Moral imperative in writing lessons from the firestorm

THIS week, leaks on the Bushfires Royal Commission led to broadsheet headlines about the government being lashed, with accusations that its stay-or-go policy had placed some of those who died at great risk. It was claimed that flaws in the policy had been known for 10 years but not fixed.
Within 24 hours, there was a leak to tabloid media that diverted the spotlight from policy and on to an individual, former police chief Christine Nixon, and the question of whether she lied to the inquiry. Counsel assisting the commission accuse her of deliberately trying to mislead when she initially failed to reveal she went out to dinner on Black Saturday (she strongly denies such intent).
Victoria has a rattled government facing an election, and a premier desperate to win a poll in his own right, just as the bushfires inquiry into 173 deaths on Black Saturday is reaching its peak.
The spectacle of hounds baying for prey makes for mesmerising theatre. And it is true that there are legitimate questions about the actions of many individuals before, during and after that dreadful day.
But any bloodletting should not distract from the big systemic flaws that underlay the Black Saturday disaster. These problems included a peculiar view in emergency services of what constituted leadership; the way funding for bushfire response has languished for years; and the government’s continued denial that stay or go was a catastrophe waiting to happen.
When it came to arguing about leadership, there was some evidence that backed the claims of Russell Rees that control of emergencies needed to stay at the local level, and Christine Nixon’s claims that good leadership involves trusting to delegation.
Herman Leonard, professor of public management at Harvard University, is also co-director of the Kennedy School of Leadership and Crisis Management. He told the inquiry that emergency management had to be decentralised because only people on the ground could understand what was happening and what was needed.
He also warned that blaming or praising emergency chiefs for how well or badly a disaster was managed was a mistake. People preferred simple explanations for complex events, he said. “The easiest one is that the leader . . . did a good or a not-so-good job, and we tend to over-attribute to him or her both the success when things go well and the failure when things go badly . . . The burdens [this places] on a single individual are completely unsustainable in a large, complex enterprise. He or she can’t even know much of what is going on.”
He also warned against viewing a disaster with “20/20 hindsight”. “It always feels inevitable that it was going to turn out this way, and it always seems like it should have been obvious to the participants as it was going along that it was going to turn out this way. Neither of those is true.”
Professor Leonard’s argument does not lift either Rees or Nixon off their respective hooks because they are being hung out to dry over other issues as well. With Nixon, it is over her inattention to the fires that evening, and her failure to ensure that when she left headquarters, someone was there to take her place. With Rees, it is because he failed to ensure the system was set up to prioritise warnings, and failed to have senior officers check both warnings and actual management of fires. Headquarters did not learn that day of the system’s collapse in terms of the Kilmore East fire that killed 119 people.
This might have been discovered had supervisors done more active checking of what was happening down the line, but the senior leadership was extraordinarily passive. They did not take it upon themselves to check warnings, to check on local incident controllers, or to study predictive maps about where fires were heading, the inquiry has heard.
Senior counsel assisting, Jack Rush, QC, said: “It’s as if the senior fire personnel were powerless behind glass.” Rachel Doyle, SC, another counsel assisting, was dismissive of the state’s defence that the chiefs were not “commanding” but “co-ordinating” the response. “The state argues that when the chief fire officers walked into the Integrated Emergency Co-ordination Centre they shed their command-and-control obligations at the door like so many coats on a rack, apparently.”
Those issues have been addressed by changes made last summer.
Inquiries and reports had pointed out for decades that the great need on days of fast-moving fires was better community warnings. Fire chiefs went into Black Saturday having heard that message many times. The ability of individuals in large systems to overlook the bleeding obvious seems to be a chronic human failing.
While the government has tried to deal with the failures of emergency command, it has been resistant on the question of the failure of stay or go. It’s a big ask, politically, to admit they had it so badly wrong.
Neil Clelland, SC, for the state, argued that research into the Black Saturday deaths had found only 5 per cent of those who died were well prepared for bushfire and were carrying out active defence at the time of their deaths. The state did not accept that the research into deaths showed that the policy failed, he said.
Is this an argument that the policy was good and would have worked well if only people had been smart enough to follow it? That the 95 per cent who died not actively defending had somehow brought their fates upon themselves?
Remember the fury of fires that day. People had been told it would probably be safe to shelter in their homes, but windows exploded inwards with the force of the gusts, and showers of burning embers sprayed right through houses; roofs lifted off. The state’s argument does not allow for the fact that the ferocity of the Black Saturday fires shattered the stay-or-go notion that people save houses, and houses save people.
And it conveniently ignores the fact that for at least 10 years before Black Saturday, studies had found many people were not following the policy. They didn’t prepare their homes, buy fire equipment, or plan to leave early. They wanted to wait and see.
Victoria’s bureaucrats, Emergency Services Commissioner Bruce Esplin among them, kept saying this was a matter for re-education. But Harvard’s Professor Herman disagreed. He told the commission: “The hope that people might do something is not itself a policy; it is what it is, a hope.” He said a policy should be judged on whether people complied with it. If they didn’t, “The policy is actually an invitation to a potential disaster.”
What those wait-and-see people needed was early warnings, help with evacuations, and local refuges in case they were caught out. But since the mid-1990s, successive Victorian governments abandoned those measures, creating a new civic contract in which the state looked after the fires, and its citizens chose how best to look after themselves. That must not happen again.
Finally, there is the question of openness. Esplin had led just one of the many inquiries over the decades that suggested various changes to bushfire response. Victoria has a pattern: a deadly fire followed by an inquiry, which is followed by recommendations that then languish as the urgency fades.
It is not as exciting as the pursuit of Rees or Nixon, but perhaps the most pressing need is for an independent auditor of bushfire response who reports directly to Parliament and who, like an ombudsman or the auditor-general, can sound a public alarm when problems arise.
Meanwhile, the commissioners are under pressure about naming and blaming. They probably will ignore the political games. They have seen and heard too much to do otherwise. They know the details of the ways 173 people died and have listened to many of the bereaved. They will carry part of that anguish with them forever.
And they must know that a moral imperative underlies the writing of their work of history. There is great power in naming the truth; in the telling of stories, the hearing of stories and their recording for posterity, as South Africa’s truth and reconciliation process showed. It relieves the pain of the living, offers a memorial to the dead and a reminder for future generations that this must never happen again.

