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A Review of Factors Associated with the Linton Fire Entrapment, Victoria. 2 Dec 1998

David R. Packham Consultant to Victorian WorkCover Authority

11 October 1999

Volunteer fire fighters from the Victorian Country Fire Authority awaiting the emergence of a fire from a pine plantation near Wandong, Victoria, 14 Jan. 1998. Photo Allan Sewell CFA.

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“Any scientific enterprise that aims to influence policy will inevitably have its political dimension. Decisions about risks – to health and safety, to the environment, or to the social fabric – are no different. They transcend, and therefore cannot be restricted to, such apparently neutral scientific questions as what are the uncertainties and consequences of hazards, and what methods and standards for assessment of risk should be adopted, but instead become part of a much wider discourse. This point is illustrated no more clearly than in the debate surrounding “narrow” or “broad” participation in institutional risk management.” Nick Pidgeon “Technology, Democracy, Secrecy and Error in Accident and Design- Contemporary Debates in Risk Management. Hood and Jones UCL Press Ltd. London 1996.

Dedication To all those who by their actions seek to enable Australians to live in harmony with fire in our unique environment and especially for those who have suffered and sacrificed so much. Acknowledgements I am very thankful for the assistance given to me by the staff of the Australian Emergency Management Institute at Mt Macedon, in particular Mike Tarrant, Rob Lee and Rob Flemming. Dennis Noonan from WorkCover and Brad Dailey and their colleagues from the Victoria Police Arson Squad have been most helpful and impressive in their dedication.

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INTRODUCTION

Background At the request of the Victorian WorkCover Authority I have reviewed many of the documents about the Linton Fire deaths on the 2 Dec 1998. I have visited the site several times and attempted to discuss the event with officers of NRE, CFA and the Bureau of Meteorology. The documents that have been obtained from CFA and NRE have been most helpful and have enabled me to confirm or change the deductions that I made as a result of the site visits. No doubt further discussions with the officers would also have been very helpful but have been inhibited. I was able to have one discussion with the Bureau of Meteorology. In any disaster it seems axiomatic that there is not one cause, if only it was so easy, but a chain of links that if broken at any stage would have and often does avert disaster. In this fire it is not too difficult to identify over 51 failures of the system that led to the disastrous outcome. I will focus on these failures as I see them. My working hypothesis in this review is taken from James Reason who has extensively studied organizations, Corporate Culture and Risk.1 “ The anatomy of an “organizational accident” is shown in Figure 1. The direction of causality is from left to right. The accident sequence begins with the negative consequences of organizational processes (i.e., decisions concerned with planning, scheduling, forecasting, designing, specifying, communicating, regulating, maintaining, etc.). The latent failures so created are transmitted along various organizational and departmental pathways to the workplace (flight deck, maintaince hangar, and air traffic control room), where they create the local conditions that promote the commission of errors and violations. Many of these unsafe acts are likely to be committed, but only very few of them will penetrate the defenses to produce damaging outcomes. The fact that engineered safety features, standards, controls, procedures and the like can be deficient due to latent as well as active failures is shown by the arrow connecting organizational process directly to defenses. The model presents the people at the sharp end (flight crew, maintenance engineers, air traffic controllers, etc) as the inheritors rather than as the instigators of an accident sequence. Its may seem as if the “blame” for the accidents has been shifted from the sharp end to the system managers. But this is not the case for the following reasons. ? The attribution of blame, though often emotionally satisfying, hardly ever translates into

effective counter-measures. Blame implies delinquency; delinquency is normally dealt with by exhortations and sanctions. But these are wholly inappropriate if the individuals concerned did not choose to err in the first place, or were not markedly error prone. One of the basic principles of error management is that it is often the best people that make the worst mistakes.

? High –level decisions are shaped by economic, political and operational constraints. Like designs, decisions are always a compromise. It is thus taken as axiomatic that all strategic decisions will carry some negative safety consequences for some part of the system. This is not to say that all such decisions are flawed; though some of them will be. But even

1 Reason, J. 1993:25, “Organizations, Corporate Culture and Risk Human factors in Aviation”, The 22nd Technical Conference, Montreal 4-8 Oct 1993. I.A.T. Montreal, & Geneva. Attachment 1.

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those decisions judged at the time, as being good ones will carry a potential downside. Resources, for example, are rarely allocated evenly: There are nearly always losers. In judging uncertain futures, it is inevitable that some of the shots will be called wrong. The crux of the matter is this: we cannot prevent the creation of latent failures; we can only make their adverse consequences visible before they combine with local triggers to breach the system’s defenses”.

Before it is thought that my views are only negative. I would like to point out that so much of what is done by the workers in the forest and the volunteers and officers of the CFA and the Bureau of Meteorology can only be described as of the highest level of professionalism. These groups serve Australia very well and can stand comparison with any other similar group in the world. What has been very helpful in this review was the fire behavior analysis of the Linton fire by NRE and CFA 2which has confirmed the lesser number of observations that I made on the subject of fire behavior. Not much seems to have been left out (notes that I have made upon reading this report are attached). Further information from the two fire agencies has not been easy to obtain, direct access to the officers has been difficult and even casual inquiries on clarification details has been accompanied by the intervention of legal council. It is possible that there could still be information that we do not have access to, but I doubt if the whole information would make a material difference to the conclusions I have reached. However it is impossible to claim that in these circumstances something of importance may not have been missed. The threat to Victoria of bushfires. In Australia, which is acknowledged as one of the three most fire prone areas in the world, Victoria faces the greatest threat. During this century some 500 people have perished in bushfire in Australia and of these about 350 have been in Victoria. The life loss in Victoria is thus about 4 persons per year. The apparently modest annual life loss does not reflect the horror and distress caused by the enormously destructive bushfire episodes that occur every twenty years or so. When weather, fuel and ignition come together on extreme fire danger days there is very little that can be done to escape the holocaust that follows. There are very serious economic threats from fire disaster episodes and these are concerned with the potential destruction of our timber industry and a potential decrease to our harvestiable water supplies of up to 50% for some decades. These issues can and should be explored in the context of recommending the level of effort that is rational to apply to our bushfire problem hopefully through improved prevention.. The are two potentially successful strategies to contain the bushfire threat. The first is to manage our forest fuels with dedication and vigiour. This is a difficult and costly exercise but is likely to be the most effective and economic risk management strategy available. The second strategy is to be applied when fuel management alone is not enough is to be capable of mounting a rapid first attack and combat wildfires when they are still small enough to be controlled. It is certain that if a fire escapes on an extreme day from the first attack there are no forces available that can control it until weather or fuel abate.

2 Ferguson and Edgar. 1999 “Report of the operations review of Linton/Midlands Fire #15 on Wednesday 2nd December 1998; CFA and NRE Melbourne. Included under separate cover.

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The first serious analysis of our fire problem was the magnificent Stretton Royal Commission into the 1939 fires3. His report lead to the formation of the Country Fire Authority and the report still contains conclusions and understanding that is essential reading as we grapple with the problem. The other strategic reviews have been the Barber Royal Commission into the 1978 Grass fires, the Miller report into the 1983 fires and the Australian, Institute of Engineers also into the 1983 fires and the Report of the Auditor General into the capacity of the Department of Conservation and Natural Resources (now NRE) to control forest fires. There is a need to review the total fire control strategies for all of the State in view of changes in technologies, public administration, scarcity of forest resources, and the economic stress on the rural sector and public expectations. I suggest that a review address the need for much increased fuel management and the restructuring of fire fighting in Victoria into three organizations. The first to be responsible for fire management in our cities. The second responsible for fuel and fire management in our forest areas and the third to be our volunteer fire brigades responsible for community self-protection on small private lands and small towns and villages. There are complex questions to be resolved not the least is the relationship of fire management with other emergency services e.g. road rescue, transport accidents and spills, large plant protection and timber plantations. A review that is independent is necessary, as nothing else will achieve for Victoria a total fire management system that could meet our needs beyond 2000.

THE LINTON FIRE

The details of fire ignition, spread and fire-fighting strategies surrounding the Linton fire are well covered in the “Report of the Operations Review on Linton Fire/ Midlands fire #15 on Wednesday 2nd December 1998”2 by a Joint CFA and Department of Natural Resources and Environment Operations Review Team and dated 11 March 1999 authored by Euan Ferguson, Tony Edgar, Mark Gilmore John Haynes, Duncan Maughn and Kevin Tolhurst. Of these authors, two had a first hand knowledge of the fire, being involved as the Deputy Planning Officer and another appointed as an investigator by 1300hrs on the day after the entrapment. I have prepared notes on the report to highlight some of the important matters raised and those notes are attached as Attachment 2. The major issues that I raised surround the timing of the wind change and the decision to leave crews on the eastern edge as the change passes. Other matters are the lack of confirmed communication of the impending wind change and the use of inexperienced volunteer firefighters in the difficult and dangerous forest fire environment. Fire behaviour The fire behaved entirely as could be expected from the knowledge of fire behaviour readily available in Australia. Fire behaviour prediction is an empirical technique being based upon fire experiments conducted especially on dry scheloryphyl forests of almost exactly the type at

3 Attachment 52. 2 Under separate cover.

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Linton4. There was as the Joint Report pointed out some difficulties with long term dryness of the fuel and the possible misleading nature of the Keetch-Byram Soil Dryness Index as adopted within the McArthur Forest Fire Danger Index (FFDI) and fire behaviour tables. The joint report put the fire at travelling at about 1.1 km/hr from ignition until arrival at the outskirts of Linton (p85). Assuming that the fire reached Linton as the wind change I had estimated that the fire traveled at 0.77 km per hour. Later information from the joint report enabled me to correct my estimate to 1.2km per hour i.e. 20m per minute or 0.33 m per second. By measuring the ground fuels in a few sample spots and finding about 12 to 15 tonne per hectare and then adding bark and elevated fuels it is however not enough for the McArthur predictions to reach the rate of spread required. If however the average fuel loads were around 25 tonne per hectare then 1.13 kph is predicted. Whilst the details can be argued and discussed it remains that within the usually accepted precision for fire management operations there is good agreement with the CFA/NRE report. This fire was easily predictable. The most puzzling feature is the reported two waves of fire experienced by the entrapped tankers. The joint report puts this down to a wave of surface fire followed by a wave of crown fire. Other possibilities are the second wave of fire came from a slightly different direction as the wind and fire oscillated in direction as well as strength with gustiness. Another possibility is that the second wave was as a result of a more southerly wind direction as the wind change established itself. There is no clear evidence as to which of these possibilities actually happened. The joint report (CFA/NRE) attributes the under estimation of rate of spread to unseasonable dryness, supported by the Bureau of Meteorology Preliminary Report. I have commented on the proposition in notes attached as Attachment 3. Whilst the empirical models upon which these predictions are based are most useful and even essential for fire management, they are now some 40 years old and despite considerable efforts to improve them they have serious limitations. Most of those limitations do not apply however in the Linton fuel types. A leap forward in fire modelling is desirable as we progress onto a more positive fuel, fire and forest management. The predictability of fire behaviour leads inescapably to the conclusion that if the fire edge was some 85 meters from the Geelong trucks when they stopped the time taken for the fire to overrun them from when the wind dramatically increased was by my estimate 200 seconds or 3 minutes 20 seconds. This counter-intuitive conclusion is shorter than the time estimated in the joint report of about 4 - 6 minutes (p120). In either case from the time that the wind change dramatically arrived the two tankers had some minutes to analyse and respond to their predicament. The bulldozer driver, some 27 m away certainly interpreted the threat accurately and had time to return in reverse to the safety of the turning zone5. . It was most unfortunate that the Infrared line scanning equipment failed before any mapping could be done. The line scan data is a reliable and unambiguous source of information that is so valuable after the event. Steps should be taken to ensure a great level of reliability of the system and may require a major upgrade. 4 Discussed briefly in the Bureau of Meteorology Preliminary report. Further published information from simple discussion to complex mathematical derivation is available from the author of this report. 5 Statement of David Rowan 8/12/98 Linton.

