Lest we forget the victims

The Bushfires Royal Commission will tell us what must be done to avert similar tragedies. Those findings, and the urgent need to act on them, are underscored by the stories of the 173 people who died on that dark day.
OVER the next few weeks, there will be strong debate about what we should learn from Black Saturday. Media headlines will be about what we do next — and how to pay for it. For those who have been touched by the work of the Bushfires Royal Commission, however, it is not the policy debate that will haunt. It is what has been learned about the last moments of the 173 people who died.
There was the 16-year-old boy, fleeing flames across a paddock, running with his father and mother and two younger brothers. They came to a barbed wire fence. The boy and his father scrambled over it. The others, struggling to breathe despite thick smoke and searing heat, could not.
The son told police, “We got down low so we could breathe but I realised that mum [and my brothers] were still on the other side of the fence . . . I pushed it down and I was looking around to see if I could find ’em. I was moving my arms to see if I could touch them to drag ’em over. I couldn’t find ’em but all I could hear was them screaming, and in the background I could hear my dad calling me back, saying to get out of there ’cause he would have lost me too, and he was calling me and calling me and . . . it was just getting too hot. My shoes were melting, I burned my legs and my elbows. I had to get out. I jumped over the gate again and I got to the road. All I could hear was them screaming and calling our names, saying they were burning. Dad tried to go back himself but I held him back. I said, ‘You couldn’t go in there’. Otherwise he would die. It was too hot.”
At the heart and soul of the work of this commission is the horrifying loss of 173 people, and the suffering it has meant for those left behind. During 83 hearings into deaths from fires, the royal commissioners heard many other anguished stories of families separated in fires, of whole families in which parents and young children died together, and of the last-ditch phone calls that many of those about to die made to their loved ones to say goodbye.
The commission needed to get a picture of each individual death, and a sense of what the fire plan had been in each case, in order to assess how well the state’s “stay or go” policy had worked. But it also wanted to minimise distress for the bereaved, many still deeply traumatised. More than 450 family members, friends and workmates came to the hearings.
The deaths’ inquiries were held in a small annexe, rather than the main hearing room, and they were not webcast, which made them more private. Photographs shown during the hearings were digitally altered to remove images that would have upset loved ones, and the evidence was given in hearsay summaries of witness statements. Families had the chance to ask questions or make comments at the end of each hearing, and psychologists were available to help anyone who needed it.
All the evidence was given by Detective Superintendent Paul Hollowood, head of Operation Phoenix, the police taskforce investigating the fire deaths. He told the inquiry more than 450 investigators worked on Phoenix: “At one stage there half our investigative effort for all of Victoria was actually dedicated to these fires.”
It is clear that many people died because they wanted to save their homes. Hollowood told of an 83-year-old Marysville man who refused his family’s pleas to evacuate the home he had built with his own hands, saying: “I’m going down with the ship.” The man’s son told police that his father had restricted mobility because he had fallen and hurt his back a few days before Black Saturday, but “the house was more than a house, not only to my father but to our family. Many family Christmases and other special events were held at the house and it was like a base for us all. It was because . . . [it] was like sacred ground to my family that my father chose to stay and defend the property.”
A Hazeldene man, 87, also refused to evacuate because he did not want to abandon his home. His wife would not leave him. Their son would not leave his parents, and the son’s wife would not leave her husband, even though it had always been her plan to get out if fire threatened. They all stayed, and they all perished.
But, while some ignored warnings, more died because they failed to receive any, or because their homes were never going to be defendable on a day of such extreme conditions. The commission heard that the four members of the Davey family of Kinglake lived on a heavily forested ridge and that a narrow gully effectively directed fire to their home. It also heard that Michael Flynn, who died of his burns after being transported to help in the back of a Kinglake West CFA truck, had always planned to evacuate in case of fire and might have survived had an urgent warning requested by the Whittlesea CFA captain at 3.58pm been uploaded on the CFA website.
Black Saturday overturned the conventional wisdom on bushfire safety. In the past, people inside houses mostly survived, and around a third of those who died were people who were on the road because they had fled too late. On Black Saturday, only 14 per cent of those who died were fleeing, either in cars or on foot. But a remarkable 69 per cent (113) died trying to shelter inside houses, sheds or bunkers.
John Handmer is head of RMIT University’s Centre for Risk and Community Safety. He and two other academics were asked by the commission to report on the deaths and what they implied for the stay or go policy. Mobile phone and computer records mean that there is an unprecedented amount of information available about the intentions and final actions of those who died that day. Handmer concluded that the stay or go policy might be sound on paper but that it presented “major challenges, particularly for very fast-moving and intense bushfires”. He found:
■Most of those who died were unaware of fire risk generally, and what the extreme conditions that day meant.