First published in The Age.

Minister kept in dark, fire probe told

IT WAS “troubling” that emergency chiefs failed to tell Police and Emergency Services Minister Bob Cameron that Victoria’s $212 million emergency paging system would run at less than a quarter of its capacity on a busy day, and that fixing it had been postponed several times, the Bushfires Royal Commission heard yesterday.
Counsel assisting the inquiry, Melinda Richard, said Victoria entered three fire seasons with agency chiefs knowing that the system would not cope with an extreme event, but “the minister was kept in the dark”.
She said the failure to fix the system “bespeaks a troubling degree of complacency within emergency services and the CFA in particular”. “The agencies . . . knew that the system wasn’t ready for a really big emergency.”
The Age revealed, and the inquiry later heard, that the pager system was overwhelmed on Black Saturday as it was locked down to low capacity because when it ran at higher speeds to carry more messages, it lost coverage.
Ms Richards said Mr Cameron testified that he was not briefed about the lockdown decision and his permission had not been sought for it, nor was he told about serial postponements of the software upgrade designed to fix it. “The minister’s understanding going into Black Saturday was that the agencies were happy with the pager system . . . What this tells us is that the minister was kept in the dark.”
She said that two days before the fires, “the minister sought assurances from the heads of the emergency services that they were ready for the Saturday to follow, and those assurances were given. At least in the case of the emergency alerting system, it was not ready.”
The system was introduced in 2006 and its weakness identified the same year. Extensive work has been done to fix it since Black Saturday, with $21.5 million allocated to it in last year’s budget. The system dispatches crews to fires and other incidents, carries wind change and other warnings, and carries administrative messages.
Kerri Judd, SC, for the state, said it had not been fixed earlier due to technical problems, including the need for final testing of a software upgrade. She argued that the state had taken care to protect the emergency-message level of the system, which delivered quickly on Black Saturday. “The state was taking action and no finding whatsoever should be made that the state was complacent about this,” she said.
Another counsel assisting, Peter Rozen, said that by June 2012 CFA fire vehicles should have a global positioning system or other vehicle location equipment for the sake of firefighter safety. He said this would help with incidents such as the crash into a ditch of a Warrandyte tanker in Kinglake on Black Saturday, which broke the spine of the crew leader.

First published in The Age.
He said repeated maydays from the Warrandyte crew were hampered by the fact that they were surrounded by smoke and flame and could not identify where they were — 200 metres from Kinglake fire station.

