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Case Number: 2021/224481
Findings Date: 27 March 2024
Magistrate: Teresa O'Sullivan
CORONIAL LAW | report on findings and recommendations made in 41 inquiries in respect of more than 110 reported fires and 25 deaths resulting from those fires during the 2019/2020 Black Summer Bushfires
The people who sadly lost their lives in connection with the 2019/2020 NSW bushfires were: Laurence Andrew; Russell Bratby; Colin Burns; John Butler; Michael Campbell; Vivien Chaplain; Michael Clarke; Rick DeMorgan Jr; Julie Fletcher; David Harrison; Paul Hudson; Gwendoline Hyde; Geoffrey Keaton; Robert Lindsay; Ian McBeth; Samuel McPaul; George Nole; Andrew O'Dwyer; Barry Parsons; Ross Rixon; Patrick Salway; Robert Salway; Christopher Savva; John Smith; and Richard Steele
| Recommendations to | Response |
|---|---|
| Commissioner of the NSW Rural Fire Service | Received |
| Commissioner of the NSW Police Force | Awaiting |
| Chief Executive Officer Essential Energy | Received |
1. The NSW Rural Fire Service review its training for Aviation and Incident Management Roles and ensure (if it does not already) that the training emphasises that tasking decisions for Very Large Air Tankers and Large Air Tankers are not to be made at a local Incident Management Team level, but at the level of State Operations.
2. The NSW Rural Fire Service develop a Flight Risk Assessment Tool for decisions about the tasking of Large Air Tankers/Very Large Air Tankers.
3. The NSW Rural Fire Service identify further guidance in its Operating Guidelines for Air Tanker Operations thresholds or assessment considerations for what constitutes ‘forecast adverse weather, poor visibility, turbulence’, such that an Initial Attack certified pilot requires a Birddog and/or Air Attack Supervisor.
4. The NSW Rural Fire Service amend its Operational Management Procedure: Rejection of Aviation Dispatch/Tasking to consistently record that, as well as a tasking rejection, the reason for the tasking rejection is to be communicated by the State Air Desk to other aircraft tasked, or likely to be tasked, to that region.
5. Policies/procedures be developed to ensure that pilots are provided with the following information:
a. weather forecast for the shift or tasking area, including fire danger and expected winds;
b. any local area assets’ rejections of taskings, where the reasons for the rejection of tasking would be relevant to other aircraft;
c. any reports received from the local area, including information from other aircraft and ground crews as to conditions such as wind conditions and visibility;
d. any known hazards;
e. contact details (including phone numbers and radio frequencies) for the fire ground or target, as well as other aircrafts assigned to the incident;
f. summary of assets in the area, including ground crew and other aircraft, and the status of those assets;
g. targets or mission intent and locations in formats that can be used by aircrafts, assets for protection and strategy for aerial operations to support the fire ground;
h. fire status and condition; and
i. air space, temporary flight restrictions and airport closures.
6. Pilots be provided with any current Incident Action Plans for any fire to which they are tasked. Such Incident Action Plans is to include at a minimum:
a. contact details (including phone numbers and radio frequencies) for the tasking fireground or target; and
b. contact details for other aircraft assigned to the incident.
7. The NSW Rural Fire Service, in consultation with stakeholder representatives, consider what improvements may be possible with communication systems and processes between aircraft, incident ground resources, Incident Management Teams and the State Air Desk.
8. On days of heightened fire activity across the State, resources be made available so that the State Air Desk can be organised such that there are duty and aviation officers assigned to specific regions (for example, Central-Metro, Southern, Northern, Western).
9. The NSW Rural Fire Service conduct pre-season briefings/inductions with pilots in respect of NSW Rural Fire Service communications and NSW Rural Fire Service operational functions and capabilities.
10. The NSW Rural Fire Service conduct training simulations for its officers of potential situations where aerial firefighting aircraft will need to be dispatched, with an aim to educate regarding tasking, decision-making and communication.
