Setting priorities - what's important and not so important to a Coroner

I'm preparing this posting being reminded that we are into the period between the Jamieson Creek fire that occurred on 19 December 2015 and eventually rampaged on to devastate parts of the residential areas of Wye River and Separation Creek on Christmas Day and afterwards kept the fire and emergency services occupied for days.

The cost to the people of both settlements has been enormous, both financially, and emotionally for some I'm told. Then there's the other costs to the broader community, such as reliability of the Great Ocean Road.

If the Colac Otway Shire and the CFA had met their statutory fire prevention responsibilities, DELWP had been serious about its fuel management responsibilities according to the Code of Practice for Bushfire Management on Public Land, 2012 and Vicroads had worked cooperatively and effectively within the Colac Otway Shire Municipal Emergency Planning Committee, surely the effect of wildfire in the forest abutting the Great Ocean Road on soil stability would have been a serious consideration. Or maybe I'm being too generous and the knowledge and commitment is lacking in Vicroads.

Add to this the adverse effect of large scale tree removal on soil stability on reconstruction in Wye River and Separation Creek.

Were the trees damaged by fire to such an extent that large scale removal was considered necessary? Who made that decision and what was the criteria?

From my observations shortly after the fire the extent of tree removal seems wildly excessive, but then so is the broad-brush approach to bushfire attack level (BAL) ratings.

Let's digress a little. The Code of Practice for Bushfire Management on Public Land, 2012 is worth reading, particularly:

page 1 – under the heading "Primary objectives for bushfire management on public land in Victoria", first dot point. The Great Ocean Road would fall in the category "essential infrastructure", also known as "lifelines".

Clearly, the government through its agency DELWP failed miserably to meet the requirements of the "Code of Practice for Bushfire Management on Public Land, 2012" when it came to helping protect Wye River–Separation Creek and the strategically important Great Ocean Road. And here's an outcome that could have been avoided or at least substantially reduced if those responsible had done their jobs. It's known as "prevention" and it's far less costly than emergency response and recovery.

Some will remember a fire that occurred in the Lancefield area of Victoria that spread from an earlier DELWP fuel reduction burn-off. Premier Andrews was quick for the government to accept responsibility for the fire and promised compensation for people who could have done more to protect their homes. Here is one example of a house clearly lost from the effect of fire spreading from ember attack:

Lancefield, a fire that due to the fickleness of the weather and limited available resources a few days later escaped from a fuel reduction burn intended to protect those properties in the path of that fire.

Just imagine if later that year under different circumstances there had been no effort to reduce the fuel on the public land and a fire occurred from other causes, taking out those same unprepared properties. Would they have been eligible for compensation? Would the owners have been critical of DELWP for not fuel reducing the public land? Probably. Regardless, "a number of times Mr Fennessy [DELWP Secretary] said sorry to locals over the fire".

An obviously worried government commissioned inquiries that ultimately led to Premier Andrews departing from a recommendation of the Victorian Bushfires Royal Commission concerning a fuel reduction burning target. Any connection with a recent statement from EMC Lapsley concerning the failure to reach the fuel reduction burning target this year? A story in itself!

Shock and horror for the government, approximately 15 weeks later on 19 December 2015 lightning started a fire in the forest a relatively short distance southwest of Lorne, and the rest is very sad history for many people directly and indirectly affected.

No apology from the DELWP Secretary this time, just government 'spin' and cover-up at a high level.

Some health and safety and incident management considerations.

After telling us that aircraft were ineffective on the fire burning in a "gorge", as the fire was entering Wye River–Separation Creek I'm reliably informed that this large aircraft, the DC10 shown at the bottom in the following photograph, arrived overhead and dropped red fire retardant presumed to be Phos-Chek on a house in Stanway Drive, and possibly houses in the nearby Harrington and Sarsfield Streets, and maybe elsewhere in Separation Creek.

Though there was some cleaning and tank water replacement at the Stanway Drive house, are there houses nearby where people unknowingly drank, washed dishes, showered, etc, using contaminated tank water? Should this be worrying having regard to the concern being expressed over firefighting chemicals contaminating land around some defence establishments?

Lots of information available on firefighting foam and similar on the web. Four examples:

Bushfire CRC File Note

ASSESSMENT OF THE EFFECTIVENESS AND ENVIRONMENTAL RISK OF THE USE OF RETARDANTS TO ASSIST IN WILDFIRE CONTROL IN VICTORIA

EFFECTS OF WILDFIRE SUPPRESSION CHEMICALS ON PEOPLE AND THE ENVIRONMENT - A REVIEW

Fire retardants and health

A response from the government when questioned on the use of Phos-Chek over the settled area seems to disagree with what actually happened. Note that it lacks a date, possibly due to it being drafted by another and taking time to get before the signatory who, no doubt under some pressure at the time, accepted what was put before him and inadvertently neglected to date stamp it?

I'm not opposed to the use of safe additives to enhance the efficiency of water dropped from aircraft, but it must be done more judiciously than appears to be the case of the DC10 over Separation Creek during Christmas Day 2015.