CFA disliked fire safety staff plan

THE CFA had an “antipathy” towards the idea of fire safety advisers and failed to appoint them to all but two control centres on Black Saturday, the Bushfires Royal Commission heard yesterday.
Fire safety advisers had been recommended by a coroner after five firefighters died at Linton in 1998, but agencies had vehemently opposed the idea then and only paid lip service to it now, said Peter Rozen, counsel assisting the commission.
Mr Rozen said the advisers were meant to examine incident controllers’ plans to check they prioritised the safety of firefighters, but that even control centres in charges of the biggest and most deadly fires that day, failed to appoint them.
“What we have is not an isolated example but a widespread non-compliance across a number of ICCs on what was recognised by all involved as the worst imaginable day, not only for the community of Victoria, but also for firefighter safety,” he said.
Mr Rozen said injuries and near-misses that could have produced multiple fatalities suggested much went wrong with safety on Black Saturday. He argued that Victoria should adopt the US-style system of fire safety officers, who have the right to veto operation plans that endangered firefighters.
Mr Rozen also criticised the internal inquiries run by the CFA into safety incidents. He said three crews out of the 19 crews who were hit by burnovers that day had been endangered when a wind-change warning was issued with the wrong time. An internal inquiry found this left them with a false sense of security.
But the incident controller who had authorised the incorrect warning had not been interviewed or notified of the inquiry’s findings, which indirectly criticised him, Mr Rozen said.
Neil Clelland, SC, for the state, said the CFA alone used 16,000 firefighters that day but only one had died, and he was not on duty. This indicated sound management, he said.

First published in The Age.

CFA chief a sacrificial lamb, QC tells fire probe

CFA chief Russell Rees had been singled out as a sacrificial lamb, “perhaps on the idea that the public needs to see a scalp taken as a result of this proceeding”, his lawyer told the Bushfires Royal Commission yesterday.
Julian Burnside, QC, said the commission had criticised Mr Rees unfairly and he had been “hounded in his evidence by counsel assisting”.
Mr Burnside said Mr Rees had shared responsibility on Black Saturday with the chief fire officer of the Department of Sustainability and Environment, Ewan Waller. But the transcript of Mr Rees’s evidence ran to 480 pages of largely hostile questioning, and Mr Waller’s to only 220 pages of mainly friendly examination, he said.
“The distinction between the two is most striking and is continued in the content of chapter nine, especially, of the interim report,” he said. “Unless there is personal fault found against either Mr Rees or Mr Waller, it would be grossly unfair to single one of them out for responsibility because the joint enterprise did not avoid the tragic consequences of Black Saturday . . . It is inappropriate to blame either of them, but it is grossly inappropriate and grossly unfair to blame just one of them.”
Mr Burnside said attacks on Mr Rees were ill conceived as expert witnesses had said emergency systems must be decentralised and those at the top should not interfere with those on the ground. He received a testy response from chairman Bernard Teague, who told him to hurry up as he was getting “a little tedious”
Jack Rush, QC, senior counsel assisting the commission, denied any difference in the approach taken to Mr Waller.
He said the extra pages of transcript reflected the broader responsibilities of the CFA, which managed most of the large fires on Black Saturday.
DSE manages fires that start on Crown land and was responsible for managing the Murrindindi fire, among others.
Mr Rees told the inquiry a major cause of the failure to issue warnings to people in the path of the Kilmore East fire was the move that summer to an integrated headquarters housing the CFA and DSE. He said in the CFA’s own headquarters, the information unit that released warnings sat near the state duty officer, “so it was very easy to tell when things weren’t going right”.
In the integrated headquarters, the two information units were together, but the two state duty officers were side by side in a separate room from the units: “In bringing the unit together, we solved one problem, but I believe we created another.”
He admitted headquarters had had no quality assurance process to ensure warnings matched predictions for the path of fires. Last summer, one person reporting directly to the chiefs was given that task. He said DSE firefighters should be under CFA command and warned that climate change meant Victoria must keep fire preparations at a high level to be ready for “that cataclysmic event”.
Mr Rees’s resignation from the CFA takes effect next month.
Police and Emergency Services Minister Bob Cameron will testify at the inquiry on Friday after a request from the commission this week.