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Topography. The topography is mentioned briefly in the joint report (p22) and is in fact not so undulating as to cause any spectacular enhancement of the fire behaviour. It is suggested that there was funneling of the post change wind as to increase the intensity of the wind change at the tankers. If this is so then it is also possible that there was a local wind direction change and the wind changed to more southerly than suggested by the wind change charts on pages 19 (fig 5a) and 20 (fig. 6a) in The Bureau of Meteorology Preliminary Report. If the SE sector direct attack had reached near Kelly Rd and there was burning out up to near Kelly Rd or the extension of Homestead track near the “Sludge Gully Label” on Fig 11 (p21) the fires that overwhelmed the tankers may well have come from this area. This is consistent with fire scars etc that indicate fire travel in the directions of 016 to 328 deg magnetic, i.e. 006 to 318 deg true. The issue of the exact time that the fire to the “NE” of the labile “Flank fire” on page 118 was lit becomes a major issue as well as the exact direction of travel.

Failures in the “Safety Chain”.

Accidents and disasters start with breakdowns in organizational policy and structures. There is considerable literature on this subject of which Barry Turner’s contribution is most worthwhile and an extract is attached.6 There have in this fire tragedy also been many links broken in the safety chain ranging from organizational structure to decisions made in the face of accelerating fire. I have addressed these links or issues. 1. Confusion in the role of CFA as a rural or urban fire organization. The CFA is a large urban fire fighting organization sometimes said to be larger than the Melbourne and Metropolitan Fire Brigade (MFB). The annual report however does not break up its expenditure (about $110m P.A.) between city and rural fire activities. In terms of the number of firefighters there are officially 78,000 volunteers7 some of whom are urban firefighters and the balance are rural fire fighters.8 There are two intersecting cultural divides within the CFA that create four separate internal territories. ? The urban paid permanent firefighter ? The volunteer urban firefighter ? The regional officer, risk managers etc who are paid permanent mostly rural firefighters

and ? The volunteer rural firefighter.

6 Turner, B., “Man –made Disasters” Wykenham publications (London) Ltd , 1978. 7 CFA Annual Report 1997 – 1998. 8 The number of active volunteers has not been made public and it may be as low as 20,000.

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Many members of the CFA overlap these categories and sometimes the borders are somewhat fuzzy, at other times distinct. Within the rural volunteers there are broad groups who have expertise and experience in grass fires, scrub fires, forest fires and the rural-urban interface. There is some overlap with individuals sometimes belonging to more than one group. The important point is that the CFA is very far from a homogenous group and has the potential for considerable internal tensions between the groups. There are two fire brigade associations, one rural and one urban and the Firefighters Union as representative of the paid workforce. The representative groups have membership on the CFA board. From a fire safety viewpoint any lack cohesion could be reflected in confusion of roles between the groups during fire operations, prevention and preparation. Overlain on this considerable structural instability is the role of fire prevention, which lies with local government using fire protection officers employed by local government to manage the rural fire risk. The Department of Natural Resources and the Environment have the responsibility for fire protection on all State declared forests including forest parks, unoccupied crown lands and national parks. Recently with the corporatisation of the State’s forest plantations with the formation of the Victorian Plantations Commission (VPC) and the subsequent change of ownership to private organizations the responsibility of plantations has shifted from NRE to the CFA.9 These complicated arrangements impact on safety issues during fire management operations and there are likely to be conflicts affecting the disposition of firefighters, and the choice of strategies and tactics. Within the CFA management there is a further divide between risk management, community orientated rural fire management and operational fire fighting philosophies. The confusion is enhanced by uncertainty as to the role of the paid operational officers and the role of volunteers as fire managers. This confusion is not only evident within the CFA but also within the rural fire services of NSW and SA and possibly in Tasmania as well. Western Australia has attempted to resolve these conflicts by combining the fire and emergency services.10. Tasmania likewise whereas Queensland and New South Wales have worked hard to keep them well apart as has the Northern Territory. There is clearly no perfect structure. An example of this confusion is the design of fire-fighting vehicles. In small brigades they are primarily for urban building fire fighting, vehicle accidents (which could be very large as in the case for example of gas tanker accidents) and for grass and forest fire fighting. The result has been generally vehicles that have been forced to compromise to be useful in all the roles. There are of course specialized vehicles in bigger brigades. The resulting equipment is not ideal for any one of these roles. It is possible that the compromises build in latent risk to the fire-fighting operation.

9 “Getting the Low Down on Industry Brigades”, Fireman, Sept 16 1998 p4, Attachment 5. 10 Mitchell, R. 1999:2-5 integrating emergency services, how WA is merging fire and emergency services agencies.” Aust J. of Emergency management 14(1) Attachment 6.

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Similar difficulties apply to the development of training programs and communication systems as well as brigade structures and systems of firefighter management and “discipline”. We can thus on occasions have situations where firefighters are working outside their training or experience in vehicles and management systems unsuitable for the particular fire or emergency. In these situations safety levels can be severely compromised. The organizational structure and behaviour of the CFA needs to be studied in the light of community needs and threats. It may be that a case can be made for the partition of urban fire management into a combined CFA -MFB structure and a separate rural and community fire organization with much diminished responsibilities for urban fires but an enhanced expertise for biomass fires. Even within brigades there could well be division into structure, road vehicle accidents and biomass firefighters. The resulting increase in expertise, training and equipment can be expected to result in more effective service and higher levels of safety. These issues have not often been raised, as such discussions are seen as territorial threats rather than opportunities for service and community improvement. These issues are also difficult to document as closed organizations work hard to ensure their internal workings are opaque. 2 The structure of the CFA board Territorial skirmishes between CFA and NRE have been ongoing ever since the creation of the CFA in 1945. In recent times considerable effort has been made by CFA and NRE management to generate more cohesion and harmony and it is possible that the present relationships are the best ever. Nevertheless the interests of CFA and NRE conflict from time to time on some issues and I would speculate that issues of plantation fire protection and fire control and the use of volunteers in thinly protected NRE lands and fuel management would need to be resolved at board level. Many of these issues have significant safety issues attached. In the resolution of these conflicts the presence of an NRE member on the CFA board without reciprocal arrangements with the CFA could be seen to skew decisions. If there were reciprocal arrangements then opportunities for the integration of equipment, training, communications, fuel management priorities and especially safety standards, practices and audits between the two agencies would be greatly improved. 3. Role confusion during fire control. After several decades of fire fighting in the world’s most fire prone region, the Victorian fire management system was very finely tuned and often the model for other regions. The system was that NRE was responsible for fire and fuel management on its own lands and used its district and regional forest management structure for fire fighting and fuel management tasks. NRE or its predecessors did not rely upon or even welcome CFA firefighters for its very specialized operations although in some cases there was minor volunteer participation. In a similar fashion NRE officers made only minor contributions to community fire fighting on rural lands although again there were exceptions. The workday relationships and the everyday networks of NRE were carried over into fire fighting. Forest work being of a high risk generated a very professional and component attitude to safety and to fire safety in particular.

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I think it is true that the lack of forest fire injuries and fatalities within NRE indicates the effectiveness of the system. The CFA system had developed for the volunteers through their brigade and group structure to take control of fire fighting in rural areas. The role of the CFA paid Regional Officers and their head office was to provide support and logistics for the volunteer firefighters. This system generated some confusion as to who was actually running a fire but by and large it was the volunteers. In the Linton fire the initial fire management was conducted by the Snake Valley brigade and especially by that key person, the communications officer. This worked well for the first response action. NRE who do not respond as quickly as CFA claim 99% effectiveness for first attack.11 On Ash Wednesday (1983) 193 out of 200 fires were brought under control by this system.12 I am puzzled as to why the first attack by the CFA took so long; some 19 minutes elapsed from the first report of the fire until the first CFA tankers arrived and 57 minutes for the first NRE units.13 On the Linton fire this first attack failed and a second phase was instigated. The second phase was somewhat spontaneous but also at the instigation of the Communications Officer (Foy). In many cases this second attack succeeds but not on this occasion. There was no excessive confusion shown in the actions of the CFA groups involved (there is always some confusion at fires on high or extreme fire danger days). One may well question the wisdom of the stand on Snake Valley Rd. and the backburn decisions but there was little uncertainty as to who was in charge and what was going to be done. Uncertainty however started to appear when NRE officers became involved 14. They did nothing to generate any confusion, in fact their analysis and understanding was a positive contribution but they could see that the rural fire north of Pittong road was about to become an NRE fire in State forest south of Pittong road. Uncertainty was generated by the different tactics of fire fighting between CFA and NRE. Uncertainty also appeared when the fire threatened and finally did cross CFA regional boundaries.15 As the group structure was being replaced by the Australisian Interagency Incident Management System (AIIMS) structure the non volunteer CFA officers and NRE officers appeared to be taking control of the fire at least in the area south of Pittong Rd. It is clear that the group officers and the deputy group officers and in some cases captains still believed that they had some control and even exercised it.16 By now confusion was excessive. Backburns were taking place, courageous stands were being taken, equipment arriving from everywhere, strike teams were being assembled. It is not clear who if anyone was managing the fire. The volunteer group officers were, it seems making decisions for the CFA non-strike team firefighters. A senior CFA paid Officer (Leach) became the incident controller with an NRE officer as his deputy. However the real strategic decisions were stated to 17 being made by a senior and very experienced NRE officer (Graham). We now have the replacement of the volunteer group officers by the paid CFA managers and NRE managers. It seems however 18

11 McCarthy and Tolhurst paper, page 29 (Attachment 7.) 12 CFA report on Ash Wednesday Fires 16 Feb 1983. 13 “Reducing the Risk of Entrapment in Wildfires, A Case Study of the Linton Fire” CFA, July 1999, page 4. Attachment 8. 14 Statement of Marcia Johns, Murray Fullerton, Gerard Stewart, Peter Keppel. 15 Statement of Smithers, Welch (esp. p 2.3 and 4.9), Keppel (p3.5). 16 Statements of Welch, Millar. 17 Statement of Keppel (p1.6), Boadle (p3.90, Leach (p5.6). 18 Statement of Pohl, Millar, Welsh.

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that some group officers were continuing to lead and direct the firefight in such a manner that the AIIMS system was to them irrelevant19. It is clear that the successful halting of the fire before it overran Linton Township was due to the leadership of the group officers and the actions of the Volunteer CFA firefighters. The forest fire strategy (use of bulldozers in direct attack) was being generated within the IMS by the deputy operations officer (Graham). If this is to be the pattern of large or campaign fires in the future it is hard to imagine that there won’t be more safety difficulties. 4. Incident management system The Australian Interagency Incident Management System (AIIMS) is an adadption of an American (NW Pacific) management structure that has to be constructed for each fire event.20 It has analyzed the actions that need to be taken in attempting to manage each fire event and ensures that those functions are fulfilled. It is very much in favour in most fire agencies in the rural fire business and has support from the Australian Fire Authorities Council who provide documentation and training packages. There is considerable room for discussion and analysis that may reject AIIMS as an appropriate management tool for fast moving but short lived biomass fires. If fires continue beyond the first shift then perhaps the AIIMS can be brought into life. The problems that I can see with AIIMS are

? The existing networks that underpin group and workplace activities are overturned and new ones have to be created in a matter of hours.