■Only half had a fire plan, many of those were of poor quality, and even the good plans had weak links.
■Forty-four per cent of those who died were vulnerable because of age, youth or disability.
■Disagreements between men and women over whether to evacuate (women wanted to go, men wanted to say) led to last-minute changes in plans or failure to commit to action in time.
■For 32 per cent, the defensibility of the property was questionable, and severe wind damage to roofs or windows emerged as a new factor that opened houses to fire attack.
■Thirty per cent were taken by surprise, and fewer than 10 per cent received an official warning.
■Many who fled in cars survived, and it was possible that modern cars provided better protection than in the past.
Handmer concluded the evidence supported the stay or go idea that it was dangerous to shelter “passively” — but he also found that “most people who became fatalities did not, and could not, respond appropriately to the risk that the bushfires presented for them on 7 February 2009 . . . This highlights the key role of clear advice tailored to people’s circumstances, timely and specific information and warnings, and of safe accessible places for people . . . to relocate to. It also suggests implications for policy-makers in the fields of land-use planning, development control and the management of bushfire fuels.”
Many bereaved relatives who attended the hearings expressed hope that the commission would lead to change.
One of them was Jill Scherman. Her son, Greg Lloyd, 22, was holidaying with two friends at a relative’s house in Steels Creek on Black Saturday. He was in phone contact with family that afternoon and reported that the house was full of smoke. By 6.18pm, he had given up all hope. He rang his mother on his mobile to say goodbye: “We are in the bathroom together, Mum. I love you very much and I am dying. I want you to know we are OK together.” His mother later said: “He was quiet, calm and peaceful. There was a click on the phone and then we lost contact.” All three died.
His mother told the commission: “In the usual course of life, you cannot gain experience without paying a price. But in the experience of the many bushfire-affected families of this state and those in charge of systems, agencies etc, the price has been immeasurable, and not learning from this experience would be even more costly, adding to the agony . . . To those in government responsible for ensuring that systems recommended by this royal commission are put in place, please listen and don’t allow further tragedy.”

First published in The Age.
The final report will be available online this afternoon at www.royalcommission.vic.gov.au. Free copies can be ordered from Information Victoria on 1800 463 684.

Plea for a revolution


BEFORE Black Saturday, Leigh and Charmian Ahern would have made a poster couple for Victoria’s bushfire policy, “stay or go”. They had always taken seriously the threat associated with life in a heavily forested area. They belonged to their local Fireguard group and had installed an elaborate fire-fighting system: two tanks with 20,000 litres of water each, a fire pump, a spray backpack for spot fires and roof sprinkler systems. Water pipes were buried to protect them from heat. Leigh Ahern kept the place clear of leaves and debris and regularly tested the fire system.
Their fire plan was based on the “stay and defend” option. This part of the state’s policy said able-bodied people actively defending a well-prepared house had a very good chance against fire; houses protect people, and people protect houses, was the mantra. Even an ill-prepared home would probably shelter people against radiant heat while a fire front passed over.
But the Aherns became two of the 173 people whose ghosts haunt Victoria’s policy-makers.
Fire ignited in the roof space of their Steels Creek home after wind lifted the roofing sheets, making all their preparation useless, arson chemist Karen Ireland told the Bushfires Royal Commission. “Once the roof sheets became detached, the sprinkler system would have been rendered ineffective . . . The occupants would have struggled to extinguish multiple fires within the home . . . and they would have been exposed to extreme temperature, wind and smoke.”
Roofs ripped off by fierce bushfire winds led to the deaths of many that day. It was one of several deadly possibilities not mentioned in bushfire advice offered to country people. And it is one of the Black Saturday problems the state government seems reluctant to acknowledge.
The government appears to be positioning itself to muffle or reject parts of the final report of the Bushfires Royal Commission, to be released next Saturday.
This week, Premier John Brumby initially announced he would not even respond to the commission’s findings until the government had spent weeks consulting with the public, agencies and business groups “to ensure that the concerns of the community are properly addressed” — even though that is precisely what the commission has just spent $40 million and 14 months doing.
It was only following pressure from Opposition Leader Ted Baillieu that the Premier agreed to hold a parliamentary debate the week after the report is released.
The government effectively put itself on trial when it set up the royal commission last year. Like any accused, it seems to fear the verdict. It is an election year, and the final report can only mean trouble — even though the explosive energy around failures in emergency leadership has now been effectively neutered.
