EXECUTIVE SUMMARY AND CONCLUSIONS

1.        Shortly after 3pm on Monday, 10 January 2005 a fire ignited in roadside vegetation on the eastern side of Lady Franklyn Road approximately 45 kilometres north-west of Port Lincoln on the Lower Eyre Peninsula.

2.        A number of members of the public who resided or were working in locations approximate to the fire witnessed smoke rising from the Lady Franklyn Road location.  One of those persons was a Mr Steven Nettle who resided at Wangary and who was at that time the Captain of the Wangary CFS Brigade.  Mr Nettle telephoned the CFS at approximately 3:20pm to advise them of his sighting of smoke.

3.        Mr Marco Visic a resident of Port Lincoln had, a little time before the smoke from the Wangary fire was detected, parked his Toyota diesel 4WD motor vehicle on the eastern side of Lady Franklyn Road.  Mr Visic had alighted from his vehicle and walked into a paddock on the eastern side of Lady Franklyn Road to inspect a pile of rocks that had excited his attention.  Mr Visic had been in the general area that afternoon prospecting with a metal detector.

4.        At the time Mr Visic’s vehicle was parked on the eastern side of Lady Franklyn Road, the weather conditions were hot and dry and there was a wind in existence.  At the time Mr Visic’s vehicle was situated on the eastern side of Lady Franklyn Road, there was no other activity of any kind at that location. 

5.        Mr Visic was to also advise the CFS of the existence of a fire on the eastern side of Lady Franklyn Road.  He did this from a payphone at the Wangary Store at 3:29pm.

6.        Mr Visic returned to the scene of the fire having made that call and encountered a Mr Thring and Mr Trevor Puckridge who had been engaged in shearing at Mr Puckridge’s property further north on Lady Franklyn Road.  Mr Visic made utterances at that stage from which it can be concluded that Mr Visic entertained the firm belief that his activities on the eastern side of Lady Franklyn Road had caused the ignition of the fire.

7.        Having considered very carefully all of the evidence that has been adduced during the course of this Inquest as to the circumstances in which this fire started, I am firmly of the conclusion that the source of ignition for the fire on the eastern side of Lady Franklyn Road was Mr Visic’s Toyota vehicle.  I am satisfied that a carbonaceous particle or particles of a sufficient size and temperature to ignite dry vegetation were emitted from the exhaust system of Mr Visic’s vehicle.  I am further satisfied that the carbonaceous particle or particles landed in dry vegetation at the side of Lady Franklyn Road and immediately, or virtually immediately, ignited that vegetation.

8.        Mr Visic’s exhaust system had a number of irregularities and defects that consisted of holes and imperfect joins in the system.  Fitted to the Toyota vehicle was a muffler that was not a standard part for that vehicle.  Compared to the standard muffler that would normally be fitted to a vehicle of that type, the non-standard after-market muffler had a lesser capacity to inhibit the passage of hot carbonaceous particles through it.

9.        A hot carbonaceous particle of sufficient size could either have been emitted through the tail pipe of the vehicle having passed through the muffler, or been emitted through one of the defects in the exhaust system as a whole.  I think it more probable that the hot carbonaceous particle that set fire to the vegetation on the eastern side of Lady Franklyn Road was emitted through the tail pipe having passed through the entire exhaust system including the after-market muffler.

10.    After the fire was detected, a number of members of the public attended.  These included farmers who had seen the smoke from a distance and who had travelled to the location in their farm firefighting appliances. 

11.    As well, a number of CFS appliances and their crews were despatched to the location. 

12.    The fire proved difficult to quell under the influence of a strong breeze.  Valiant efforts were made to contain the fire during the course of the afternoon.  Further CFS appliances were brought to bear on the problem.  It became obvious fairly quickly that sourcing water in this general area was a problem. 

13.    A Mr James Casanova who had been approaching the scene along Duck Lake Road, also noticed the smoke.  Mr Casanova was driving a SAME tractor with a square bulldozer blade.  Mr Casanova attended at the fire scene and during the course of the afternoon cut a number of bare earth breaks in the trees at the junction of Duck Lake Road and Yorkies Gully Road and in the stubble paddocks on the property to the north of Yorkies Gully Road.

14.    The fire proceeded in a generally east or north-easterly direction throughout the course of the afternoon and it quickly ignited trees in a large stand of sugar gums at the junction of Duck Lake Road and Yorkies Gully Road.  The fire that ignited the trees at that location proved very difficult to quell during the course of the rest of the daylight hours of Monday, 10 January 2005 and overnight.  Continuous efforts were made by both farmers and CFS crews to contain the fire within the sugar gum stand.

15.    At some time during the course of the Monday afternoon fire traversed the stubble paddocks in an easterly direction from Duck Lake Road across the properties of Christopher Hull and Mr Siegert into a paperbark swamp that was to the north of Yorkies Gully Road and to the west of Settlers Road.  The swamp was situated on the property of Messrs George and Les Hull.  This property was situated north of Warunda Road.  The swamp crossed Warunda Road into the property of Mr Peter Cabot.  Mr Cabot maintained stubble paddocks to the west of Settlers Road and to the north of Yorkies Gully Road.  For the purposes of the Inquest, and for the purposes of my findings and summary, those paddocks have been referred to as Area A and Area C as depicted on aerial imagery of the location.  Mr Cabot’s homestead was situated in the north-western quadrant of the intersection of Settlers Road and Yorkies Gully Road.  At the western extremity of Mr Cabot’s property a hundred line formed the boundary with the property of Christopher Hull.  The swamp continued to cut across Christopher Hull’s property until it crossed Yorkies Gully Road at a culvert which was known as Yorkies Crossing.

16.    The fire that burnt into the swamp penetrated it from its north-western side on the Monday afternoon and evening but did not come through to the south-eastern side.