? There is an initial concentration on developing overhead and structure instead of a total focus on fire control at the stage when the fire is most vulnerable to fire fighting.

? In a disaster situation where hundreds of fires can erupt in Victoria between noon and 5pm it is just not possible to establish AIIMS for even the fires that could be expected to overwhelm initial or secondary attack.

? There develops multilayer (in this case 10) decision layers between the incident controller and the firefighter21. This is much too vertical a management structure.

? In a disaster situation organizations collapse, individuals function beyond expectation and new leaderships emerge.22. The AIIMS takes no account of this disaster sociology reality and hence may only function for fires that are not too large or too small and that will last for a suitable length of time.

? It is unlikely that the decisions actually made will be made according to the AIIMS but rather traditional and effective leaders and strategists will tend to continue in their normal role no matter where they are placed within the AIIMS.

19 See statement of Phelan for example. 20 In “ NRE Basic Fire Awareness, Presenters Notes p18 “Chain of Command, Normal chains of command do not necessarily apply during fires. A separate organizational structure is constructed during fires.” Attachment 9. 21 Linton Bushfire Investigation, Operation Hierarchy Chart, Vic Police. Attachment 10. 22 Quantallie , E.L., (1970) “ A selected and annotated bibliography of social science studies on disasters” American Behavioral Scientist 13 (3), 452 – 456.

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It is clear that there must be much more analysis of AIIMS. It is possible that in campaign fires, in less fire prone areas the AIIMS could be of considerable use. Objective and independent analysis of case studies from Australia and overseas would be a good start to evaluating AIIMS. In the Linton fire, AIIMS did little to ensure that correct information was available to all levels nor ensure that only trained and experienced firefighters were tasked. It did not oversee or challenge the safety of the management actions or even ensure that only appropriate equipment was used. The well developed group structure of the CFA volunteers and the work team structures of NRE are disrupted when AIIMS is put into place. Decision vacuums developed and without the resourcefulness of the fire fighters one could imagine that fire fighting would have to stop. For example the operations centre was moved from the CFA station at Linton to the Shire Officers where it had no direct access to radios23. Communications vehicles had to be provided to enable AIIMS to function. That the AIIMS structure was never adequately established was underlined by the fact that the OIC of the communications van situated outside the Shire Office thought that the Incident Control centre was in the Linton Shire office when it was actually in Ballarat. The correct location was not discovered until a couple of days later 24. The shire phone system did not know that the operations centre (as distinct from the incident control centre) was in fact in its own Shire Office. It must be expected that confusion will continue whenever the established group and crew arrangements are replaced with an AIIMS structure. 5. Downsizing of NRE The speed of response of the NRE teams and the total number of NRE employees used on this fire in their area of legislative responsibility (despite the considerable dedication of the officers themselves) was just too slow and too small to manage the Linton fire. NRE has no alternative but to use volunteer firefighters to effectively do NRE work. This would not be the wish of the NRE fire managers but a necessity forced upon them by the reductions within the NRE workforce. Fire-fighting is mostly a dirty, often boring and frustrating activity that requires mostly simple and repetitive skills e.g. raking of trails, blacking out with water. However on occasions there is a rapid transition from benign to fatal fires. It is at this time that the highest levels of knowledge, experience and training are required to conduct a safe and effective operation. Very high levels of judgement are also required to be able to determine when a firefight is a waste of time and dangerous. Fire fighters with such levels of judgement, knowledge and skill abound in Victoria both in grass, scrub, mallee and forest fires. However there are many others who have little experience, little knowledge and insufficient training and should not be exposed to the risks of fire fighting when there is a potential for life loss.

23 Statement of Graham, 1 May 1999 page 4. 24 Statement of Roberts (p2.10, Smithers(p4.4).

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Grass, scrub, mallee, dry schelophyll, pine plantations, wet schelophyll and alpine forest fires all require different fire-fighting techniques and skills. The complexity, and risks generally increase from grass to wet forests. All types of fires are potentially dangerous and all have caused firefighter life loss. The good record of NRE in firefighter safety stems from their extensive safety, education and training programs. The CFA also have training programs but indications from statements and documents and discussions with volunteers suggest that the program is not extensive enough and that relatively untrained or even totally untrained firefighters are involved in fire-fighting. Indeed there is a tradition of unregistrated casual firefighters who are covered by the same insurance and indemnity as registered CFA volunteer firefighters. On this occasion there were 10 fire-fighters on the two Geelong tankers and it appears that some were totally untrained, some had partial experience and training and a few were well trained but that none were extensively skilled in forest fire fighting. No person should be involved in fire fighting outside the initial attack, who has not reached the required level of knowledge, skill and experience. Initial community protection will always depend upon who and what is available at the time and the lesser skilled firefighter and casual firefighter will always be necessary. Their participation must cease after the first attack has failed or the first hour of the fire passed. The overwhelming losses of fire fighters have been in forest, plantation or scrub fires.25 Grass fires have caused deaths of firefighters in extreme circumstances but fortunately in lower numbers. Forest fire fighting has more complex terrain, access, fuels, visibility and meteorology than grass fires and requires a higher degree of training, knowledge and experience. Within forest fire fighting in particular, leadership at all levels is especially important and crew leaders need to be very experienced and sensitive to sudden risk expansion. Downsizing within NRE have lead to a decrease in availability of highly experienced crew leaders and fire operations managers26. Further reliance by NRE on contract bulldozers means that they cannot as effectively provide quality and safety control on this primary fire control equipment. The use by NRE of contractors increases the risks. This is evidenced in the fact that NRE have had no fire related deaths except for two contract machine operators in 1983. NRE insists on an effective training program for its own employees and in principle for contractors but is less able to ensure that contract and volunteer firefighters have the same training before they are involved in forest fire fighting. It is suspected that a more difficult fire management resource situation exists within VPC and the now privately owned pine plantation27 28. 6. Organizational psychology 25 Paix. Attachment 16, Table1. 26 Cheney. Attachment 15 and 12.. 27 Including Linton, which changed hands at 10:00 on 3rd Dec 1998. Letter to WorkCover from NRE. 28 The fireman Sept 16 1998 p4 “Getting the low-down on industry brigades” Attachment 5.

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The culture of both CFA and NRE and just about every fire management agency is combative; fire is the enemy.29 In the entrapments of firefighters whether here at Linton (1988), at Upper Beaconsfield (1983), Storm King Mountain (1997) in Colorado or Man Gulch in Montana (1947), the “troops into battle”, military style operation is the prevailing paradigm. There is an acceptance that casualties are inevitable as in wartime. This paradigm will no doubt be vigorously denied but it is very seriously being challenged. The outspoken challengers themselves find themselves under attack but nevertheless their points contain considerable power.30 The Attachment 11 contains the provocative arguments of Frank Campbell and also Jason Greenlee the Director of the International Association of Wildland Fire. For a high level of firefighter safety the cultures must change. There are signs and indications that this is recognized in NRE by Attachment to the CNR, Code of Practice 31 and by the considerable dedication by some members of the CFA to community fireguard programs. 7. Excessive reliance on technology Faced with the reality that there are insufficient forest firefighters and even more importantly insufficient forest workers and supervisors to maintain a safe fuel management program there has been an attempt to use technology to replace manpower. Increased expenditure on air attack has been claimed as the reason that there has been a decrease in the numbers of fires 32 but there has also been an apparent decrease in the fuel management program which was judged to be insufficient by the Auditor General in 1985 and has not improved since. As fuels steadily increase (see for example the Berringa fuel map) increased technology will not be sufficient. 8. Use of volunteers in forest fire fighting. A difficult policy question is to what extent volunteer firefighters should be relied upon to provide fire-fighting capacity in protected state forests areas. It can be argued that such fire fighting is especially dangerous and outside the training and experience of the majority of volunteers. In the case of Linton no threat existed to the town of Linton or to any significant private property after 18:00 hours.33 There was however a very high threat to the VPC pine plantation which was to become private property the following morning. The policy question of volunteer responsibility for fire protection assistance to corporately owned plantations is a political one and one that needs to be appropriately addressed. It can be argued that the impost of self-protection on the rural population by CFA membership is in itself large enough without having to take on the responsibility and risk of providing additional fire-fighting capability for corporate plantations. It is my opinion that safety considerations dictate that volunteers should not be used for fire fighting in plantations outside of initial attack. The risks are too great. The particularly violent nature of pine plantation fires is graphically shown on the cover of this report. Inside a plantation is no place for volunteer firefighters. Their interests lie in mutual self-protection for

29 See Campbell, Attachment 11. 30 See attached correspondence in the international journal “Wildfire”. Attachment 12. 31 Dept of CNR “Code of Practice for Fire Management on Public Land” December 1995. Attachment 13. 32 See Incoll. Attachment 14 also CFA Annual Report 1997-1998. 33 Statement of Keppel (p2.30, Graham (p3.0, 5.5)

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homes, villages, towns and businesses. The questions need open debate but it is certain that if volunteers had not been called upon to undertake the difficult task of dozer support and burning out when a wind change was possible to protect a pine plantation no fatalities would have occurred at Linton. 9. Fuel management in the Linton area. Entrapments of both firefighters and civilians in SE Australian forest fires have usually had two common features. They have taken place in areas of high fuel loadings34 and during a wind change35. There is however a paucity of information and even the important study of Krusel and Petris36 pointed out that detailed information is seriously lacking. Whilst it is noted that 46 of the 47 deaths in the Victorian Ash Wednesday fires took place on the passage of the cold front or soon after it is also true that many of the deaths were associated with particularly high fuel loads e.g. the deaths on Bailey Rd Cockatoo and the 14 firefighters in Upper Beaconsfield. It is inescapable that fire intensity is directly related to fuel loads and it can be expected that the threat to life in a forest fire will be directly related to fire intensity and hence fuel load. The fuels directly to the north of Linton consisted of a narrow band about 250m of priority 1 fuel reduced within the last few years and could have been expected to be less than 5 tonnes per hectare. The fuels to the west of the pine plantations had been fuel reduced in the last two years and consisted of an area with an average width of about 600m. That fuel managed zone was to the south of Possum gully road. (See joint report CFA/NRE page 73). It could have been expected to stop a fire of medium intensity. To the north of Possum Gully Road on the east side of Homestead Road the fuels had not been reduced for 22 years and would be extremely dangerous. It is fortunate that the fire control action (including the back burn) to the north of Possum Gully Road was so effective as to prevent fire spread on the passage of the change. An escape would have threatened Maxwell Park Camp and the town of Snake Valley. The Linton fire is a dramatic illustration of the importance of fuel management. Low fuel loads considerably lower the threat to property and ensures that fire fighting can be both successful and safe. The remainder of the fuels in the forest were mostly 20 – 25 tonnes per hectare being greater than 15 years old. At the start of the fire and up to the Snake Valley – Linton Road the fuels were stated to be in excess of 30 years old which leads to expectations of 30 tonnes per hectare.37 Fuels at these levels are classified as very high and extremely hazardous in the NRE guidelines 38 and there is no doubt that that is so. Fire behaviour on a very high or extreme fire danger day would be catastrophic with full crowning, fast moving fire and spotting that could be expected between 2 – 10 kilometers down wind of the fire. A 250 m priority one fuel reduced zone whilst helpful would not contain such a fire.