State ‘against’ fire service merger

THE state government opposes merging all its fire services into one agency, partly because of problems with a hostile firefighters union, the Bushfires Royal Commission heard yesterday.
The stance was announced by Penny Armytage, secretary of the Department of Justice, in evidence that effectively silenced fire chiefs who had been asked by the inquiry to comment on the issue.
In her witness statement, Ms Armytage said amalgamation would be unlikely to bring great benefits and instead would disrupt the system, leaving its members more focused on their own futures than the need to plan for bushfires. She said it would probably cause:
■Despondency, loss of confidence and resignations.
■Loss of experience, as many senior staff would not find a place in the new entity.
■A long period of looking inward as staff jostled for position rather than focused on work benefiting the community.
She said that given “the present context” and climate change, “the state simply cannot afford to break in a new system, that is, suffer a loss — even temporarily — of operational effectiveness and continuity.”
The CFA, Metropolitan Fire Brigade and the Department of Sustainability and Environment had been asked to comment on amalgamation, but Ms Armytage told the inquiry that she was giving the “state-endorsed view from a whole-of-government perspective”.
In 2003, the CFA told the Esplin bushfire inquiry that it should take over the firefighting functions of the DSE, which manages forest fires.
Ms Armytage dodged questions from Rachel Doyle, SC, about whether the CFA had changed its stance on this, and about whether any of the fire chiefs had alternative proposals.
Ms Armytage said the agencies “have acknowledged the state’s position”.
The fact that the United Firefighters Union’s relationship with the management of the CFA and the MFB “could be characterised at times as being quite hostile and acrimonious” was a factor in the state’s decision, she said.
The government was also concerned that volunteers might be sidelined or disaffected by any structural changes.
The chief executive of the CFA, Mick Bourke, agreed under questioning that the CFA had asked last July for funding for another 684 career firefighters to cope with growing populations on the urban fringe.
He said he wrote to the UFU last month saying that he had written to Ms Armytage at the board’s request, telling her that the funding was a priority.
Ms Armytage said no decision would be made about the funding until after the commission’s final report, due in July.
Mr Bourke said the CFA’s current position on amalgamation was that the government should decide. In regard to union problems, he said the CFA had “some strong monopoly traits” and he hoped to work out good outcomes for all parties over time.

Volunteers and career firemen at loggerheads

THE often-hostile divide between the CFA’s volunteer and career firefighters widened yesterday as they staked out different sides of a turf war in a hearing of the Bushfires Royal Commission.
The United Firefighters Union wants all Victoria’s fire services merged into one, and about 10,000 volunteers ditched in favour of career officers.
Volunteer Fire Brigades Victoria opposed amalgamation and said it would damage the CFA’s community-oriented culture.
David Ackland, a volunteer firefighter in Seymour, said he would probably leave if any amalgamation of the CFA and the Metropolitan Fire Brigade led to a devaluing of volunteers.
“The way I see amalgamation is the start of the end of volunteerism,” he said. “I see career firefighters coming into my brigade . . . and basically taking over. I have seen and heard through the state where there’s a bit of friction [between the two groups] . . . I don’t want to see that happen. My region is totally volunteer firefighters and we are proud of that and we don’t want to see career staff coming into our stations.”
Mr Ackland and other witnesses painted a portrait of an agency captive to the union of its career officers, with the UFU allegedly having power of veto over CFA management decisions about issues ranging from protective clothing to the resourcing of volunteer brigades.
Mr Ackland said his region recently spent two years without a sessional instructor to provide training because career officers did not want the job but volunteers were effectively locked out of applying for it.
“This caused a great deal of unnecessary frustration for the volunteers,” he said. He would not want to put up with the inconvenience of workplace agreements, he said.
Professor David Hayward, dean of the school of global studies, social science and planning at RMIT, presented a report commissioned by the UFU that argued for a shift to career firefighters for large regional centres and for the whole of metropolitan Melbourne (one-third of greater Melbourne now falls under the CFA).
This would reduce duplication and difficulties associated with different equipment, uniforms and communications, he said.
Under his model of a Victorian Fire Board with a rural and an urban division, the reliance on volunteers would be lowered but it was not intended that it would disappear, he said. Professor Hayward said that over the next 30 years communities of only a few thousand people, such as Officer, would take on an inner-city character with new multi-storey dwellings that would require more urban firefighting techniques.
Lex de Man, a CFA area manager, said that in 2009, the CFA responded to 30,876 urban incidents and 8664 rural incidents, and the value of the work done by volunteers had been estimated at up to $840 million a year.
He acknowledged “there are tensions at times” between volunteers and career officers. Professor Hayward’s model would mean the loss of about 10,000 volunteers, he said.
Volunteer Firefighters Victoria CEO Andrew Ford said he had not seen any model of amalgamation that he believed would satisfy volunteers.