17.    Mr Robert Chambers was the recently elected Group Officer for the CFS Lower Eyre Peninsula Group.  His Deputy Group Officers were Mr Robert Maddern, Mr Jeffrey Lock and Mr Russell Branson.  Messrs Chambers and Branson attended the fireground on the Monday afternoon.  Mr Chambers was in possession of one of the Lower Eyre Peninsula Group’s CFS 4WD command vehicles.  Ultimately Messrs Chambers and Branson were joined by other members of the CFS and a Forward Command Post was, for the time being, established at a group of sheds on Christopher Hull’s property north of Yorkies Gully Road.  That area became known in the Inquest as Christopher Hull’s hayshed.  In due course Mr Jeffrey Lock, another Deputy Group Officer, attended the scene.

18.    Messrs Branson and Lock attempted to circumnavigate the fireground in order to survey it, to identify its boundaries and for the purposes of sectorisation.  It had become evident that the fireground was of a significant size and that it extended as far as the property of Messrs George and Les Hull to the north of Warunda Road.  Messrs Branson and Lock did not complete their circumnavigation of the fireground because Mr Chambers demanded that they return the CFS command vehicle to the hayshed.  It was evident from their circumnavigation of the fireground, albeit truncated, that significant fire had penetrated the paperbark swamp at locations to the west of Area A on Mr Cabot’s property.

19.    Fire had also penetrated the swamp north of Warunda Road into Messrs George and Les Hull’s property and it had also penetrated the swamp in the location where it exists on the property of Christopher Hull.

20.    Areas A and C on Mr Cabot’s property and to a lesser extent on Christopher Hull’s property largely remained unattended by firefighting resources during the course of the Monday afternoon and evening and overnight into the Tuesday morning.  There was some firefighting activity conducted in the early hours of the morning in the swamp to the north of Area C and in the vicinity of the hundred line that divided Mr Cabot’s property from Christopher Hull’s.

21.    Mr Chambers declared the fire contained at 8:54pm on the Monday evening.  By then the unfavourable weather conditions for firefighting had abated.  The fact that the fire was said to be contained carried no implication that the fire was extinguished.  In fact the fire was still active in the sugar gums and in the swamp.

22.    During the course of the afternoon on the Monday, volunteers at the CFS base at Port Lincoln (Lincoln Base) and paid staff of CFS Region 6 Headquarters situated in Port Lincoln were having difficulty in obtaining information from the fireground, particularly in relation to fire progression, location and size.  Mr Simon Vogel was on that day the Regional Duty Officer for Region 6.  Ms Sonia Post, another CFS Regional Officer, was also on duty that day in Port Lincoln.  The Regional Commander, Mr Neil Ellis, was in Adelaide attending a meeting at CFS State Headquarters.  Attending the same meeting was Mr Robert Maddern, the Lower Eyre Peninsula Deputy Group Officer 1.  Mr Maddern had left the second CFS command 4WD vehicle at the airport. 

23.    Mr Ellis remained in Adelaide overnight.  Mr Maddern returned to Port Lincoln early on the Monday night and proceeded to Region 6 Headquarters.  There he was asked by Mr Vogel to go to the fireground and seek information and ensure that a proper incident management structure had been put in place.  At about the same time it was decided that the hall at Wanilla would be used as an Incident Control Centre.  Also at around that time, initiatives were taken to engage a relief Incident Management Team to take over from Messrs Chambers and his colleagues later that night.  A Ms Angela Whillas, who was the Greenpatch CFS Brigade Captain, was chosen as the Incident Controller for the overnight shift.

24.    Ms Sonia Post and Mr Maddern travelled out to the Wanilla Hall.  Ms Post set up the hall as an Incident Control Centre.  Mr Maddern proceeded to Christopher Hull’s hayshed where he advised those present, including Messrs Chambers, Lock and Branson and a number of police officers, that the Incident Management Team would be moving to Wanilla Hall.

25.    Following that, Mr Maddern and the other gentlemen proceeded to the Wanilla Hall where an incident management structure was set up.

26.    Meanwhile Mr Peter Cabot and his son-in-law, Mr Treloar, conducted a backburning operation on the edge of the swamp to the north of Area C. 

27.    Mr Cabot’s backburn was conducted without the approval, assistance or knowledge of the CFS.  Mr Cabot conducted the backburn because he believed that with the weather conditions forecast for the Tuesday morning the fire would come out of the swamp and proceed into the stubble paddocks to the south in Area C.  Mr Cabot essentially wanted to eliminate as much flammable material at the edge of the swamp as he could.  Mr Cabot did not conduct any backburning in Area A because of the presence of canola stubble on the edge of that swamp.  Canola stubble is difficult to light but once alight is very flammable.  He also did not have the resources to manage a backburning operation on that section of his property.

28.    The backburn that Mr Cabot conducted on the edge of the swamp at Area C penetrated the swamp.  Mr Cabot and Mr Treloar believed that after they had conducted the backburn the fire that they had lit had been completely extinguished and that the area was safe.

29.    Mr Cabot did not have any contact with the CFS on the Monday night. 

30.    The weather forecast for the Tuesday morning was very unfavourable for firefighting.  The forecast was the subject of a CFS and Bureau of Meteorology joint teleconference on the Monday afternoon.  At that teleconference the weather was described in terms that suggested that the Tuesday was going to be, for the whole of the State, a very difficult day for firefighting.  Total fire bans for the whole of the State were put in place.  A weather forecast obtained in relation to the fireground late on Monday afternoon suggested that there would be very high temperatures on the Tuesday and strong north-north-westerly winds in the morning.  This would naturally prove problematic for firefighting, particularly in an existing fireground that had a south-eastern perimeter in relatively inaccessible swamp country.  During the course of the night, the very unfavourable weather forecast was confirmed.  The forecast suggested that there would be extreme conditions existing at 10am.  Also predicted was a westerly change in the course of the late morning, early afternoon.  That change would also not be favourable for firefighting and would put any person on the eastern flank of a running fire in great danger on the change of the wind.