34 Cheney 1998:8 Attachment 15. 35 Paix 1999:310. Attachment 16. 36 Krusel and Petris (1993) Hotsheet (now Wildfire). Attachment 17. 37 CFA/NRE joint report. 38 NRE Fuel guide. Attachment 18.

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If it is argued that the 250m zone is enough on a very high danger day or worse, then why was it not considered to be sufficient in the evening of Dec 2 when in a couple of hours before the wind change the fire danger was only high.39 Due to its strategic location, north of Linton and adjacent to and west of a major pine plantation the whole of the Linton forest was a threat that should have been classified as zone 1 and managed appropriately. If the failure to classify the whole forest as zone 1 or perhaps zone 2 was due to the strain that such fuel management would put on resources, then more resources must be provided. This is the strong recommendation of the Auditor General’s report of forest fire fighting in 1992. Not much seems to have changed and one must ask about the risk assessment for the rest of the state where protected state forests abut towns, villages and other major assets. The generation of a safe work environment for both forest and volunteer fire fighters means provision of minimum fuel levels. There are levels of fuels which when combined with an expected fire danger generate a dangerous work environment and fire fighter exclusion is the only option. If we examine the Linton forest combination and agree 3000 kW per meter fire intensity as the maximum safe limit 40 then the Linton fire exceeded this intensity at the head during the afternoon and upon passage of the front. During both these times the environment in front of the fire was unsafe.41 It could be expected that if the forest to the north of Linton had been treated as zone 1 or 2 and been fuel reduced then the fire threat would have been much diminished and the need for aggressive fire-fighting at both Homestead Road and Snake Valley Road would have not been required. A zone 1 or 2 should have been allocated in view of its strategic northley location to Linton and westerly location to extensive pine plantations. Even if firefighters had been caught by the wind change the lower fuel loads would have ensured a much-diminished risk. If the fuels had been reduced to less than 8 tonne/ha the exposed firefighters would have had to withstand a fire intensity of less than 16% of what occurred. The Joint report estimated that the fire intensity was between 4000 and 11000 kW/m; both ends of the range presenting very difficult survival problems. If the fuels were the maximum 8 to/ha for a priority one the fire intensities would have been between 640 and 1760 kW/m. these intensities could be expected to be survivable. It may be argued that the 250 or so meters of priority one zone to the north of Linton and the average 600 m to the west of the pine plantations was enough to provide a sufficient barrier. If this is so then one must ask why fire-fighting that required crews to be at the eastern edge of the fire in heavy fuels on the passage of the change was necessary? The fuel loads in the forest were unacceptable. It is a situation identified by the Auditor General in 1992 and one that is probably repeated at many places throughout Victoria. These high fuel loads place many towns and villages at risk and generate a dangerous environment for both volunteer and professional firefighters.

39 Fire danger from AWS at She Oaks, CFA/NRE Joint Report. P141. 40 Cheney 1998:9. Attachment 15. 41 The maximum intensity for survival has not been directly measured or estimated in the literature. Knight’s work on fire shelters claim 5600kw/m and US studies suggest tankers and fire shelters are both about as effective as shelters. A max figure of 3000kw/m would be a reasonable starting point for a quantitative assessment of human risk in forest areas.

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10. Lack of indemnity for fuel reduction. There are four reasons for the failure of a vigorous fuel management program in our socio-political system. The first is the lack of resources to undertake the program. Governments rapidly provide large sums of money for fire fighting during a fire emergency but fail to provide all the resources necessary for a sufficient large fuel, fire and forest health management program. The second reason is the lack of suitable weather, totally beyond our control. Thirdly, we are sensitive to extreme conservation viewpoints when almost all conservationists in Australia agree that fuel management by fire is the only way to ensure forest safety and health. Finally the lack of indemnity for fuel managers from fire escapes beyond their control.42 It is worth noting that in Florida43 all agencies and individuals are state indemnified against properly conducted fuel management fires on their lands that escape and cause damage. This State needs such legislation to provide security to agencies; local government and individuals who need to undertake this difficult and dangerous operation to protect us all. The effectiveness of fuel management in community protection was well demonstrated at Mt Dandenong in 1977. NRE have long undertaken sensitive fuel reduction on that extreme risk with high environmental values. 11. Corporatization and privatization of plantations. Pine plantations are an extreme fire risk. They have had so far the highest photographed flame heights, being over 200m in the case of the Ash Wednesday fires in the SE of South Australia and over 100m at Wandong in 1998 (Cover photo). Depending upon how they are managed they can range from extremely dangerous as unpruned heavy litter plantations to safe pruned and prescribed burnt. With aggressive fuel management pine plantations can in fact be firebreaks giving considerable protection as in the case of Mount Burr in South Australia in 1983. However eight firefighters were entrapped in South Australia, Wandillo fire in 1958 in one of our worst fire tragedies in heavy pine fuels. If corportization and privatization leads to a decrease in workforce in pine areas there will be an increased reliance on volunteers to manage fires in this “private” property. Unless the fire fighters are highly skilled, trained and with a considerable self-preservation instinct then we must expect the likelihood of entrapments within this forest type. Without externally applied enforcement of fuel management and fire fighter resources then we can expect a minimum of fire protection driven by economic considerations. Risk analysis including safety audit is required for fire management in these special areas. The risk to the pine plantations at Linton is likely to be the reason that a decision was taken to “leave resources in the area until after the change”44 and to put pressure on the firefighters to complete the link up. After 18:00 there was no longer any threat to the town; the threat was to the plantations. 12. Resources The use of CFA volunteers in forest fire fighting is argued on the basis that management of a fire whilst small increases the safety for all rural dwellers. The pervasiveness of CFA Fire Brigades makes them ideal for first attack which is a very effective form of fire fighting. Their 42 Robinson, et al. Attachment 19. 43 Attachment 20. 44 Fire management plans, Attachment 21.

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coverage of some protected state forests ensures that there is good fire coverage of these important assets. The cost of providing a similar level of protection professionally as in the United States would be very high. Whilst it is true that most CFA volunteers are happy to assist NRE in meeting their statuary responsibilities there must be a point in any fire where it is not fair and reasonable to use volunteers to achieve the level of fire protection intended in the various acts and forest policy45. I suggest that in these economically rational times the following conditions apply before volunteers can undertake extended forest fire fighting other than first attack in lands under the fire management of NRE or VPC.

? The first attack must not have finished i.e. when the first tankers have exhausted their safe water or an agreed period of time which ever is the sooner.

? The firefighters must have undergone the same fire safety training as NRE or VPC firefighters.

? They must be under the direction of a crew leader level trained NRE or VPC firefighter and

? CFA must be paid a rate equal to employed firefighters in either NRE or VPC and the monies to be distributed to all brigades in excess of normal budget allocations.

13. Risk assessment by Incident Management Team. Within the planning documents and the statements supplied to WorkCover and the Police there does not seem to be a systematic attempt to evaluate the risks and the skill levels required for various strategies adopted (direct attack and back burning). The situation reports which lay down the fire management strategy do not for example have any box for risk assessment and noting life-threatening hazards. There is some scope for safety considerations in the “critical issue” box. The safety link in this case that was broken was that in determining the strategy to be followed there was apparently little consideration of the risks of the actions. This is especially true of the situation report prepared at 2000 hours where the Incident objective states “Hold resources in area until after wind change”. There is no assessment of the risks associated with this strategy nor any specific instructions to ensure that the “resources” were totally aware of the jeopardy in which they were now placed. No instructions were apparently given to ensure safe practices were followed. Upon reading the fire awareness document46 produced as required induction for NRE firefighters, one is struck by the emphasis on safety. There is evident a culture of safety at the training and induction stage for NRE firefighters. Safety does not seem (in this fire) to have the same emphasis in fire-fighting operations. That the same level of knowledge was not required of CFA fire fighters as forest fire fighters is a weak link. 14. Culture of safety, audits and challenge.

45 See especially Cheney’s letter to Wildfire, Attachment 12. 46 Attachment XXX

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On reading the joint report on the Linton fires, various statements of participants 47 and the account of the Creswick fire it becomes clear that there is not a culture of workplace safety amongst volunteer fire fighters. There appears to be such a culture amongst NRE probably driven by an NRE safety commitment during normal workplace activities. The culture referred to can be described by the following quotation from WorkCover Safety Map,48

“To manage health and safety, every organization, large or small needs to evaluate the degree of risk associated with its operations. The higher the risks, the more extensive the management system needed to maintain a safe workplace. The level of documentation and types of systems required are determined by the exposure of people to health and safety risks not the size of the organization”.

In proposing the 18 watch outs and the 10 standard fire orders the US fire system places great emphasis on safety being the responsibility of the individual firefighter.49 However that cannot be very effective in fire fighting where the stresses of the moment, the culture of “can do”, the pressures to get the job done create an environment that makes such a workforce safety system inadequate. If the case of the Linton entrapment 10 out of 18 watchouts were infringed. Putting responsibility for safety almost wholly onto the individual fire fighter ignores the reality of the situation .50 A safety audit on the fire-fighting process is required to overcome the conflict between safety and expediency. Safety management during fire fighting is also required. An essential improvement to build the safety of fire-fighting strategies and tactics would be to designate at every level of fire-fighting from tanker crew to operation centers and agencies a safety officer with the authority to intervene in the conduct of any fire-fighting or fuel management operation and if necessary terminate it. It is likely that having been aware of the decision to leave resources in the area until after the change and to re-supply fire tankers through long un-burnt fuel and using heavy vehicles on bulldozer tracks in hilly terrain at night would have caused the intervention of fire safety officers and halted or modified the activity. For safe operations, each person must feel free and confident to challenge any decision or instruction that threatens their safety. It could be expected that throughout the events of Linton some individuals were not convinced of the safety of many decisions that were made or instructions that were given.51I suggest that there were one or more people in NRE, CFA or the Bureau of Meteorology who may have felt like challenging the safety aspects of some decisions but who did not do so. In fact no mechanism exists for this challenge to be exercised. In many organizations e.g. hospitals, airlines, firing ranges, space launch facilities there are designated safety persons within the operational structure with the power to intervene to ensure that safe practices are not ignored in the imperative to achieve operational and organizational objectives. That there is no such officer or function in fire fighting breaks another safety link. The ability to over see and audit safety levels is essential to avoiding future

47 Statements of Lowe, Scarf, Sharrock (p3.3). 48 Attachment 23. 49 Attachment 24. Cook (1995:49) Wildfire. 50 Wildfire. Attachments 30 and 31. 51 For example Hood and Jones (1996). Attachment 25.

