a threat to Kinglake is mentioned on radio. “Kay” from Kinglake calls 774 ABC and reports smoke in the sky, believing it is from a fire at Kilmore. “If I didn’t know about those fires I’d say we’re about to be hit by a wall of flames.”
3.53pm Urgent threat messages issued for Whittlesea, Hidden Valley, Heathcote Junction and Upper Plenty.
3.30pm Fire spotting into Pheasant Creek and Strathewen.
4pm-5pm Spotting starts in St Andrews.
4.01pm 774 ABC broadcasts urgent threat message for Whittlesea and Hidden Valley.
4.10pm Kilmore ICC drafts an urgent threat message warning for Clonbinane, Mt Disappointment, Kinglake, Heathcote Junction, Upper Plenty, Humevale, Reedy Creek, Strath Creek.
4.24pm Seymour RECC asked to distribute the Kilmore message through its fax due to problems with communications.
4.24pm 774 ABC radio reports fire is south of Kinglake escarpment.
4.35pm Alex Caughey at Seymour RECC sends out the Kilmore urgent threat message to IECC and others (message inexplicably goes missing, never appears online).
4.35pm Urgent threat message issued by CFA for areas including Whittlesea, Humevale, Arthurs Creek, Nutfield, Eden Park and Doreen.
4.43pm CFA spokesman mentions Kinglake is under threat in an ABC radio interview. First official threat warning on ABC about Kinglake.
5.20pm Kilmore incident controller Stuart Kreltszheim asks for urgent threat message stating communities from Kinglake to Flowerdale will be directly affected to be issued (Kinglake West, Pheasant Creek, Wandong, Wallan, Humevale, Kinglake, Glenburn, Flowerdale). Strathewen never mentioned.
5.35pm Map predicting fire spread produced at IECC based on 12.33pm linescan. Predicts that by 9pm fire could hit Kinglake, Pheasant Creek, St Andrews and Smith Gully to Diamond Creek.
5.40pm Kinglake-Flowerdale urgent threat message sent.
5.50pm Kinglake-Flowerdale message “reviewed” 5.55pm Urgent threat message for Kinglake and Flowerdale appears on CFA website. First time Kinglake mentioned online.
6pm – 6.30pm Fire hits Kinglake 7.44pm CFA chief officer Russell Rees interviewed on 774 ABC radio.
Says fire is “putting enormous pressure on areas like Kinglake West and Kinglake”.First published in The Age.

Rural agencies catalogue failings in fighting last summer’s fires

IN THEIR first detailed admission of fault, Victoria’s two rural fire agencies yesterday released a joint report cataloguing their failures during last summer’s fires, including the Black Saturday blazes that killed 173.
Problems included poor equipment, equipment shortages, a lack of fully trained leaders, confusion over roles and a refusal by managers to listen to local input. The lack of warnings to the public was criticised, as was the poor flow of information within the agencies.
The CFA’s acting chief officer, Steven Warrington, yesterday denied the report was an admission of failure: “It doesn’t say we failed.”
Asked whether knowing of these problems before February 7 might have saved lives, he replied, “That’s difficult to answer.” He said the circumstances on the day were unprecedented and, while the agencies would try to learn and improve, “the reality is it’s still incumbent upon Victorians to accept some responsibility” for fire safety.
The Country Fire Authority and the Department of Sustainability and Environment, which manages fires on Crown land, conducted 176 debriefings of staff and volunteers across the state.
The complaints they made echoed much of the evidence before the bushfires royal commission, which has heard that an overwhelmed system failed to warn communities about to be hit by firestorms.
The Operational Debrief Report: 2008-09 Fire Season said emergency headquarters in Carlton on the day were cramped, noisy and confusing. There was a “lack of consistency in IT and phone systems, procedures and roles, particularly at the state duty officer, state co-ordinator and chief officer level in both CFA and DSE, which made it difficult for staff to work together efficiently in the areas of logistics, resources, situation and planning”.
Out in the field, “There was dissatisfaction with the manoeuvrability and lack of power of Nissan Patrol vehicles, the lack of GPS in DSE vehicles (and) non-emergency vehicles.”
Fire personnel were frustrated when radios were jammed with traffic or useless due to black spots: “They then reverted to whatever worked, be that ‘go to’ conventional channels, trunking, mobile phone or UHF radio.”
Incident control centres were not well-equipped with IT and telephones, and “the mechanism for transfer of fire control to another location when a fire crosses a certain ‘boundary’ proved difficult and needs review. An instance of a necessary change of location of ICC during a fire was a stressful task for those involved.”
The commission has been told that the Kilmore fire, which killed 121, was managed by a control centre whose communications had collapsed and whose manager did not relinquish control of the fire even when it crossed out of his area.
CFA and DSE staff criticised “the inadequate, inaccurate or outdated information to the community about the locations of fires and their potential impacts”. The report said there was a “perceived breakdown” in information flow between headquarters and the Victorian Bushfires Information Line.
“Information that was available or should be known on the fire ground did not get to the Incident Management Team in some cases. This was considered due to (control centres) being too remote, or . . . sectors too large, or (managers) not sharing information. An inability of the fire ground to contact (supervisors) because telephones were engaged or not answered … was also reported.”
THE REMEDIES
– Improve co-operation between DSE and CFA and give their joint headquarters better phones and computers; look at shared IT systems, procedures and website; encourage them to work together more often.
– Develop well-equipped, high-level incident control centres that have enough trained staff and improve co-ordination among them, “including division of control in a fast-moving fire across administrative boundaries”.
– Train more ground observers, fire behaviour analysts and intelligence officers who can go to fires that are so intense that fire-fighting teams don’t have time to report back.
– Improve information flow from control centres to headquarters, and from the Bushfire Information Line to the community.
First published in The Age.