11. That the NSW Rural Fire Service review its Authorised Fire Investigator training and consider providing refresher training to specifically incorporate the following matters:
a. that an Authorised Fire Investigator is encouraged, as part of their canvassing, to contact the Police Officer-in-Charge of a bushfire investigation to request any information relating to origin and cause of the fire, obtained by the Officer-in-Charge up to that point, that the Officer-in-Charge is prepared to release;
b. that an Authorised Fire Investigator may advise the Police Officer-in-Charge of a bushfire investigation of the desirability to seize exhibits if they have not already done so;
c. that an Authorised Fire Investigator is encouraged as part of their canvassing to contact private landowners or land tenure managers (such as the National Parks and Wildlife Service, the Forestry Corporation of NSW, or Crown Lands NSW) at the area where a bushfire is believed to have originated, to inquire about any information which may be relevant to determining the cause and origin of the bushfire;
d. that an Authorised Fire Investigator should include within their report any information obtained at the scene which might bear upon their conclusion as to cause and origin, even if that information is contrary to the final conclusion reached; and
e. the appropriate procedure to be followed when an Authorised Fire Investigator becomes aware of information, after their fire investigation report has been finalised, which causes them to change their opinion as to the cause and origin of the fire.
12. That the NSW Rural Fire Service review Standard Operating Procedures 3.1.9 to:
a. incorporate matters referred to in Recommendations 11 and 25d; and
b. provide that, where it is suspected that a wildfire has breached containment lines or proposed containment lines, leading to a significant escalation of a fire, the Fire Investigation and Compliance Unit should consider:
i. asking an Authorised Fire Investigator to examine the scene of the containment line breach to determine the cause of the breach; and
ii. asking the NSW Rural Fire Service’s Predictive Services Unit to undertake modelling to consider what would have occurred if the backburn in question had not been done.
13. The NSW Rural Fire Service review its training for positions within an Incident Management Team to ascertain whether there is scope for improvement to better equip staff to determine:
a. whether intelligence needs to be verified; and
b. the appropriate steps to be taken to obtain that verification.
14. The NSW Rural Fire Service investigate the possibility of improved integration of the emergency alert system within the Rural Fire Service system, with a view to limiting the duplication of the entry of information, such as polygons and the text of emergency warnings.
15. The NSW Rural Fire Service develop training for Public Liaison Officers and Incident Controllers that addresses the significance of early warning to communities with limited access to reliable communication systems.
16. The NSW Rural Fire Service amend its policies and training (where required) to ensure that where a breakout prediction has been carried out, the completion of that prediction is logged in the ICON system.
17. In establishing automated alerts in the Athena system, the NSW Rural Fire Service ensure that alerts are to be sent to the Incident Controller, Fire Behaviour Analysts within the Incident Management Team, and the Public Liaison Officer of the completion of any fire prediction within the section 44 declaration area of that Incident Management Team.
18. The NSW Rural Fire Service carry out a review to determine:
a. appropriate means to better ensure the prompt uploading of reports from the fireground onto the ICON system, including through the use of technology in note taking;
b. whether there is a need for further training of Incident Management Team personnel to ensure that information relevant to fire prediction is provided promptly to Fire Behaviour Analysts; and
c. whether there is a means to make available to NSW Rural Fire Service staff recordings of telephone calls and radio messages in the period immediately after the receipt of that call or message.
19. The NSW Rural Fire Service, either itself (if feasible) or through the Australasian Fire Authorities Council, cause the Vesta Mk II fire prediction model to be incorporated within the SPARK software.
20. The NSW Rural Fire Service continue to work with the Bureau of Meteorology towards:
a. developing fire-atmosphere coupled modelling; and
b. obtaining a better understanding of the interrelationship between atmospheric instability and bushfire, including to develop ensemble forecasting capabilities, to be integrated into training of Fire Behaviour Analysts and the development or refinement of models for fire prediction.
21. That the NSW Rural Fire Service engage Monash University Accident Research Centre, or an equivalent expert body, to:
a. establish a fit for purpose set of rollover and falling object test criteria; and
b. assess potential design solutions for rollover and falling object protection in an experimental setting.