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entrapments. The lack of safety audit is also a feature of the Ash Wednesday, Storm King, Creswick, Barringa and Mann Gulch entrapments. For a safety function to work the officer involved must have a mandate from top management with the ability to halt whatever function that is unsafe and potentially leading to injury or death. The skills and training of such officers must be of the highest level and reflect the world’s best practice. The lack of a safety audit capacity was not a safety link that was broken but a link that was not even in existence. 15. Limits of direct attack. Fire fighting strategies are based upon the type of fuel, rate of spread and intensity of the fire and weather. If a fire is slow and of low intensity and if water tankers are available in rural areas or hand tools and machines in forest areas direct attack on the fire front is used and is mostly successful. If the speed of the fire is too great and the fire intensity too high then direct attack will fail and at high intensity there will be a considerable threat to firefighters who are at the hottest and fastest part of the fire. The limits and probability of success of initial attack and the limits to fire-fighting capability have been studied a little in Australia and hardly at all elsewhere. The logit analysis of first attack in forests by McCarthy and Tolhurst 52(after Wilson) give a most useful guideline to the expectation of the success of the first attack as a function of fire danger index and fuel quantity. My calculation indicated that in the Linton fire a first attack success of 86% could be expected. It would be useful to enquire why such a high certainty was not realized. The explanation that the CFA tankers could not cope with property and fences 53 seems unlikely. The work of Tolhurst and McCarthy is valuable and deserves wider application. I doubt that such probabilities are routinely calculated on bad fire days to aid decision making at NRE and CFA regional centers or anywhere else. There is no mention of such strategic assessments in the statements or the joint report. Loane and Gould 54 give the only published Australian 55limits to fire fighting direct attack and are quoted by Tolhurst in the Joint Report & indicate that a fire intensity of 2000 kW/m is the limit for successful attack by tankers on a good break. Where the Snake Valley tanker and others made their stand the fire intensity was stated to be around 10,000kW/m. My calculation agrees with this estimate. That the stand must fail is to be expected and would not have taken place if any fire strategist had considered the probability of success. The backburns along Madden Flat Road and Homestead Road were examined. Backburning rarely succeeds and often adds to the total area burnt. In the case of the Madden Flat Road backburn it is clear that wind and fire intensity created an impossible task. In the absence of workable guidelines the difficulties for firefighters in deciding to try this last ditch technique is very difficult. It can be sure that the decision was not lightly taken and in the wind its failure was assured56.

52 Extracts in Attachment 41. 53 See statement of Smothers. CHECK. 54 Loane and Gould 1985 quoted in McCarthy and Tolhurst 1997, page24 Attachment 7. 55 There is a US Forest service study that generates a “Hauling chart” that gives guidance for fire fighting strategies. 56 The winds at the time were 15:15 30-40kph, Pittong rd (CFA/NRE page 76), 43kph at Mortlake, 43kph at She Oaks. Gusts were to around 60kph. (CFA/NRE page 104-5)

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The Homestead Road backburn, or more correctly a burnout was both successful and unsuccessful. The success comes from being held and limiting the north east spread of the fire in heavy fuels during and after the change so protecting considerable assets. The unsuccess comes from generating another fire that traveled towards Sludge Gully. It was this fire that entrapped the firefighters Sludge Gully. It is my opinion however that if that fire was not in Sludge Gully the entrapment is just as likely to have occurred but some 400metres to the west. At the time of the entrapment the original fire and the backburn would have coalesced and been indistinguishable. It is likely that the coalescence occurred around 16:45 causing the spot fire activity around Linton at that time. There is an urgent need for another logit analysis on the success probability of back burning and direct attack to discourage unsuccessful and dangerous stands at future fires. It is fortunate that the fire intensity was moderate, as the possibility of multiple fatalities as fire intensity increases must be avoided. Similar studies on the relationship between fire intensity and risk of fatalities should also be made. Back burning in particular needs study especially as the failure of a back –burn can add considerably to the total area of the fire and even create jeopardy for firefighters and residents down wind of the fire. The limits to back-burn success are not known and so firefighters who in desperation attempt a back-burn are doing so in the absence of any rational guidance. This puts them in a very difficult position. I would strongly recommend study and analysis of these two operational problems with urgency and the application of the resulting guidelines with discipline and rigor. 16. “Can do”. Within the two “combat” agencies, that is CFA and NRE there have been observed two different cultural or work place attitudes to wild fires. Within CFA the prevailing (but not universal) operational attitude is one of combat, risk, bravado and “can do”.57 NRE workers however mostly see wildfires as just another job. Thus safety attitudes can be expected to be different for the two agencies, CFA as pseudo warfare and risk with subsequent reckless behaviour and heroic actions. Volunteers do not see fire-fighting as an occupational health and safety situation whereas the culture of safety that has been achieved in the forest workplace carries over from everday activities in the case of NRE. There is some possible cause for concern in the case of aerial activities, which have their own elements of bravado and reckless behaviour. The actions of the strike team leader have overtones of “can do”. This is a complex area as it is expected that leaders will carry out the orders of their fire managers. The dividing line between discipline and “can do “ is often hard to find58. An other possible “can do” action was the decisions to hold the resources in place until after the change. It is not hard to imagine a judgement that the crews “can do” even in the face of a serious and gusty wind change. Only an organization behavioral study and analysis could resolve whether there is a problem here. Clearly the direct attack on the fire in the early stages by the group of local tankers at Pittong road and the chase of the spot fires into the bush by the Snake Valley tanker may also have elements of “can do” associated. What exactly can be done is always a matter of difficult

57 Campbell, F. Attachment 11. 58 Vaughan, D., Wildfire, (1997:36) Attachment 32.

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judgement which must by developed with experience and training and assisted with scientific guidelines. 17. Fire behaviour prediction. There has been considerable effort gone into developing fire behaviour models in Australia with the aim of providing a tool for the prediction of fire rates of spread and intensities. The models were developed to enable meteorologists to forecast the likelihood of fires and hence warn of fire danger. The models are necessary for the Bureau of Meteorology to meet its legislative responsibilities. Fire models that work reasonably well in the Linton fuel system have been available ever since McArthur presented his fire prediction tables at the Bureau of Meteorology Fire Weather Conference in 1958. In the Linton fire it does not appear that the models available were ever used to predict the behaviour of the fire from start to finish. No mention was made in the fire plans or statements of any fire spread predictions. There were no apparent predictions of fire behaviour in the pre change, during change or post change periods. If these predictions had been made then the extent of the fire blow up would have been apparent and the decision to leave resources in the fire area may have been reviewed. It may be considered safe to leave crews close to or on the fire edge during and immediately after the wind change but due to falling timber and burning embers this is doubtful. It must be recognized that not all firefighters will have access to a safe edge or burnt ground, some are likely to be in transit, some on reconnaissance, some involved with re-supply. From a risk point of view the decision to “leave resources in place” seems reckless. It would have been very easy to predict the fire behaviour at the peak of the fire (as it crossed Pittong Rd) and on the passage of the wind change. These simple predictions yielded fire intensities of approximately 10,000 kilowatt per metre, which is above the levels that can be survived. i.e. 2000 – 3000 kW/m for a tanker caught in a burnover. 59 Prudent planning requires that fire behaviour be calculated for all fires at all times. They are a professional action that should be done for all fire fighting operations. These simple calculations taking a couple of minutes would clearly show that the expected fire intensities were several times greater than direct fire control limits and fire survivable limits. Back-burning decisions should also be made on a quantitative and professional basis using predicted fire behaviour and the probability of success. There is no current data or studies or guidelines on the predicted success of back burning. Such studies are urgently required and could take the form of the McCarthy and Tolhurst study of predicted success for first attack. Whilst the CFA Incident Report form 60has a box for estimated forward rate of spread (kph) to be inserted, it wasn’t, and there is no instructions to calculate expected fire intensity or to record it. There is no provision for comparison of Forward Rate of Spread (FROS) and Fire Intensity with the limits of attack or safety.

59 Paix p 312.3 – 312.7, Attachment 16 and Cheney p6. Attachment 15. 60 Attachment 8.

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The NRE Fire Incident Report61 has provision for Forward Rate of Spread (FROS) and Fire Intensity only in qualitative terms, high, moderate, low or unknown. This is all that is required of fire behaviour prediction by NRE. The Wildfire Control Plan has nothing about fire spread, intensity or predicted fire parameters like flame height, crowning or possible spotting. If such predictions had been made for pre, during and post wind change it is possible that the dramatic change in fire intensity would have been anticipated and appropriate safety instructions and decisions made. 18. Decision making layers. Even single fires are rapidly developing situations. If fire intensity and rate of spread increase and the numbers of fires also increases the management tasks can become insurmountable. In the initial stages a fire is usually a single tanker fire and a little later the fire becomes a brigade fire and the command layers are few. The tankers at Snake Valley turned out on the call of the local communications officer and there were three layers between the communications officer and the firefighter. When it became a brigade fire another layer (the captain) was added. When it became a group fire two more layers were added by the addition of group officers and deputy group officers. At the group fire stage and in parallel the AIIMS incident management system was set up. The group system was I suppose expected to dissolve at this stage, proponents of the AIIMS would argue that an AIIMS is in place from the first response until the fire is declared safe. Parallel systems are not supposed to exist but they do. AIIMS is supposed to be present from the beginning, but it isn’t. Within this particular AIIMS the decision layers between the incident commander and the fire fighters has now reached 13.62 At each level there is the potential for miss-information, distortion, loss of control and a greater risk for firefighters. Bushfires can and do start at the most inconvenient places and sometimes in great numbers. Ash Wednesday, 1983 in Victoria is said to have involved 200 fires. December 2 1998 although not an extreme day it has been mentioned that 560 fires occurred63. Most Victorian fires are of short duration and over before the following day, sometimes however in heavy fuel and remote forest areas fires can burn for several days e.g. Alpine fire 1997 and the Cann River fire 1983. Fast response by locally actuated and controlled fire-fighting resources is very effective in first attack and is still effective during secondary attack. The maximum size for fire-fighting command may well be the group. If the fire requires more resources than that the fire could be broken down into group sized sectors. There is an urgent need for a rigorous, unbiased investigation of AIIMS for fast moving but short lived fire situations. Networks are established in business and private activities and it is the use of these networks in times of stress that enables many fire and disaster management activities to proceed. The AIIMS system requires that these networks are not recognized but new ones generated in their place. This is not possible in fewer than 2 – 4 hours during which time primary and secondary attack has taken place. 61 Attachment 21. 62 See police analysis of control structure. Attachment 10. 63 CFA/NRE Joint report.

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19. Communications confusion In this fire there were several official and unofficial communication systems in operation and some “unauthorized” ones as well. The networks seem to be.. 1. Channel 24 (region 7C or R7 Go to 02) Simplex, which connected the tankers of the

Geelong and Consolidated Ballarat strike teams working on the south east and north east of the fire. This channel was not used by anybody else at the Linton fire. It was for the co-ordination and control of the two strike teams. It was not part of the “official” and not universally promulgated communications plan. It relied upon the strike team leader for the transfer of information to the firefighters. Flow of critical information to the firefighters relied totally upon the strike team leader. There was no redundancy in the system. Rarely was the strike team leader in a position to monitor this channel and any of the outside communication channels at the same time. He apparently spent most of his time away from his vehicle with channel 24 on a hand held radio but the command channel 68 (Region 15B) was on his vehicle radio. The strike team leader had a scribe and a driver who could be expected to participate in the communications link. The scribe stated that she had not received any weather reports or warnings although the Linton communications van claims the wind change was broadcast.64 She believed that she was on channel 15B and later explained the lack of weather reports as “We were working on channel 15B while other units were on 15A or C; I did hear other units on our channel during the fire. No messages were directed to us during the time we were fighting the fire.” Thus effectively there was a weak or broken communications link between the outside world and the strike teams and the firefighters working on these teams.