31.    At Wanilla Hall Mr Lock plotted the fireground on a map.  It was clearly understood that there was fire in the swamp along its length from Warunda Road to the south-west. 

32.    At Wanilla Hall Mr Chambers articulated an Incident Action Plan that was not reduced to writing but which was that the fireground would be blacked out to a distance of 30 metres.  This was subsequently altered to a distance of 60 metres at some point in time. 

33.    The fireground was sectorised into a number of sectors.  The relevant sectors for the swamp were the Swampy Sector and the Yorkies Crossing Sector.  The Swampy Sector at first encompassed that part of the swamp north of Warunda Road on the property of Messrs George and Les Hull, but did not encompass Area A or the swamp to the west of Area A in Mr Cabot’s property.  The Yorkies Crossing Sector encompassed the fire perimeter north of Area C on Mr Cabot’s property and on Christopher Hull’s property.  This meant that there was a gap in the sectorisation of the fireground which consisted of Area A and the swamp to the west of Area A.  A Sector Commander was appointed for the Swampy Sector and a Sector Commander was not appointed for the Yorkies Crossing Sector.  In due course the boundary of the Swampy Sector was extended to encompass Area A and the swamp to the west of it.  However, this extension was not communicated to the Sector Commander either for the first shift or the second shift being the overnight shift.

34.    When Mr Chambers devised the Incident Action Plan to black out, he had not examined the fireground. 

35.    No other containment measures for the south-eastern perimeter through the swamp were devised.  Other than Mr Cabot’s backburn there was no other backburning operation conducted on the south-eastern perimeter of the fire.  Nor were any bare earth fire breaks created in the stubble paddocks to the east and south of the swamp, either in Mr Cabot’s property or Christopher Hull’s property.

36.    No aerial firefighting resources were sought or organised for the Tuesday morning to guard against the eventuality that the fire might flare-up and break away from the swamp under the influence of the predicted strong north-north-westerly wind.

37.    Neither Area A, nor the swamp to the west of Area A, were attended by the CFS during the course of the Monday night and Tuesday morning.  It is to be inferred that one reason for that was the fact that the Sector Commander for that area was unaware of his responsibility in relation to it.  In any event, no containment work was implemented in the paddocks of Area A nor in the swamp itself to the west of that area and that remained the position until a breakout of fire eventually occurred there on the Tuesday morning.

38.    As far as Area C was concerned, no appliances attended in that location or the swamp to the north until about 3:30am on the Tuesday morning.  Christopher Hull had requested the presence of an appliance in the vicinity of the hundred line.  Blacking out work took place there.  Mr Branson also arranged for CFS attendance at the site where Mr Cabot had backburnt.  The Karkoo appliance performed blacking out operations on the edge of the swamp at that location.

39.    Without any other supporting containment measures and without detailed information as to the nature and accessibility of the terrain in the swamp, the plan to black out was a facile solution to a complex problem.  The plan was flawed in its execution.  No resources were applied to one of the most vulnerable areas (Area C) until the early hours of the Tuesday morning.  In the other very vulnerable location (Area A), no resources were in place at all.

40.    In addition, there was an imperfect assessment of risk at the time the Incident Action Plan was devised.  It failed to take into account the very grave risks posed by the weather forecast for the Tuesday morning. 

41.    For some reason for which there is no clear explanation, Mr Chambers left the Wanilla Hall that night at a time before the oncoming Incident Controller, Ms Whillas, arrived.    When Mr Chambers left Wanilla Hall this left the Incident Management Team without an Incident Controller for a substantial period of time.  Mr Maddern, although a very experienced firefighter and incident manager, did not regard himself as a member of the Incident Management Team except in a minor capacity as a scribe.  There was confusion as well about the role of Mr Lock.

42.    Ms Post, a paid officer of the CFS, had been advised by Mr Vogel, the Regional Duty Officer, not to become involved in incident management issues.  She therefore gained a very limited understanding of the situation as it applied to the fire and did not in any sense scrutinise or validate the Incident Management Team’s plan of containment. 

43.    Ms Whillas, the Greenpatch Brigade Captain and incoming Incident Controller for the overnight shift, had participated in an incident management course in 2004.  She had no experience in the management of an incident of this complexity.  Her incident management experience was limited to incidents involving only a few appliances.  To my mind Ms Whillas’ appointment as the Incident Controller for the overnight shift on this large and complex fireground was not appropriate.  Mr Branson continued in his role as the Operations Officer. 

44.    Ms Whillas remained at Wanilla Hall overnight.  Her knowledge of the fireground was very limited.  Any risk assessment that she performed was superficial.

45.    Mr Branson proceeded out to the fireground where he made an inspection.  In Area C he caused some appliances to conduct some work including that performed by the Karkoo appliance to which I have already referred.  However, nothing was undertaken in Area A or to the west of Area A in the swamp.

46.    However, much work was conducted overnight in relation to the sugar gum area that was still burning.  A number of CFS appliances and farm appliances remained at that location throughout the night and blacking out and other firefighting activity took place there.

47.    In the daylight hours of the Tuesday morning, a change of shift occurred and this involved the implementation of a new Incident Management Team.  Mr Chambers returned as Incident Controller and Mr Maddern became the Planning Officer. 

48.    District Council of Lower Eyre Peninsula grader operators had left their plant and equipment at the fireground overnight.  That equipment had been engaged in containment activity on the northern part of the fireground on the Monday.  When the plant operators reported at Wanilla Hall on the Tuesday morning they were told their services were not required.  This meant that no bare earth containment work was undertaken in the areas to the east and south of Areas A and C.  I find that there was a clear opportunity for plant and equipment to have been used to create or attempt to create bare earth breaks in those locations.