QUESTIONS THAT DESERVE HONEST ANSWERS

Deployment of the DC10 Air Tanker

On deployment of this large aircraft to the fire that was already in the Separation Creek area, who made the decision to use it, was it the Incident Controller, was it under the direction of an accompanying Air Attack Supervisor or Birddog aircraft?

If under the direction of an Air Attack Supervisor or Birddog aircraft, why the decision to drop on a house amongst other houses when there could have been people present defending their homes?

I understand that this aircraft deployed direct from Sydney, dropped its load and returned to Sydney. If I'm correct, why at such a late stage in the day? Why was it not deployed when the fire first began to run or did the fire catch everyone 'napping'?

Expensive exercise committing that DC10 aircraft, was it cost-effective as a firefighting tool or was that not a consideration and the aircraft deployed from a level above the Incident Controller as a desperate last-gasp PR exercise?

For those interested in cost-effectiveness, and governments should be, the Bushfire CRC report "EVALUATION OF THE EFFECTIVENESS OF THE 10 TANKER AIR CARRIER DC-10 AIR TANKER, VICTORIA 2010" should be food for serious consideration. Whilst it may look impressive to the gullible masses, could the money have been better spent on prevention over the years prior to the fire?

Appreciation of the situation

Firefighter health and safety

A critical concern that should have been on the mind of the Incident Controller and above at the Regional Controller level was the health and safety of firefighters who, in the event of the fire getting away from its control line, would need to be deployed into Wye River and Separation Creek to save houses.

Due to the age and standard of construction of some buildings, there would have been vulnerable old buildings clad with asbestos fibre cement sheet. While a risk to CFA firefighters, would DELWP firefighters have been trained and equipped with the appropriate protective apparel to become involved with numerous burning houses in a residential environment the nature of those two settlements?

And what of the pathogens associated with old septic systems? Did any of the firefighters become directly exposed to systems damaged by the fire as they fought to save houses?

In conducting an early broad appreciation of the situation — if that was actually done — on which to base a suppression strategy and regularly review and update it as required, would the Incident Controller have been made aware of the failure of the Colac Otway Shire and the CFA to effectively address their statutory fire prevention responsibilities for both settlements hence their extreme vulnerability?

Would the Incident Controller also have been aware of the failure of DELWP to meet its fuel reduction burning plans for the forest between Lorne and Separation Creek, and the consequent critical need to 'pull all stops out' to extinguish the Jamieson Creek lightning strike before the wind increased later in the week?

Incident Management Arrangements

In establishing the Incident Management Team for this fire, was there 'churn' early on before an Incident Controller was settled on and if so why?

Concerning the Incident Controllers appointed to manage this fire, were they Level 3 qualified AND have the knowledge and on-the-ground forest firefighting experience required to successfully manage a forest fire in such a location as this to be able to recognise the appropriateness or otherwise of Incident Action Plans developed for his/her approval?

What arrangements, if any, were in place to assess ongoing effectiveness of Incident Action Plans and adjust accordingly?

Were there any financial, environmental or political limits imposed on the firefight?

Fuel reduction burn off

To me, it is beyond comprehension that this fire was not contained and made safe in the first couple of days.

It begs the question, was the failure to make this fire safe due to DELWP using it as an opportunity to undertake some fuel reduction burning off that had previously been denied it for 'political reasons' in the recent past?

That the forest burned so vigorously surely must question the government's statements that the forest had been to damp to fuel reduce.

Coronial investigation

To conclude, there are numerous questions around the failure to extinguish the lightning strike before it eventually took off to devastate Wye River–Separation Creek.

Towards the end of January, State Coroner, Judge Sarah Hinchey "determined that it was in the public interest to investigate the fire". Since then, nothing from Coroner Hinchey, except for a response from the Coroners Court to an inquiry from me early last week: "Unfortunately I cannot provide any time frames as to when the investigation will be complete."

Far be it from me to suggest what should be important and not so important to a Coroner setting work priorities, but given the requests for an investigation or inquiry, including one from the United Fire Fighters Union that I imagine would have known of firefighter health and safety concerns, I'm surprised that there's "no time frames as to when the investigation will be complete".

Given the time that has elapsed the evidence will be 'cold' and memories dimming, I'm beginning to wonder, was the Coroner influenced by the government — no doubt concerned over the potential for compensation claims — to give the investigation a low priority in the hope that it would go away?

Or is the Coroner the victim of a 'snow job' in the form of mountains of paper presenting the government's position?

Coronial Inquiry

As a concerned stakeholder citizen of Victoria I respectfully urge the Coroner conduct an open Inquiry and subpoena key players at all levels to give evidence and be able to be cross-examined for this shameful episode in our history to be fully transparent, if for no other reason that it must not be allowed to happen again.

Finally, there are 'key players' out there patting themselves on their backs that this was a very successful operation. On the contrary it was and is an ongoing disaster for many who put their trust in the emergency services, particularly the CFA that relies on community support to function.