It is possible that the weather warning was never actually broadcast on Channel 15B(68) as nobody has stated being on 15B and having received the weather-warning broadcast. The Consolidated Ballarat strike team leader also on 15B stated that he did not receive the weather warning.

2. Channel 68 (Region 15B) was a fire ground channel actively used and monitored by the

communications van outside the Shire Offices where the Deputy Operations Officers at the Operations point were located. Channel 68 was used for communications to those parts of the fire that were in CFA region 15.

3. Channel 72 (Region 16A) was used for a similar purpose for other sectors of the fire. 4. Channel 74 (Region 16C) was as far, as can be determined used for the same purpose as

CFA Region 16A (Channel 72). 5. Channel 67 (Region 15A) was the channel used by aircraft observers to communicate

with the fires through the Cherry Hill Tower CFA remote transmitter. This was also available to the communications van. One must ask about the effectiveness of the monitoring of the communications that traveled this network when one reflects upon the statement of the communications van OIC parked outside the Linton Shire Office “I

64 Statement of Roberts 2.9

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believed the incident control centre was at the Shire Offices, it was a couple days later I found out the centre was actually at Ballarat”.

6. Channel 67 was used as the command channel so presumably the sector commanders,

divisional officers, Deputy Operations Officers, fire ground Deputy Operation Officers, operations point, Operations Officer at the Ballarat Incident Centre, and even the Incident Officer may had had access to this command channel, but not the strike team leaders.

7. An UHF citizens band channel was also in use to link some of the CFA tankers.65 8. NRE was using their Channel 118 (Simplex) with some difficulty to communicate with its

officers and units until channel 126 was installed as a duplex channel in the Cherry Tree Tower. They were also using their statewide network for command and strategic communications.

The failure in the transmission of critical weather and fire information to the forces working on managing the fire ground was not one of equipment or channel availability but one of long tenuous links. Consider the critical aircraft information that the wind change was very close. That was transmitted by the aircraft on Channel 67, to be received by either the Communications van or the operations point to be rebroadcast to the strike team leaders on channels 68, 72 and 74. The leaders must ensure that each of their radio-equipped crews receives the information (Channel 24 in the case of the Geelong tankers). Each tanker crew leader must then inform each firefighter verbally. It is asking a lot for a weather warning to remain unchanged when it must pass through four levels. One must be concerned when the passage of critical warnings is so tortuous. The possibility for delay, confusion and distortion is significant. The communications situation described above, is the situation after the AIIMS had been established some hours after the fire started. It seems that the initial stages of the fire whilst the local communications structure was in place was satisfactory, For example consider the effective control exercised by Dianne Foy. The difficulties for NRE with long distance communication on VHF from Linton to Ballarat disappeared when a repeater was installed at Cherry Tree tower. This repeater was co-located with the Linton CFA radio which has its base radio (on 16A) at the tower for maximum coverage. How do NRE conduct their communication for their forest works in the Linton forest without a repeater on Cherry Tree? It is very difficult to develop communications systems that work in rapidly expanded emergency situations. Two conflicting criteria apply, one is to have everybody across every important piece of information and the other is communications convergence as the channels saturate to overload and collapse. Communication systems must be developed with the close cooperation of communication psychologists and organization behaviorists, not only by radio engineers. This was a medium sized fire, moving in medium fuels with no other fire seriously competing. On a major fire day, with many fast moving fires there will certainly be communications overloading that will render systems dysfunctional.

65 Statement of Hadler page 4.9. 1 June 1999.

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In high-risk situations when communications systems break down the knowledge and experience of crew leaders becomes critical to safety. Rather than relying upon higher levels to provide warnings especially of weather changes they must anticipate the possible changes and how they may affect their crews safety. In this case the crew leaders and the strike team leaders did not have the knowledge, training or experience to interpret a difficult and misleading meteorological situation. The fire situation was mild and apparently benign, the change was not expected, the wind was almost totally calm and cooler conditions were upon them as nightfall approached. It would take an experienced crew leader to anticipate the oncoming problems in the absence of outside information but that is what was required as the communications link become weak after the strike teams arrived at the fire. Subject to expert human communication study I suggest that the communication arrangements that were established by CFA regions including the local operators be retained as the main communications managers especially for their knowledge of locations, brigades, resources, skills, customs and structures. The marine system of calling and emergency channels with dual watch or the aviation system of channels determined by location may be other models to be considered. The clogging of communication channels with routine information is an unnecessary cause of overload. This is now occurring and the system is overloading even in mild fire situations. Routine data can now be transferred digitally and even automatically overlaid on voice channels as for example in taxi operations. The channels then become freed of most communication, operators likewise. The rapid emergence of responding GPS systems would enable continuous location of any active unit to be established. In nearly all burnovers reported by Piax (1999)66 warnings67 of sudden changes failed to penetrate the communication system.

“In almost every case, engine burnovers follow sudden and severe intensification’s of fire, usually following a wind shift.” Linton is a classic case. Communication hardware has often been blamed for fire communication difficulties (Ash Wednesday 1983 for example) however there do not appear to be any such difficulties in this case except for some VHF communications problems between Linton and Ballarat. The distance and line of sight from the entrapment site to Linton could hardly have been better 68and the CFA repeater at Cherry Tree Tower would have ensured excellent technical communication capability. The problem was in frequency management, oversight and situational awareness. Within the constraints of the current CFA /NRE communications scheme which is very complex and confusing, the most important break down was in the fragile link between the communications van and the region 7 strike team leader. That link did not function. One would expect that if the strike team leader had heard the weather warning his instructions for water re-supply might have been different 20. Transition confusion. 66 Paix “Improving burnover Protection for Australian Bushfire Appliances” Bushfires 99. Attachment 16. 67 See Attachment 58. 68 Attachment 54.

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The initial attack on the Linton fire was by a CFA tanker initiated by Dianne Foy (Communications Officer, Snake Valley Brigade) and later supported by other local tankers through the CFA pager network69. Foy had it under control and her positive contribution can be seen in her suggestions for future action to the Snake Valley Brigade Captain and the various Group Officers. (See her statement). NRE was independently activating its initial attack. For the primary response it probably does not matter too much who is in charge as long as any groups function to extinguish the fire when it is small. Later, when secondary response occurs coordination becomes more important. As the fire grows, so does the structure. In this case the structure was growing appropriately when the AIIMS was instigated. During the next three hours it is very difficult to say who was developing strategy and who was conducting the strategy. Orders were given and counter ordered, back-burns were undertaken legitimately but were considered by some to be unauthorized. It was confusion that continued until the fire was made safe after the wind change. In this confused environment the opportunities for people to be in the wrong place at the wrong time is fairly large. The potential for serious situations is much greater in multiple fires in a rural/urban interface. The problems have been implicitly recognized and suggestion have been made to employ “street fighting” (Frank Campbell would not be surprised by the term) for rural/urban interface fires. In the interface the problems are the same as for other fires, grass, scrub and forest it is just that there are many more properties and people to create more confusion. In the inevitable collapse of communication structures under heavy system stress the fall back is to good tactical fire management by independent well-trained units. The Linton fire never reached these proportions and thus weather and fire behaviour warnings should have been possible. I suggest that local operators would know which units were present and ensure they were advised of the wind change. It is totally unacceptable for a communications unit to broadcast a critical warning, ask for confirmation and upon getting a very small response leave it at that. If there is no confirmation then one must assume that the message has not got through and take other actions. It is a puzzle that mobile phones are removed as a communications link for firefighters. A principle of communications in emergencies is that any means may be used where life is at threat. The banning of mobile phones seems to be contrary to this principle. I do not think that having mobile phones disabled helps. In the failure of a communications system, mobile phones and trunk radios as well as normal phones and broadcast radio can be useful. It must be expected that in a communications convergence, however, that mobile and trunk systems will also fail. 21. Bureau of Meteorology. The entrapment of 13 firefighters on Ash Wednesday occurred after a forecast that was accurate about the speed and intensity of the wind change but the information was not integrated into the fire management structure at field level. There is considerable scope for paradigm changes in both fire management agencies and the Bureau of Meteorology. The reports 70on the Storm King Entrapment (USA) also indicates the necessity for the

69 An officer of the Buangor Rural Fire Brigade on a national radio program (Australia all over- ABC) stated that a recent Telstra decision put the pager system under immediate threat. 70 Wildfire. Attachments 30 and 31. .

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meteorological service to be a bigger player in fire management especially as a fire grows to become a campaign fire. The Bureau of Meteorology forecasting centre feel a considerable sense of responsibility in collecting meteorological information, analyzing it, forecasting from it and dispatching the forecasts as required. They also feel a sense of service to the public and others who ask them for specific information. They do not (I am sure with some exceptions) consider themselves as having a duty of care to go beyond the normal duties to ensure that those warnings reach exactly the threatened people. In fact such ‘interference’ in the business of other agencies is considered to be impolite or totally outside their authority. As the wind change approached, the Bureau had a legislative responsibility (Section 6c, Meteorological Act) and a duty of care to ensure that the wind change information reached those threatened. They should have contacted the Incident Controller and the Operations Centre by telephone to personally advise of the changes to the expected spread of the frontal passage, as it approached impact. I have been unable to find any information that would suggest the Bureau undertook such proactive actions or would even consider doing so in the future. It would be useful to obtain information from the forecasters (Kollmorgan and Rooney) and hear from them why they did not pursue the wind change information and in effect misforecast the frontal movement. It is possible that there was some sort of system failure as my personal knowledge of these two officers is that they are both exceptionally conscientious and skillful with extensive experience. The duty to do so becomes a greater responsibility if they discover that their forecasts were incorrect. If they had doubts of the impact time before the impact then it is probably in default of Section 6c not to take great efforts to ensure that the warnings were effective. There was some direct contact which may have been initiated by telephone from the Bureau of Meteorology Regional Forecasting Centre, Melbourne (RFC) AT 14:40 on 2nd December. The Regional Forecasting Centre appears to have advised the Incident Control Centre that the wind change could be around midnight. This communication took place 28 minutes after the spot Fire Weather Forecast issued at 14:12. The Spot Fire Weather Forecast issued at 19:53 on Dec.2, the last before the entrapment, does not seem to have been issued as a result of a written or faxed request as no such form is attached (Spot Weather Forecast Request). The request may have been by telephone, which would have given the Regional Forecasting Centre and the Incident Control Centre (Ballarat) an opportunity to discuss the inconsistencies in the forecast of the change and the location of the wind change as reported by aircraft and other observers to the ICS. If the telephone call took place we do not know when and what was exchanged. At the least the communication line would have been established and hopefully used. The Regional Forecasting Centre certainly invites discussion and contact. At the bottom of the Spot Forecast form is the exact contact number and name of the forecaster. To this extent the duty of care is in place but a complete implementation would require the forecasters to make the contact if they consider that there could be some aspect of the forecast that should be known by the Incident Controller or other Fire Managers. A quality service would enquire about the forecast reception and may even seek to spread it more widely. It should be known that when weather conditions change one channel of communication alone should not be relied upon. A very careful forecaster would have ensured that the forecast went not only to the ICS but also to the Linton Centre and even to a Brigade or two in the area. It is likely that such