49.    Mr Simon Vogel had remained at Region 6 Headquarters until 1am on the Tuesday morning.  Ms Post had remained at the Wanilla Hall also very late.  Mr Vogel and Ms Post were back on duty early on the Tuesday morning.  Ms Post travelled directly to Wanilla Hall.   Mr Vogel commenced his duties at Region 6 Headquarters in Port Lincoln.

50.    At 7:45am at Wanilla Hall, Mr Maddern declared that the fire was controlled.  This declaration had occurred after a briefing that had been conducted by the outgoing Incident Controller, Ms Whillas, and by the outgoing Operations Officer, Mr Branson.  The declaration that the fire was controlled was flawed.  A declaration that a fire is controlled by definition means that the fire perimeter of a fireground is secure and that no breakaways are expected.  In my opinion there was no proper foundation for any assertion that the fire perimeter was secure or that no breakaways were expected.  This is especially so given the severity of the weather forecast for the Tuesday morning, and the absence of any meaningful containment work to the east and south of the swamp.  This meant that communities and assets to the south-east of the fireground were at risk.  If that risk was appreciated by anyone on the Tuesday morning it was not articulated.  In particular, the police were not alerted to that risk and no warning was given to members of the public.  No measures were taken to alert possibly affected communities.  Communities and individuals to the south-east of the fireground went about their daily business in ignorance of the risk.  Exceptions to that state of affairs were residents very close to the fireground such as Mr Cabot, Messrs George and Les Hull and Mr Giddings who owned premises on Settlers Road known as Beaumont.  This property and homestead was on the eastern side of Settlers Road and the east-south-east of Area A.

51.    During the course of the Monday evening Mr Vogel had received information from the fireground via Lincoln Base.  Mr Vogel had an incomplete picture as to the nature of the incident.  He was taken by surprise when he learnt that the fireground had become magnified to an area of 1800 hectares with a south-eastern flank of several kilometres.  Mr Vogel learnt of Mr Chambers’ declaration that the fire was contained within a few minutes of the declaration. He took it at face value.  Mr Vogel did not scrutinise or validate any plan that was put in place to secure the overnight fireground.  Mr Vogel had forwarded information that he was receiving from time to time to CFS State Headquarters via facsimile.  None of that information, including the revelation that the fireground was 1800 hectares, was actually passed on to anyone in authority at State Headquarters that night.  The Deputy State Coordinator, Mr Miller, had not received any of the faxes nor any verbal communication.  The last information he had was that the fireground was of about 40 hectares and would likely be contained overnight.  He had received that information at the weather teleconference on the Monday afternoon.

52.    It was not until approximately 11pm that anyone at State Headquarters gained an appreciation of the size of the fireground being 1800 hectares.  As a result of that realisation, junior staff at State Headquarters caused a Significant Incident page to be sent to senior CFS Officers including Mr Miller and the Chief Officer, Mr Ferguson.  Mr Miller did not receive that page.  Mr Ferguson received the page but believed Mr Miller would have received it and acted upon it.

53.    If Mr Miller had received the necessary information as the fire incident was developing on the Monday night, it is very likely that steps would have been taken to address the incident at a State level.  This may have resulted in important resources such as aerial water bombers being made available for the Tuesday morning.  Those resources were never put in place.  They were not available until well into the Tuesday after the fire had become uncontrollable.

54.    On the Tuesday morning, the Incident Control Centre was moved from Wanilla Hall to the Wangary Sports Complex.  This proved to be somewhat of a distraction.  Mr Nettle was with the Incident Management Team.  He was meant to be the Sector Commander for Yorkies Crossing Sector which incorporated Area C but had no knowledge of that. The Sector Commander for the Scrubby Sector did not know that he had responsibility for Area A.

55.    No containment work was conducted on the Tuesday morning, nor were there any appliances placed in Area A in anticipation of possible breakouts.  In Area C there was spasmodic attendance by CFS appliances.   

56.    At approximately 9:30am the weather started to deteriorate.  It was hot and windy.  There was a flare-up in the sugar gums that required the presence of a number of appliances.

57.    At about 9:50am two farm firefighters in a utility, Messrs Andrew and Byass, observed fire creeping along the northern side of the swamp in a south-westerly direction towards the narrow part of the swamp on Christopher Hull’s property.  They witnessed the fire enter the swamp a quite narrow portion and then proceed across it.  The fire then entered the paddocks to the south-east of the swamp where wheat stubble caught alight.  Appliances and farm units that had been at the sugar gum area attending to the flare-up were brought into that area but the fire in Christopher Hull’s paddocks could not be brought under control.  At around that time fire also spread into the vegetation in the hundred line that divided Mr Cabot’s property from that of Christopher Hull.  Some minutes later, fire emerged from the swamp to the east of the hundred line on Mr Cabot’s property.  At that location, a large amount of spotting from the swamp proceeded into the stubble paddocks.  Ultimately, the fire from the narrow of the swamp. the fire at the hundred line and the fire in the paddocks to the east of the hundred line became uncontrollable.  This was in spite of the very courageous efforts of CFS crew members and farmers.  Fire that emanated from its various sources in Area C on Christopher Hull’s and Mr Cabot’s stubble paddocks spread uncontrolled in a south-easterly direction under a strong north-westerly wind.  It proceeded across stubble paddocks to the south of Yorkies Gully Road towards the Murrunatta Conservation Park.  The fire entered the park, traversed the park, crossed Settlers Road and made its way in a south-easterly direction towards the Wanilla Forest.  By then the time was a little after 11:30am.

58.    Mr Darren Borlase and his wife Natalie Borlase lived on Borlase Road which was just to the east of Wanilla Forest.  Mr Borlase was in hospital in Port Lincoln at the time.  Natalie Borlase went to work on the Tuesday morning.  Her parents, Wayne and Judith Griffith, were visiting from Adelaide at that time and were looking after the Borlase children, Star and Jack.  They were in the Borlase home on Borlase Road. 

