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.

Terror defendants ‘were mistreated’

TERROR defendant Bassam Raad, who was this week acquitted of all charges, claimed a German shepherd dog sniffed around his naked genitals during a strip-search by guards at Barwon Prison.
Mr Raad claimed he was made to stand naked for 10 minutes and apologise for calling the officers “pigs” before being allowed to put his clothes back on. He alleged the incident involved three guards and a dog handler and occurred on March 22 last year.
Other claims were made about ill-treatment in jail of the accused in the Benbrika terror trial, which concluded this week. They include allegations of assault, of men spending hours in a van with no water and no air circulation on a hot day, and of asthmatics being forbidden from carrying their inhalers on two-hour road trips.
The incidents allegedly occurred when the men were in high-security at Barwon Prison and commuting to court in the city each weekday.
Their daily routine involved rising at 5.30am, spending four hours in transit with their hands and feet shackled and being subjected to at least two strip-searches. Lawyers said they saw no daylight except when entering and leaving the van.
The claims can be revealed following verdicts this week in the trial of Abdul Nacer Benbrika and 11 other Melbourne Muslims on charges of fostering terror in the pursuit of violent jihad. Seven were convicted, four acquitted and no verdict was reached for one defendant.
Bassam Raad’s claims were made in an affidavit by his then solicitor, Peta Murphy, which was tendered on March 27 last year during pre-trial hearings.
The affidavit also made other complaints about the way Bassam Raad and others had allegedly been treated when returning to Barwon jail, near Lara, after court in Melbourne on March 22.
Mr Raad, along with Hany Taha (who was also acquitted) and Benbrika, later complained that they had been assaulted by Security and Emergency Services Group escort officers that day.
Mr Taha said he was manhandled, resulting in a mark on his left arm, and Benbrika alleged he was pushed into a holding cell and assaulted.
The complaints were referred to police, who concluded there was insufficient evidence to support the allegations.
That the assault claims were reported to police was revealed in an affidavit to the Supreme Court in June last year by Michael Carroll, acting deputy commissioner of prisons.
Mr Carroll said the men were rated in prison as “A1”, the highest security risk. He said this was due to the seriousness of their charges, the risk that they might join together to threaten prison security, their likely danger to the community if they escaped, and the risk to the defendants from other prisoners “when the defendants may be vocal in contrary views from those of other prisoners”.
He said the rating was based on information about the defendants from Australian Federal Police. He said jails had since developed a national policy on dealing with those accused of terrorism offences.
“In May 2007, the Correctional Services Administrators Conference agreed in principle with the approach taken to deal with prisoners charged with terrorism offences in security classification and reviewing their security status,” he said.
In her affidavit, Ms Murphy said the men claimed that on March 22 the air-conditioning had failed in one prison van, leaving no ventilation on the 33-degree day, and that in the other van the air-conditioning was flipping between extreme heat and extreme cold.
When the armour-plated trucks reached the jail, the men were left inside without air circulation and denied water for up to one hour and 45 minutes, the affidavit said. One of the vans was parked in the sun.
Ms Murphy said the men told her that they were sweating profusely and suffered from dehydration, dizziness and breathing difficulties and that defendant Shane Kent lost consciousness. (The jury this week failed to reach a verdict on whether Shane Kent was a member of the organisation.)
Ezzit Raad vomited several times throughout the night, she said, and another three defendants requested consultations with a psychiatric nurse following the incident. (Ezzit Raad was this week convicted of being a member and of attempting to make funds available to the organisation.)
Ms Murphy’s affidavit was was not relied on in the proceedings as it was hearsay.
Benbrika’s lawyer, Remy Van de Wiel, QC, told the court: “I mean, not even Carl Williams, a man who has reportedly … killed 10 people, suffers the deprivations that these people do in custody.”
Mr Carroll said he had reviewed the failure of air-conditioning on March 22. “I consider it was a most unfortunate incident … Now that checking of the air-conditioning is a standard part of servicing of the truck, I believe the risk of breakdown of the air-conditioning should be substantially minimised.”
The long-running issue of the men’s jail conditions came to a head publicly in March this year when defence lawyers applied to have the trial stopped on the basis that the men’s treatment was inhumane and prevented the trial from being fair.
Justice Bernard Bongiorno agreed that the regime was intolerable. He said he would stop the trial and consider bail applications if the men were not moved to the Metropolitan Assessment Prison. He said they should not be shackled and should not be strip-searched if they had been under constant supervision in secure areas.
His warning followed a weekend in which two of the defendants were moved in crisis from Barwon and assessed as having psychiatric conditions.
The 12 men were moved and their security regime eased.
· See a terror trial multimedia special

Errors led to bushfire tragedy

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.
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.

Leaders seek to spin their way forward

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

“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
– 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.
– 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.
– END ABC’S exclusive role as emergency broadcaster and enlist commercial networks in disseminating bushfire warnings.
First published in The Age.


‘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.

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.”
– 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.

The system that failed its bravest

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

Lessons still to learn

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