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participation could be seen by some CFA and NRE personnel as crossing the lines of communication and attracts considerable criticism to which the Bureau is sensitive. It is true too that the workload on the Bureau could become very great. This dilemma illustrates the difficulties of ensuring that critical information is made known to affected people. Some of these aspects of warning were addressed by the Bureau and others in Warning Effectiveness Guidelines and are the subject of disaster literature. I am unaware of any directives within the Fire Weather Warning Service of the Bureau of Meteorology that put great emphasis on the contemporary notion of Duty of Care. It would take a long and careful study of the files of the Bureau to establish the current attitudes and policy on Duty of Care issues. In this entrapment, a more careful monitoring of the forecasting and nowcasting of the wind change and a vigorous effort to ensure that amended information was available and received may have provided confirmation to the Incident Control Centre (Ballarat), various operations and communication units, field commanders, sector commanders, strike team leaders that the wind change about to hit the Linton fire. This could have prevented the Geelong tankers from being caught on unburnt country. However, if the communication links around the fire were as severed as suggested, then the strike team were truly on their own and no amount of amended forecasts would have helped. Similarly, if the Strike team leader and his higher commanders were not aware of appropriate protective action in the light of such a forecast warning then the outcome would again have been the same. 22. Fire weather skills Within the brigade and group structures that undertook the initial and secondary attack and later in the ICS and Ops Point there does not appear to be anybody with any formal capability to receive and interpret the meteorological forecasts or undertake their own nowcasting. In large fire situations there are sometimes meteorologists and their equipment outposted from the Bureau into the Incident Control Centre to provide this information and to monitor the meteorology at the fire. That service was not requested for this fire, reasonably perhaps, because of its earlyness in the season and the moderate size. It is worth noting that in the Creswick burn over, the Berringa blow up and the Linton fire it was apparently reasonable also that such outpostings were considered unnecessary. Whilst the AIIMS structure contains planning officers that should undertake this task and have access to fuel information and undertake fire behaviour prediction it is almost certain that the work loads, training and experience were not be at the required level for the three tasks of weather, fuel and fire prediction. Paix (attached) lists all burnovers inside and outside Australia since 1980 and 15 out of 37 involved sudden change in fire behaviour. Such changes should be predictable at the various scales of occurrence. The analysis concerned tanker overburns only and did not make reference to the Storm King event which did not involve tankers but in many other respects has many parallels within the Linton incident. Just as aviators and mariners must have a high level of meteorological skills so must firefighters who are also very weather sensitive. Firefighters have fuel structure and loadings to appreciate as well. Considerable improvement needs to be made into integrating these activities into all levels of fire fighting. First attack fire behaviour and weather skills can be improved by work force or

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volunteer training. Secondary or group fire-fighting by NRE or volunteer staff having a qualified weather, fuel and fire specialist who must be present The failure to integrate meteorology into the fire event occurred at the Incident Control Centre level with no specialist meteorological skills available; at the Operations Centre (Linton Shire Offices), at the group and also field command level. Finally the strike team leader demonstrated no fire weather capability and believed that the wind change had in fact taken place late in the afternoon71. Crew leaders and the crews themselves also appear to have dangerous levels of fire weather ignorance. 23. Failure to correctly forecast the wind change. As agreed in the CFA/NRE joint report the wind change passed through the Linton Fire area at about 20:45 on Dec. 2. The change is estimated 72 to have taken 3.2 minutes from arriving at the Linton Shire centre to passing through the Sludge Gully entrapment site. The last Bureau of Meteorology regional forecasting center forecast for this change before it arrived at Linton was “around 11pm” (23:00) Wednesday 2 Dec.73. This error of over 2 hours 15 minutes before the change is a gross forecasting (or nowcasting) error. The reasons for this error are not known at the writing of this report. Dr Michael Reeder (Monash University) is undertaking a special investigation of the forecasting process but currently awaiting further requested meteorological charts from the Bureau. The forecast was however accepted apparently without dissent and it is interesting to list the perceptions that key players had of the timing and intensity of the change. The listing shows that expectations went from 18:30 at (19:00) for the strike team leader to 0:00 for the incident controller at 18:00. The last Bureau forecast at 19:53 was for 23:00 but many at about 19:50 were expecting the change at 20:50 within five minutes of the actual time of arrival. Significantly and in a similar fashion the Storm King Disaster firefighters had no weather information and no way of finding out. It was a very strong recommendation of the Storm King investigations 74 that all crews have weather, fuel, fire information and maps. None of these were available to Geelong City crew and presumably the same can be said for the Geelong West crew. The list below gives the reported expectations of various people for the timing and intensity of the wind change at the fire area. Person Position Time Expected time and intensity ------------------------------------------------------------------------------------------------------------------- Actual change 20:45 30 – 40 kph Kollmorgen Bureau forecaster 14:12 02:00 30 –35

71 Statement of Scarf (p6.2 and 6.9). 72 My calculation Attachment 34. . 73 Spot fire weather forecast issued at 19:53. Attachment 35. 74 Attachment 30 “The Occupational safety and Health Administration’s Investigation of the South Canyon Fire, February 8. 1995”. (Also known as the Storm King Mountain Fire”). page 4.6c from Wildfire, March 1995 p 1-6.

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14:40 00:00 17:00 01:00 40 Rooney Bureau forecaster 19:53 23:00 gusts to 60 Leach Incident controller 17:00 19:00 70 18:00 01:00 18:00 Quicker than forecast 19:00 Quicker than forecast Boadle Planning officer ICC ???? Ferguson Planning officer ICC ???? Harris Ops officer ???? 21:00 Mahoney Ops officer ICS ???? Graham Dep ops officer at ops. point 19:50 <20:50 20:30 shortly Anderson Dep ops off at ops point 19:50 <20:50 Roberts Mobile Comms Van 19:53 <20:50 ???? Sinclar Dep group Officer 19:53 <20:50 Britton DOO fireground 19:53 <20:5075 Phelan GO Div command east Hamilton plus 2 – 3 hrs Skipton plus 5 – 10 mins Millar GO Div Command West ~21:30 Lightfoot Sector Command East 19:53 <20:50 Fullerton Sector Command East 18:00 ~20:00 Taylor Sector Command East 19:53 <20:50 Pohl Sector Command East at briefing forgot Kavanagh Cemetry briefing soon Scarf Strike team leader 18:00 ~18:30 ~19:00 ~18:30 Rowan Bulldozer driver after 18:00 In an 1 1/2hour i.e.19:30 McPhail Strike team leader driver ??????

75 Acknowledged broadcast also Anderson, Roberts, Sinclar

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Lanchaster strike team scribe ?????? Sharrock Geelong City had no information Daly Geelong city had no information Bencle Geelong City had no information Lowe Geelong City had no information 24. Lack of fire behaviour information in the Bureau of Meteorology By and large the severe weather forecasters in the Bureau of Meteorology have little fire behaviour knowledge and mostly no actual fire experience, there are some notable exceptions. They are not all well equipped to understand the needs of fire managers and firefighters. It will probably be quite clear (if RFC staff are interviewed) that they did not anticipate the importance of this early season, benign fire and the effect upon it of the rapid and gusty wind change. There are within the BoM meteorologists who do have an excellent appreciation of fire management but the rotation of forecasters ensures that those skills rarely stay for long in key locations. Much improved and increased training is required and consideration must be given to forecasters having to undergo NRE fire tactics training and fire management training before they take on fire weather forecasting duties. 25. Weather forecasting in fire agencies. The forecasting of wind changes is a very challenging forecast problem. The Bureau of Meteorology often achieves a very high degree of accuracy in forecasting the timing and intensity of these changes. Sometimes however there are errors. In the absence of professional or trained meteorological skills in the fire management teams there is a temptation to indulge in amateur forecasting and forecast interpretation instead of seeking professional assistance. In this case, simple extrapolation of the wind change would have been quite accurate. On other occasions e.g. the Dandenongs Fires 1997 a wind change forecast based on persistence would have produced an incorrect result. Agency forecasting will need trained forecasters. 26. Lack of challenge in fire management decisions. Several decisions were made in the management of the Linton fire that contributed to the outcome. Amongst these were:

? Failure to correctly zone the Linton forest as Zone 1 for fuel management ? Incorrect forecasting ? Leaving resources in for the wind change ? Incorrectly acting on a clearly incorrect forecast

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? Use of inappropriate vehicles on bulldozer tracks ? Choice of control line ? Re-watering of tankers through un-burnt fuel ? Deviation of bulldozer from fire edge

Some of these decisions were questioned in statements but except in a few cases there was no challenge of decisions and subsequent resolution of the difficulties. The practice of challenge in decision making in aircraft cockpits is a fundamental of modern aviation safety management. It is a well-developed technique and has resulted in significant improvements in airline safety. These safety techniques need to be applied to fire management. Other fire events Creswick, Upper Beaconsfield, Mann Gulch, Storm King Mountain have had the same situation where life critical decisions have been flawed but not challenged. 27. Untrained volunteers and permanent firefighters. Fire-fighting is a dirty, often boring and frustrating activity that requires mostly simple and repetitive skills e.g. raking of trails, blacking out with water. However on occasions there is a rapid transition from benign to fatal fires. It is at this time that the highest levels of knowledge, experience and training are required to conduct a safe and effective operation. Very high levels of judgement are also required to be able to determine when a firefight is a waste of time and dangerous. Fire fighters with such levels of judgement, knowledge and skill abound in Victoria both in grass, scrub, mallee and forest fires. However there are many others who have little experience, little knowledge and insufficient training and should not be exposed to the risks of fire fighting when there is a potential for life loss. Grass, scrub, mallee, dry schelophyll, pine plantations, wet schelophyll and alpine forest fires all require different fire-fighting techniques and skills. The complexity, and risks generally increase from grass to wet forests. All types of fires are potentially dangerous and all have caused firefighter life loss. The good record of NRE in firefighter safety stems from their extensive safety, education and training programs. The CFA also have training programs but indications from statements, documents and discussions with volunteers suggest that the program is not extensive enough and that relatively untrained or even totally untrained firefighters are involved in fire-fighting. Indeed there is a tradition of unregistered casual firefighters who are covered by the same insurance and indemnity as registered CFA volunteer firefighters. On this occasion there were 10 fire-fighters on the two Geelong tankers and it appears that some were totally untrained, some had partial experience and training and a few were well trained but that none were extensively skilled in forest fire fighting. No person should be involved in fire fighting outside the initial attack, who has not reached the required level of knowledge, skill and experience. Initial community protection will always depend upon who and what is available at the time and the lesser skilled firefighter and casual