59.    Mrs Griffith and the two children perished when they proceeded onto Borlase Road in a motor vehicle.  Mr Griffith who was in a separate vehicle survived.

60.    The fire that caused the deaths of Mrs Griffith and the Borlase children I find was sourced from Area C being the area encompassing both Mr Cabot’s paddocks and Christopher Hull’s paddocks to the south of the swamp. 

61.    At about 10:25am a large flare-up was seen to occur in the swamp to the west of Area A.  When this was observed, CFS appliances were sent into Area A in an attempt to combat spotting that was emanating from the swamp.  The courageous crews of those appliances unfortunately were not able to contend with the large amount of spotting and eventually a fire front emerged from the swamp that very nearly overwhelmed one of those crews.  The fire spread unchecked in a south-easterly direction at first, fanned by a strong north-westerly wind.  Sometime shortly after 11:30am, the wind at that location changed to a westerly.  Messrs Murnane and Richardson had been at the Beaumont property on Settlers Road assisting other farmers to wet down assets at that property.  Messrs Murnane and Richardson perished when they proceeded in their farm firefighting utility from the Beaumont premises onto Settlers Road.  The fire that overwhelmed them I find originated from the swamp in Area A.

62.    During the course of the morning and early afternoon fire proceeded across the landscape of the Lower Eyre Peninsula in a westerly direction.  The fire was in the main carried by stubble fuels. 

63.    Ultimately, the fire reached North Shields on the coast.  It also reached Poonindie which is a settlement on the Lincoln Highway to the north of North Shields.  The source of the fire that crossed the landscape was the fire that had emanated from Area C to the south of the swamp on the properties of Mr Christopher Hull and Mr Peter Cabot. 

64.    Mrs Helen Castle and her husband occupied a premises on the eastern side of Dorward Road at North Shields.  Mr Castle was at work on the Monday.  Mrs Castle was on holidays from her job as a school teacher and was at home.  Mrs Castle perished in her home at North Shields when the premises was destroyed by fire.

65.    Mr and Mrs Kay lived at Hirschausen Road at Poonindie with their two children Zoe Russell-Kay and Graham Russell.  Mr Damian Kay that morning had flown to Adelaide for a medical appointment.  This left Mrs Jody Kay and the two children at the Hirschausen Road house.

66.    Mrs Kay and her children proceeded onto the Lincoln Highway at Poonindie in their car.  The vehicle was overwhelmed by smoke and it struck trees off to the side of the highway.

67.    As the fire approached Wanilla Forest and then across the Lower Eyre Peninsula landscape, the CFS issued a number of phase warnings advising residents in certain locations about the approach of the fire.  The approach of the fire was very rapid.  Many of the phase warnings were mis-timed and not particularly appropriate for the locations to which they were directed.  There was no evidence that any of the persons who lost their lives were relying on the existence of, or accuracy or otherwise, of CFS phase warnings.

68.    A new phase warning system has been implemented by the CFS since this incident.  The question of public warnings in a bushfire setting is a difficult one.  If the risk that had existed in the uncontrolled fire within the swamp had been identified, either on the Monday night or on the Tuesday morning, there would have been a significant need for a public warning well in advance of any possible or anticipated breakout.  There was a likelihood, if not inevitability, that the fire would break out of the swamp and once out of the swamp, would be uncontrollable.  There was an inadequate appreciation of that risk on the Monday night or the Tuesday morning.  A heightened level of vigilance by the members of CFS Incident Management Teams, and Region 6 Headquarters and State Headquarters personnel may have identified that risk.  If this had taken place, it would have been impossible to justify withholding information about that risk from the general public.  In those circumstances a warning would have been inevitable.  In the event, the community to the south-east and east of the fireground were unaware of the risk of fire in many instances until it was too late.

69.    As to the suggestion that nothing would have stopped that fire, or that nothing could have been done to prevent the fire from escaping from its fireground overnight, one has to view the matter with the disadvantage of hindsight.  The fact of the matter was that no adequate measures were put in place or attempted which meant that opportunities to alter the outcome were not taken.  Because the risk to the public was never properly addressed or appreciated, none of those measures were ever adequately considered.  For the same reason no adequate warning was given.

70.    In dealing with the performance of volunteer Incident Management Teams, and that of the individual members of those teams, it has to be borne steadily in mind that one can always find fault in a setting of such complexity.  The temptation to criticise the minutiae of every decision that was taken by a group of individuals or by the individuals themselves is sometimes difficult to resist.  Whilst one always strives for excellence, excellence is not to be equated with absolute perfection.  This is especially so in my view when one considers that many of the individuals concerned, and who have been the subject of very strident criticism, were volunteers who bestowed their time and effort on this very complex problem with no thought for their own self promotion.  It has to be also considered that if there had been a favourable outcome in this fire, it is unlikely that the members of the Incident Management Teams would have been accorded accolades in any sense proportionate to the criticism that they have had to endure.

28.             Recommendations from other investigations into the Wangary Bushfire

28.1.       Phoenix Report

Following the Wangary fire, the CFS Chief Officer, Mr Euan Ferguson, initiated an independent investigation which was designated Project Phoenix.  Mr Ferguson told me that he was aware that the CFS were being criticised by the public for their role in the fire and ‘believed that he needed to set out pertinent facts and criticisms and develop strategies to make possible improvements to CFS’s systems of work’[2].

28.2.       Mr Ferguson employed Noetic Solutions to undertake the investigation with the assistance of two senior CFS personnel.  The following Terms of Reference were chosen:

'Project PHOENIX will require the following steps to be undertaken:

6.1  Gather issues:  Project PHOENIX will gather information and issues from all available sources.  This will include debriefs, issues raised by the media, and various individuals and interest groups and organisations.  Documents to be reviewed include existing plans, letters, newspaper cuttings and recent reports.  The Council of Australian Government’s Inquiry into Bushfire mitigation and Management should be included in the scope of documents reviewed.