22. That, in its role as a participating member of Australasian Fire Authorities Council, NSW Rural Fire Service is to make representations to Australasian Fire Authorities Council to the effect that Australasian Fire Authorities Council is to consider engaging with Standards Australia in relation to the development of a data supported minimum Australian Standard (or Standards) which addresses the crashworthiness test criteria and experimental setting for testing of rollover protection, falling object protection structures, and cabin strength for frontal impacts for such firefighting appliances, noting that any such representation should not impede the work of NSW Rural Fire Service in implementing safety measures at the State level.
23. That the NSW Rural Fire Service provide Australasian Fire Authorities Council with a copy of the following documents:
a. Expert Reports of Professor Raphael Grzebieta dated 14 December 2022 and 26 March 2023;
b. NSW Rural Fire Service: Fleet Safety Summary Report of Monash University Accident Research Centre dated March 2023;
c. NSW Rural Fire Service: Vehicle Safety Technical Report of Monash University Accident Research Centre dated March 2023;
d. Transcript of the oral evidence of Professor Grzebieta, Associate Professor David Logan, and Dr Shane Richardson given on 29 March 2023; and
e. Copy of any findings relevant to:
i. the Vehicle Design & Safety Stage 2 Inquiry;
ii. the Inquest into the death of Geoffrey Keaton and Andrew O’Dwyer; and
iii. the Inquest into the death of Samuel McPaul.
24. That the NSW Police Force review any related Standard Operating Procedures to incorporate matters referred to in Recommendation 25b to 25d.
The Commissioner of the NSW Rural Fire Service and the Commissioner of the NSW Police Force
25. That in the course of undertaking the five yearly review of the Memorandum of Understanding, Joint Agency Fire Investigation in New South Wales consideration be given to:
a. directly incorporating the provisions of State Coroner’s Bulletin No 22 – October 2022;
b. expressly recording that a bushfire suspected of having started as an unintended result of a strategic backburn may meet criteria requiring a report to the Coroner as relating to a safety issue that is of public interest;
c. providing that in such cases where there is suspicion of a bushfire having started as an unintended result of a strategic backburn, the NSW Police Force may request modelling from the NSW Rural Fire Service to consider what might have occurred if the backburn had not occurred; and
d. noting that the Officer-in-Charge of any Police Investigation into a bushfire must be notified (whether by the Forensic Evidence and Technical Services Command or by the NSW Rural Fire Service or both) in the event that a cause and origin examination of a particular scene requested by the Officer-in-Charge is not going to occur as contemplated by the request.
26. That the NSW Rural Fire Service develop, and the NSW Police Force participate in, an additional ICON training and awareness session to assist officers from Strike Force Tronto navigate ICON in order to:
a. locate information earlier recorded for individual fires that later merge and are managed on ICON as one larger fire or fire complex; and
b. understand NSW Rural Fire Service naming conventions used when a fire spreads across a Local Government Area or other boundary and is accordingly renamed and managed as a new fire.
27. That those undertaking the re-model of Essential Energy’s Bushfire Risk Classification System be:
a. provided with a copy of any findings relevant to this Inquiry, in addition to the following documents which Essential Energy has submitted it has already provided to the relevant individuals:
i. Expert Report of Mr Paul de Mar dated 11 February 2022;
ii. Supplementary Expert Report of Mr Paul de Mar dated 4 August 2022;
iii. Expert Report of Professor Jason Sharples dated 22 August 2022; and
iv. Transcript of the oral evidence of Mr de Mar and Mr Sharples given on 28 September 2022.
b. tasked to take into account the limitations identified by Mr de Mar and Professor Sharples in the documents referred to in (a) above (as applicable), in developing, and carrying out, the re-model.
28. That a copy of the documents referred to in Recommendation 27a above also be provided to the Chief Executive Officer of Energy Networks Australia to inform the IGNIS Project Team in its ongoing work, as they see fit.
06 Nov 2024