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.