6.2  Identify stakeholders:  Identify particular individuals and organisations who should be consulted or have an ongoing involvement during the life of Operation PHOENIX.

6.3  Confirm issues:  Issues will be clearly articulated.  If there is another party who may have an interest in the issue, they will be consulted to ensure the issue is written so they agree with the issue.

6.4  Identify quick actions:  There may be issues that have been identified that need no further discussion.  That is the issues is agreed, and may be urgent; the solution is clear and unambiguous.  In this situation, an immediate recommendation of action should be made.

6.5  Sift and sort issues:  Issues will be analysed, grouped and prioritised.  The issues will be reviewed to ensure that the cause is properly identified (not just a symptom of the cause).

6.6  Develop action plan:  Including resources required for implementation, the recommended person who is responsible for implementing the action, and the timetable for implementation.  The action plan should be confirmed with relevant stakeholders.

6.7  Implementation review:  Advise what processes may be required to ensure that actions are implemented and that appropriate resources are applied to implement each action.' [3]

28.3.       The Project Team met with various members of the CFS and the public during their investigations.  They undertook a visit to the fireground and examined a wide range of CFS documentation relating to the fire and to general CFS procedures.  The project team also held a workshop in Adelaide in May 2005 which included a number of stakeholder agencies and organisations which examined lessons learnt from the fire and developed plans for the future.

28.4.       A report entitled ‘Outcomes from the South Australian Country Fire Service Project Phoenix Lessons Learnt Activity From the January 2005 Bushfires’ was produced by Noetic Solutions in May 2005[4].

28.5.       The Phoenix Report made numerous recommendations, some very general in nature.  During the course of Mr Ferguson’s evidence he produced to me a very useful document that illustrates the action taken by CFS to implement those recommendations. 

28.6.       The Phoenix Report articulated a number of conclusions about the manner in which the CFS managed this fire.  I have read those conclusions.  The recommendations made by Noetic Solutions are based on those conclusions.  The conclusions that I have expressed in these findings are my own conclusions, based upon the evidence that was adduced during the course of the Inquest and have not been influenced by the conclusions set out in the Phoenix Report.  If my own conclusions coincide with those of Noetic, so be it, and as far as their recommendations are concerned, I agree with them.

28.7.       Report of Dr Smith

Dr Robert (Bob) Smith is a self-employed consultant with a background in forestry and risk assessment.  He has a Master of Business Administration, Doctorate of Philosophy, Master of Science (Resource Economics) and a Bachelor of Science in Forestry.  Dr Smith is a Director on the VicForests Board in Victoria and has previously worked as the Director General of the NSW Department of Land and Water Conservation. 

28.8.       Dr Smith was commissioned by the South Australian Minister for Emergency Services in May 2005 to provide a report into the management of the Wangary fire.  Dr Smith undertook tours of the fireground, had access to CFS documentation and interviewed many people involved in the fire.  A report entitled ‘Report of Independent Review of Circumstances Surrounding Eyre Peninsula Bushfire of 10^th and 11^th January 2005 (Wangary Bushfire)’ was produced by Dr Smith in September 2005[5].  I have dealt elsewhere in these findings with the use to which I have put Dr Smith’s report and evidence.

28.9.       Dr Smith’s recommendations and the CFS response to these recommendations are outlined in the document produced below.  This document was presented by Mr Ferguson and is part of Exhibit C280f, attachment EF116.  As far as Dr Smith’s recommendations are concerned, I agree with them.

29.             Recommendations

29.1.       Pursuant to section 25(2) of the Coroner’s Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the Inquest.

29.2.       It is inevitable that in the aftermath of an event of this nature that the need for positive change will be identified and change implemented.  The coronial Inquest is not the only means by which change can be effected.  Some might argue that in a matter of this nature, a coronial Inquest is not the most suitable vehicle for affecting change.  The National Inquiry on Bushfire Mitigation and Management, conducted under the auspices of the Council of Australian Governments (COAG), produced a report dated 31 March 2004.  The report contains the following observation in relation to coronial inquiries as they relate to deaths in bushfires:

'Due to the legalistic and potentially adversarial approach that can develop during coronial inquiries into bushfire events, significant periods of time are involved in the establishment, conduct and finalisation of coronial inquiries. Such complexity and delay is problematic for several reasons:

·          Operational issues that require rectification may not be identified prior to the next fire season.

·          Individuals involved in decision making during a bushfire event are placed under enormous stress for an extended period, often including the following bushfire season, until the coronial process is complete.

·          Those that have suffered during the fire event fail to benefit from a timely resolution.

·          The public and media are involved in considerable speculation during an extended period of uncertainty.

·          The ‘value for money’ from a public perspective is open to question.'

29.3.       The COAG Inquiry questioned whether coronial inquiries were the best option for investigating operational issues not directly related to bushfire deaths and suggested that the extent to which coronial inquiries should investigate the operational issues of a major bushfire – other than those concerned directly with the fire deaths – needs to be critically reviewed.