CFA chief Russell Rees, who presided over a chaotic system that failed to warn thousands in the path of the most deadly fire, resigned this year (although it is believed the decision that he would go was made last year). Former chief police commissioner Christine Nixon found herself in the village stocks for having gone out to dinner on Black Saturday despite knowing a disaster was unfolding, and for fudging her evidence on that point to the commission. Now she, too, is gone, having fallen on her sword as head of the recovery effort last week. While neither admitted quitting over Black Saturday, their absence from the public arena is a blessing for the government.
But there are other big problems for which there is no easy “exit, stage right”. The first is the government’s responsibility for the failures of its stay or go policy (more formally known as the Prepare, Stay and Defend or Leave Early policy). The second is its declared reluctance to pursue some of the likely recommendations.
The inquiry heard that, for more than 20 years, experts had warned that the stay or go policy had problems, but successive governments and their mandarins failed to act. They included:
■1984 Ash Wednesday researchers found that fires starting in roofs were dangerous to occupants, who were unlikely to survive if houses were destroyed quickly. They also warned that people in houses surrounded by exceptionally high levels of fuel, such as those near mountains or ash gullies, might be wiser to evacuate.
■1992 CFA researchers studying the 32 civilian deaths on Ash Wednesday concluded that if people did not receive a warning in time, a good understanding of bushfire safety was irrelevant.
■1999 Researchers told the CFA the stay or go policy was asking people to make extremely complex decisions, and that most people ignored it: “Those who really conform to the two ideas of the Stay or Go Early options are in the minority . . . It is highly likely that there will be people who will ‘wait and see’ or ‘do as much as possible’ then leave.” This report told the CFA it had to develop new strategies for those people.
■2004 A report called for different survival strategies for extreme events that might make it hard to stay and defend; assessment of the effect inadequate warnings might have on the safety of those preparing to stay; and a definition of when it was not safe to stay.
■2008 A study of 552 bushfire deaths over 100 years largely backed the policy but said even those who planned to stay and defend were often not well prepared, had no back-up plan and did not expect the ferocity of fire or sudden wind changes.
Lisa Nichols, counsel assisting, said the caveats in these studies were ignored, and that bushfire advice to the public also wrongly presented staying and going as almost equal in terms of safety.
Stay or go solidified as policy from the mid-1990s, when there was a shift in the balance of responsibility over bushfire in Victoria. Much of the burden for human safety was lifted from emergency services and placed on people living in the bush. Authorities called this “shared responsibility”.
But the commission’s lawyers say this led to authorities ducking responsibility and abandoning other protective measures, such as refuges. Nichols said stay or go also meant “excluding assisted or directed evacuation, excluding giving specified advice about the defendability of homes and excluding the giving of concrete, directive warnings during fires”.
Instead, warnings were designed for those who had prepared to stay, telling them to activate their fire plan and offering little help to those who had no idea what to do. On Black Saturday, even that limited warning system collapsed: an incident controller who felt bound by protocol refused to issue warnings over the Kilmore fire; those managing other fires also failed to alert the public, and to alert firefighters to the dangers of a wind change; and those higher up the CFA and police hierarchies failed to notice that warnings were inadequate.
Despite stay or go telling people to make their own choices, research found the community continued to believe emergency services would help them during bushfire. Authorities persisted in believing that education would change people’s attitudes and behaviour.
It didn’t.
Counsel assisting said in a submission: “The evidence did not support . . . the offering of a one-size-fits-all choice between two apparently equal options for survival, the ruling out of back-up options and the effective removal of the role of fire agencies in giving advice and assistance during fires. Well before 7 February 2009, the risks, ambiguities and leaps of faith exposed in the analysis of a decade earlier ought to have been obvious to policy-makers . . . The community was, because of the stay or go policy, predisposed to suffering major losses.”
At hearings, the government vehemently denied that it had ignored warnings about the policy. It conceded Black Saturday showed up “weaknesses” but said no one could have foreseen them and that it should not be abandoned. Neil Clelland, SC, said it was the approach in all states and territories and was based on 100 years of “bitter experience” that people who sheltered in houses were likely to live, and people who fled late were more likely to die.
“Nowhere was it suggested, right up until the eve of 7 February, that the policy should be abandoned, or that it was flawed, or even that it exposed people to the risk of death,” he said.
But the intention to stay and defend played a significant part in deaths, disaster expert Professor John Handmer, of RMIT University, told the inquiry. He said this was an indictment of the policy and agreed it called on ordinary people to fight fires in situations where we would not put our most experienced firefighters.
