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.