29.4.       There is some validity in the assertions made in the COAG report.  However, the focus of this particular coronial Inquest is not just about operational issues connected with this bushfire, nor is it the performance of the CFS.  The focus of this Inquest was the cause and circumstances of the deaths of the nine deceased as well as the cause and circumstances of the fire.  The issues concerning the operational performance of the authorities in the management of the Wangary bushfire to my mind was only relevant insofar as they formed part of the circumstances of the spread of the bushfire the circumstances of the nine deaths that resulted from it.  My view is that a number of operational issues surrounding the management of this fire by CFS personnel have been shown to be relevant to the circumstances of what transpired on the Tuesday morning.  However, this report is not intended to be, and should not be viewed as, any sort of benchmark for future bushfire prevention or bushfire operational management.  As I stated in open Court during the course of this Inquest, I cannot possibly be expected to reinvent every wheel that relates to bushfires[6].  This is especially so given the fact that I have been satisfied that a large measure of change, based on an obviously perceived need for it, particularly in relation to CFS practices, has been effected.  Much of that change has been based upon the conclusions reached after two separate and independent inquiries conducted within the first year following the Wangary fires.  I refer here to the Phoenix Report and that of Dr Bob Smith.  The Chief Officer of the CFS, Mr Ferguson, produced evidence to the Inquest that suggests very strongly that the recommendations that were made consequent upon the findings made in the Phoenix and Smith inquires have been fully embraced by the CFS.  Those recommendations were in the main based upon the factual conclusions reached in those inquiries about the operational performance of the CFS during the Wangary fires.  Many of the conclusions reached by both inquiries coincide with my own conclusions.  I make the observation here that the CFS embracing of the conclusions and recommendations reached by Dr Smith is somewhat ironic when it is remembered that counsel for the CFS, Mr Cuthbertson QC, referred to Dr Smith’s inquiry as ‘essentially a complaint box’ that recorded and perpetuated the complaints that were being made by disaffected citizens after the Wangary fire, complaints which he said had been based on less than full information.  Mr Cuthbertson also referred to the Smith Report as ‘the Bible of those complaining’ and ‘the Bible for counsel assisting’[7].  However, it would be as well to remember when those sorts of comments are to be evaluated that the Smith Report seems to have been at least one of the Bibles that the CFS have used to embrace positive change. 

29.5.       It is also worth observing that the conclusions and recommendations reached and made by Dr Smith were closely aligned to those conclusions and recommendations expressed in the Phoenix Report, which also seems to have been embraced as a template for change.

29.6.       Thus it is that much of the work that I might have otherwise had to perform as far as recommendations for change are concerned, has been done.  Attached to this report is a schedule that was current as at January 2007 that outlines the actions taken by the CFS as against the recommendations from the Phoenix Report and the Smith Report.  As it happens, I agree with all of those recommendations and applaud the SACFS hierarchy and its Chief Officer Mr Euan Ferguson in particular for having quickly implemented those recommendations.  In fact, it would be remiss of me not to say that in my opinion the performance of the CFS since the Wangary incident in terms of its recognition of the need for change and the implementation of that change has been exemplary.

29.7.       During the course of this Inquest I was shown an impressive array of innovation that the CFS have implemented since the Wangary fire that have been designed to improve the flow of information from one level of the CFS to another.  I speak here of the CRIIMSON system, the operation of which was demonstrated to me at Region 1 Headquarters in Mount Barker.  Essentially it involves a computerised system for the transfer and viewing of information including that which relates to key risk exposures.  Inter alia it ensures that situation reports and reports as to the fires status and other crucial and relevant instruction is conveyed to senior CFS personnel so that it is available online for their evaluation.  I also heard something about SITCHECKS which is a system designed to ensure among other things that risk and fire containment strategies are properly considered.

29.8.       The utility of the so-called Elvis Aircrane helicopter, and the desirability of having one situated in South Australia is a complicated matter.  The Government have resisted the idea of acquiring one.  There are obviously significant cost implications involved in this.  As Mr Ferguson told me, if the money is to be spent on firefighting resources, consideration would have to be given to allocating the funds to resources that may have a greater priority.  All I can say about the desirability of having a Aircrane helicopter stationed permanently or even primarily in South Australia is that the evidence revealed that it would have been useful in the sugar gum area and that it has a greater capability to extinguish fires at a higher fire danger index because of its ability to hover and its greater capacity.  I intend to recommend that further consideration is given to acquiring the Aircrane helicopter.

29.9.       I make the following recommendations:

1)           I recommend that the Minister for Emergency Services, the Chief Officer of the South Australian Country Fire Service, the President of the Farmers’ Federation of South Australia and the Minister for Local Government, with a view to developing a Code of Practice, establish a body to investigate the impact of existing farming practices on bushfire risk and prevention. 

2)           I recommend that the Minister for Emergency Services cause independent scientific or other research to be undertaken to identify the effects of continuous cropping, minimum tillage, direct drilling seeding practices and of the retention of cropping stubble, in respect of bushfire risk and prevention. 

3)           I recommend that the Minister for Emergency Services cause independent scientific or other research to be undertaken to establish means by which risk of bushfires, as created by continuous cropping, minimum tillage, direct drilling seeding practices and the retention of cropping stubble across the landscape, can be minimised.

4)           I recommend that the Minister for Emergency Services and the Minister for Local Government consider the enactment of legislation that would empower Local Government to require the owners or occupiers of rural land to create fire breaks on the land of a kind that Local Government may determine and/or to require the removal of flammable materials from the land, as measures for preventing the outbreak of a bushfire, or for preventing the spread or extension of a bushfire.

5)           I recommend that the President of the South Australian Farmers’ Federation of South Australia draws these recommendations and findings to the attention of its members and constituents.

6)           I recommend that the South Australian Farmers’ Federation encourage its members and constituents to keep and maintain on rural land in proper working order machinery that is capable of removing, modifying or reducing cropping stubble at short notice in order to minimise or mitigate bushfire risk.

7)           I recommend that the Minister for Local Government cause rural councils to appoint an Officer whose duties consist entirely of bushfire prevention, such Officer being required to become a trained, operative member of the South Australian Country Fire Service during the currency of his or her appointment.

8)           I recommend that the Minister for Emergency Services in conjunction with the Chief Officer of the South Australian Country Fire Service, the Chief Officer of the South Australian State Emergency Services and the Commissioner of South Australia Police develop policies and practices regarding the issuing of public warnings that address the risk posed to the public by an existing fire incident with a view to disseminating such warnings to the public at a time before the escalation of an existing fire incident occurs.