Lawyer Clelland argued that Handmer found only 5 per cent of people who died were well prepared and carrying out an active defence at the time of their deaths, and this did not suggest the policy had failed.
But crisis expert Professor Herman Leonard, of Harvard University, 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”.
MOST of those who died were not like the Aherns; they had no intention of defending but did not receive enough help or warning to escape in time. An extraordinary 44 per cent were vulnerable because of youth, age, illness or disability.
The oldest was Karma Hastwell, 88, who used a walking frame, and the youngest was Alexis Davey, who was eight months old and just starting to crawl; both died sheltering with able adults in Kinglake. A Marysville woman was eight-and-a-half months pregnant; an elderly couple died at Narbethong with their son, who was in a wheelchair; and a disabled man with epilepsy, schizophrenia and palsy caught alight in his driveway in Bendigo. Foreign tourists with no understanding of wildfire died on a bush track near Marysville.
Many others who thought they were well prepared were caught out by a single weak link: a failed fuel pump, melted water pipes, or windows that exploded and exposed them to a blizzard of embers.
Stay or go failed to provide a contingency plan, a place to go when all else had failed, or even a specific warning to “Get out, now!” Police superintendent Rod Collins said police believed the policy left them unable to organise fire evacuations: residents were permitted to defend their properties, which meant “you effectively have a right to make a decision about staying and dying”.
Lawyers for the commission want a revolution. They want people warned that defending could mean death or injury. They want evacuations prioritised, with incident controllers made responsible for issuing specific advice — including routes, if possible. They want sites nominated as places where people can shelter during fire. They want local councils to keep a list of vulnerable residents who might need early warning, and they suggest police should help them leave.
And here is where the crevasse between the parties widens. Councils don’t want to be responsible for such lists and the state says it is not possible for police to be responsible for evacuating individuals, or for incident controllers to tell residents when or how to evacuate. The state denied it was dragging its feet over community shelters, even though Victoria still has only one formal fire refuge and 83 Neighbourhood Safer Places designated, compared with 600 in New South Wales.
Even late in the hearings, Emergency Services Commissioner Bruce Esplin was resisting the idea of a range of safety choices. He warned: “The difficulty with a suite of options . . . is that it might encourage individuals who would otherwise choose the less risky ‘leave early’ option to feel unrealistically more secure there are ‘other options’.”
To its credit, the government has implemented bushfire changes costing tens of millions of dollars. Emergency services have better warning systems, staffing, training and communications. There are new fire danger ratings, advice to householders on the defendability of their homes, improved bushfire resistance in school buildings and township protection programs for 52 high-risk areas. An enormous amount of thought, time and energy has gone into doing a lot, fast.
But the final report might call for even more dramatic and expensive measures. Counsel assisting, Melinda Richards, has argued for a buyback of high bushfire-risk land to allow residents to move to safer places in a “retreat and resettlement” strategy. Richards also said development of 50,000 small lots outside the urban growth boundary should be limited. They have no reticulated water, poor road access and many are too small to achieve defendable space, a combination one witness called “death-trap planning”.
The government opposes the buyback because it would be expensive and complex, said a lawyer for the state, Kerri Judd, SC. More public land might raise the bushfire risk for people left behind and communities would suffer from population loss, she warned.
Another proposal that would cost billions is a massive upgrade of the state’s ageing electricity system. Five of the biggest blazes on Black Saturday, including the Kilmore East fire that killed 119 people, were allegedly started by electrical lines or fittings.
Jonathan Beach, QC, for power company SP AusNet, said the proposals would cost up to $7.5 billion in its distribution area and could force up power bills 20 per cent every year for 20 years — not a prospect any government would relish.
It was bad luck for the Brumby government that Black Saturday happened on its watch. The stay or go policy seems to have been seeded initially under the Kennett government. If it were not for 12 years of drought and 11 consecutive days of searing heat, Black Saturday might not have become Australia’s worst bushfire catastrophe.
But it did, Victoria was not ready for it, and Labor was at the helm. Now it faces the ugly reality that serious improvement in public safety in the most fire-prone place on the planet requires vast sums of money over a long time — and even then, it will never guarantee safety for all.
The Aherns’ son, Dale, says: “My parents were prepared for bushfire. They were not prepared for what hit them that day. We just hope that future policies will reflect the new reality that no one had imagined prior.”
Next Saturday, we will learn the commissioners’ verdicts. The government’s verdicts on which proposals will be accepted are likely to dribble out over weeks or months. The voters’ verdicts will come when the Premier faces the polls.