9)           I recommend that the Minister for Emergency Services, the Chief Officer of the South Australian Country Fire Service, the Chief Officer of the South Australian State Emergency Services and the Commissioner of Police establish a panel to develop policies and practices to ensure that at the time bushfire warnings are created and delivered, all such warnings are made known to all emergency service entities, and to ensure that warnings of an approaching fire are delivered in a timely manner with detailed and specific information relevant to the circumstances of the section of the public to whom they are directed. 

10)       I recommend that South Australian Country Fire Service create and develop the role of a Regional Public Warnings Officer as a member of the paid staff of the SACFS whose role it would be to identify the need for, and to deliver, timely bushfire warnings to the public during the course of a bushfire incident.

11)       I recommend that the South Australian Country Fire Service empower the Regional Public Warnings Officer to create and deliver public warnings on that Officer’s initiative without the necessity of seeking the approval of personnel at State Headquarters.

12)       I recommend that the Minister for Emergency Services in conjunction with the South Australian Country Fire Service conduct tuition courses to be made available to the general public to enable members of the public to acquire the necessary knowledge and skills to implement their preparation and planning for bushfires.

13)       I recommend that the Minister for Emergency Services and the South Australian Country Fire Service implement programs to develop in the minds of citizens a heightened awareness of bushfire risk, and in particular to encourage citizens to listen for radio announcements relating to the progression of a fire during the course of a bushfire incident.

14)       I recommend that the Minister for Emergency Services, the South Australian Country Fire Service, the South Australia Police and the South Australian Farmers’ Federation together continue to develop strategies to reduce the risk of harm to private firefighters and in particular:

a)     Formulate a code of practice to ensure that the South Australian Country Fire Service and the South Australia Police are aware of the presence of private firefighters and private fire appliances at a fireground so as to discourage the ad hoc deployment of private firefighters and private farm appliances;

b)     Develop an education program for private firefighters dealing with implementation of safe practices for private firefighters, with emphasis on but not limited to, consideration of the effect of wind changes and the dangers associated with proceeding into a fireground with lack of information about the existing circumstances pertaining to that fireground.

c)      Formulate a structure whereby private firefighters at a fireground act in conjunction with, and not separately from, South Australian Country Fire Service resources;

d)     Develop protocols relating to minimum requirements in respect of reliability of private firefighting units, dress for private firefighters, the need for appropriate radio communication, but not limited to those issues;

e)     Develop a position within the structure of Level 2 and Level 3 Incident Management Teams of a Private Firefighting Liaison Officer.

15)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident Management Teams responsible for the management of bushfire incidents make all reasonable attempts to contact and maintain contact with the owners and/or occupiers of rural land on which a fire is situated.

16)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident Management Teams responsible for the management of bushfire incidents seek information from the owners and/or occupiers of rural land on which a fire is situated as to the topography, vegetation, existing fire breaks, accessibility and local weather conditions pertinent to that land.

17)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident Management Teams responsible for a bushfire incident seek advice from the owners and/or occupiers of rural land on which a fire is situated as to the possible firefighting strategies and possible containment measures that might be implemented in order to bring a fire on the land under control, and to take such advice into consideration in the management of the incident.

18)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service consider the creation of a position within an Incident Management Team of a Landowner Liaison Officer the duties and responsibilities of whom is to establish contact with and liaise with the owner and/or occupiers of rural land on which a fire is situated.

19)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the duties and responsibilities attaching to that position insofar as they apply to an ongoing fire incident, and in particular to recognise the need to conduct a risk assessment in relation to an incident and the need to scrutinise, evaluate and validate the strategies and Incident Action Plans of Incident Management Teams.

20)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the need to deliver to the Deputy State Coordinator timely, accurate and relevant information pertaining to an ongoing fire incident.

21)       I recommend that the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of all Incident Management Team members, in particular but not limited to the Incident Controller and Planning Officer, of the need to conduct a full risk assessment that not only addresses operational risk, but the risk posed to the general public by an existing incident and at all times to consider and identify the ‘worst case scenario’ outcome.

22)       I recommend that the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in risk assessment.

23)       I recommend that the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in risk assessment.

24)       I recommend that the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public.

25)       I recommend that the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public.

26)       I recommend that the South Australian Country Fire Service establish pre-planned Level 2 Incident Management Teams in each Region for deployment to Level 2 incidents.

27)       I recommend that the South Australian Country Fire Service utilise wherever possible the skills of paid, professional staff to perform the roles of Incident Controller and/or Planning Officer in Level 2 Incident Management Teams.

28)       I recommend that the South Australian Country Fire Service identify and impart minimum skills and competencies to members who fulfil the roles of the four core AIIMS functionaries of a Level 2 Incident Management Team.

29)       I recommend that the South Australian Country Fire Service create as part of a Level 2 and 3 Incident Management Team Logistics Division an Officer whose function it is to seek out, locate and identify sources of water, be they on land or provided by carrier.

30)       I recommend that the Minister for Emergency Services give further consideration to acquiring a firefighting helicopter to be permanently or primarily stationed in South Australia.

31)       I recommend that the Chief Officer and the Editors of all newspapers and other media outlets develop a Memorandum of Understanding that ensures that all CFS press releases concerning total fire ban days and ongoing bushfire incidents are published in full.

32)       I recommend that the Minister for Transport, in conjunction with any other relevant authority, conduct research in relation to the question as to whether or not after‑market, non-standard mufflers are suitable devices to be fitted to vehicles that are used in rural environments.

33)       I recommend that the Minister for Emergency Services, the Minister for Environment, the Chief Officer of the CFS and the Native Vegetation Council, together develop a Code of Practice relating to the management of native vegetation as it affects bushfire prevention.

34)       I recommend that the Minister for Emergency Services and the Minister for Local Government cause local council plant and equipment that is suitable for use in bushfire fighting be fitted with radios connected to the Government Radio Network.

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