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firefighter will always be necessary. Their participation must cease after the first attack has failed or the first hour of the fire passed. The overwhelming losses of fire fighters have been in forest, plantation or scrub fires.76 Grass fires have caused deaths of firefighters in extreme circumstances but fortunately in lower numbers. Forest fire fighting has more complex terrain, access, fuels, visibility and meteorology than grass fires and requires a higher degree of training, knowledge and experience. Within forest fire fighting in particular, leadership at all levels is especially important and crew leaders need to be very experienced and sensitive to sudden risk expansion. Downsizing within NRE have lead to a decrease in availability of highly experienced crew leaders and fire operations managers77. There is a level of fire-fighting expertise and training needed in forest fire fighting that is not a reasonable expectation of the average volunteer. I suggest that in forest areas the limit of CFA volunteer participation should be for the protection of private property especially dwellings and first and fast attack. Back burning, direct attack, machine support and mop up in forest areas is not the role of unpaid and untrained volunteers. Large plantations fall into the same category as protected state forests i.e. fire fighting after the initial attack should be done by the plantations themselves. If it is considered impossible for a plantation to provide sufficient fire-fighting forces then they must increase their level of fire protection especially by fuel management to better reflect the rational economics of state and private forests. There is a special risk in plantations as pines can burn with ferocity and are particularly dangerous. The distribution of fire-fighting forces between CFA and NRE for the Linton fire that was initially a CFA responsibility until it crossed the Pittong road and NRE thereafter is shown in the table below . Agency People Tankers CFA 200 61% 39 91% NRE 70 21% 1 2.5% VPC 30 9% 1 2.5% Total 330 41 These figures are taken from the situation report at 20:00 78 but seem in some doubt as there are statements that indicate that there were many NRE slip on units (SOU or PIGS) in the area. The traditions and practices of the Victorian rural fire brigades are to include untrained and inexperienced firefighters in times of great threat i.e. novice, occasional and casual firefighters. It is unsafe to ask them to undertake fire management activities outside their capabilities, training and experience. This happened here as the Geelong brigades did not have

76 Paix. Attachment 16, Table1. 77 Cheney. Attachment 15 and 12.. 78 Attachment 21.

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enough training or experience nor were equipped appropriately for forest fire fighting. They should not have been there and the policy that has created this utilization needs to be examined and then changed. At senior fire management level there is a unique problem as extreme fire conditions (the Linton fire was not extreme) are such a rare event (about once every 30 years) that fire managers have no opportunity to gain experience nor maintain famililaity. The AIIMS system helps to approach this difficulty although it can be argued that the appropriate response to high level threat should be an intensification of routine safety and work procedures rather than taking a quantum jump and establish a new structure when an emergency situation is declared. I do not consider that any one of the Geelong crews were at a sufficient level of knowledge, training or experience to be undertaking the operation they were engaged in. They certainly were not experienced enough to be left at the eastern edge (even if adjacent to the burnt edge) during a gusty and intense wind change. The strike team leader also did not have the knowledge, training or experience in these fuel types and should never have been placed in such a difficult task. His performance and conscientious approach within his knowledge, training and experience was commendable. The supervision and monitoring of the strike team leaders seems to be non-existent and no matter how well they conducted themselves they were placed in an impossible position. There was no process to identify problems. Within the NRE structure there are normal work relationships that ensure that skills and capabilities are known and appropriately applied. There is a smooth chain of supervision which coupled with a positive attitude to safety goes a long way to avoid entrapment. Within the CFA group arrangements there is a lesser amount of such supervision of skills. Networks do exist and leaders have a good knowledge of their fellow volunteer’s skills but in the case of strike teams or “out of area” volunteers the safety net is tattered and torn. In summary the level of training, experience and knowledge at the strike team level was not sufficient for the task, the supervision and monitoring of performance was non existent and the safety of networks was compromised as networks did not exist. 28. Training package. Fire operations are conducted in a dangerous environment but then so are many other activities in our society. An appropriate level of training and knowledge is essential and fundamental for safe operations. Forest fires are particularly difficult and dangerous and in recognition of this risk is the training package generated by NRE. It appears from statements and the Basic fire Awareness training package79 that no NRE employee will participate in forest fire fighting unless they have completed the basic fire course and have a copy of the appropriate manual. Compliance with Occupational Health and Safety requirements would require no less.

79 Basic Wildfire Awareness Training Package, NRE, Attachment 9.

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This does not seem to be the case for CFA. I would suggest that here is no justification for the existence of two standards for fire-fighting skills depending upon which agency they come from. If a firefighter is required to undertake forest fire fighting then they must be suitably qualified. Having their own copy of “Wildfire Safety and Survival” 80 is not sufficient. A suitable course of instruction, exposure to the forests and fires and achieving a suitable and updated standard is the minimum necessary. Exception should be made for first attack, to allow effective extinguishment in the first stages of a wildfire. The course materials and assessment for CFA volunteers and permanent paid officers should be the same as the NRE basic course. Grass fire fighting has faired no better. The lack of training for grass fire tactics and survival have prompted a volunteer groups i.e. Moorooduc to develop their own training videos. This is a help but no substitute for a comprehensive and well conducted training program in fire strategy, tactics and safety. They have no forest fire video. 29. Insufficient research and lack of encouragement of independent research. Safety at the fire line depends upon well trained firefighters responding to recognized threats and applying knowledge arrived through rigorous, peer reviewed research into fire behaviour, fire meteorology, fire physics and survival. CFA undertakes little research into these subjects. NRE has about two effective full time people so engaged and the Bureau of Meteorology presents other research as fire research, although they do opportunistic studies. In the past study of the loss of civilians in rural fire disasters have been the subject of both non peer reviewed studies by the CFA and peer reviewed studies published in International and National journals. This body of work has been a major resource in developing public protection policies. Little fire-fighting safety research has been done other than the work of King in the 1960’s (peer reviewed) and some recent conference papers. None from Victoria have addressed fire-fighter safety. It is indefensible that Australia, one of the major bushfire areas of the world and Victoria in particular as the most fire prone state have such a low priority on fire research. Validated, verified and even duplicated research that is peer reviewed is the only foundation on which to base sound policies. Research often produces uncomfortable results that call for changes in agency direction, e.g. the change from protection to fuel management, the change from evacuation to defense and it takes a progressive and courageous organization to foster such uncomfortable studies but it is necessary to long term success. Other research however provides a sound basis for long-term development e.g. the empirical fire behaviour studies in Western Australia and Victoria (to a lesser extent) that facilitates the policy of fuel management by fire.

80 Attachment 55.

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A fire safety research program for fire fighters and the public should be high priority and be courageously implemented, fostered and encouraged, as should the resulting extension and debate that follows. There is almost total absence of research into the human sciences that are relevant to firefighter safety. CFA appears to have 2 or 3 positions devoted to research all of whom have other duties as well. They do not have an established facility; workshop or laboratories devoted to research. This amounts to about 0.45% of their staffing levels. CFA does not appear to mention fire weather research in its mission statement. The fire research activities of NRE seem to be similar but at a slightly higher level of activity. The efforts of both agencies needs to be increased. Other agencies that also have a stake in forest and rural fires appear to conduct no specific fire behaviour or safety research at all. Vis. VPC Melbourne Water, Parks Victoria. 30. Lack of comprehensive briefing and firefighter documentation. A major recommendation of the USA Storm King disaster was that all firefighters be provided with basic information that enables them to assess their risks and apply their judgement and take responsibility for their own safety. Without information, making correct judgements is very difficult, probably impossible. There was no documentation provided to the front line firefighters and only the most minimum data provided to the line managers. There were no communication plans, weather forecasts, fuel maps and expected fire behavior, fire fighter deployments or management plans. The only information of a written form was a photocopied map that the strike team leader obtained from the staging area. 81 There was a briefing or two to which the firefighters were excluded 82 and even then the whole story was not disclosed. “I didn’t give the strike team leaders the time of the wind change was expected, I never do because sure as I give them a time the time changes”.66 It is likely that as a result, the firefighters were in the dark, unsure of the weather, uninformed of the fuels and their state, unthinking of the possible fire behaviour and uncertain of their location. It is understandable that during primary (first attack) and secondary attack that such documentation is not available. The CFA have made great advances in providing an excellent system of rural Directories but that is not enough. Good practice would require that fire stations that have access to Internet could and should maintain weather information and have access to fuel states on all fire danger days. Certainly by the time that the staging area was established adequate documentation should have been available to all firefighters and no one should have been left in the dark. Statements 83 suggest that there was very little briefing on the state of the fire, the potential for weather change and other factors that affected firefighter safety. The extent of the briefing

81 Statement Stepnell. 82 Statement Kavanagh (p4.0). 66

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was uniquely captured by a TV crew who filmed the on-site briefing given just before the commencement of a bulldozer direct attack operation and some two hours before the entrapment. This briefing did not address the safety issues of fuel weather and access. Nor did it reinforce routine but necessary aspects as in the watch out code. Every member of the fire crew must receive a safety briefing (and documentation) even en-route, on all safety aspects of the incident they are attending. If the Geelong crews were alerted to all the factors of weather and fuels and fire behaviour it is possible (but not certain) that they may have challenged the decision to re-water through unburnt country when a wind change was possible. It seems that there was little meteorological briefing from the Bureau to the fire managers. Nowhere do we find this meteorological information briefed downwards from the incident headquarters in Ballarat. Information flow is a critical factor in effective and safe fire operations and is often a serious casualty itself during an emergency. Considerable bodies of knowledge exist in this area and some are attached.84 85It is clear that there are many reasons for this failure to inform and share. Knowledge and information are considered to be the basis of effective and safe operations and in the field of rural fire management the flow of information has become a trickle despite. A “must” in the NRE code of Practice for fire management on public land. (Item 253 – 258). The fire management plan at 20:00 hrs state that the wind change is forecast for 01:30 hrs.86 At the same time it was known by the Incident Control Center planning team, the operations Point and the communications van that the change was only a few kilometer down the road and expected around 20:50. The Bureau of Meteorology had brought the change back to 22:30 and had sent forecasts to that effect to the ICC. The plan was nevertheless generated using the 01:30 information and not amended when it was clear that the wind change was not only vigorous and gusty but imminent as well. The kindest interpretation is that wishful thinking or self-deception was operating. An unkind interpretation is that an incorrect Bureau forecast could be used to indulge in a reckless decision to leave resources in the area until after the change. Still at risk is a threat to the pine plantations (due to change of ownership at 10 am the following day). In the minds of the fire managers this may encourage the reliance on faulty but “official” information to provide cover for a high-risk strategy. The bare earth break around the fire needed to be closed before the wind change. In the case of a breakaway on the passage of the wind change fire-fighting forces would then be close enough to contain it. The uncertainty did not appear to encourage communication to the Bureau of Meteorology to query the forecast in the light of other knowledge of the wind change. Could it be that an

83 Statements of Buchland, Kavanagh, Lightfoot, Lowe, McPhail, Roberts, Robertson, Rowen, Scarf, McGinnes. 84 Wagenaar, Hudson and Reason, “Cognitive Failures and Accidents.” Applied Cognitive Psychology 4:273-294 (1990). Attachment 1c.. 85 Hood and Jones “Accident and Design- contemporary debates in risk management”. University College London Press Ltd. 1996 Extracts in Attachment 25. 86 Attached Fire plans (Attachment 21) and Fire Weather Forecasts (Attachment 35).

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amendment to the forecast would not be a welcome development as a safety driven withdrawal of firefighters on the eastern flank would then be indicated? 31. Failure to take account of the weather observations The aircraft observer went to considerable lengths to ensure that his knowledge of the position and vigor of the cold front was known to the fire area.87 There was also ground evidence from the CFA network 88 as to the location of the front and its movement. The CFA at Tally Ho, The Incident Control Centre and perhaps the Operations Point (Linton Shire Offices) had internet and hence access to the automatic weather station (AWS) network which showed the winds to the west of the fire area (but not with the resolution in time or space desirable). Karen Chatto had already called from Lismore at about 20:00 saying the change was there. It is not apparent that there were any inquiries of other weather informants e.g. Lismore, Derrinallum, Skipton fire stations nor the group communications officers to the immediate west to verify or validate the weather situation. My suggestion is that the closeness of the change was known, understood and expected but that the mis-forecast of the weather bureau as the official forecaster was convenient and provided the justification for the risky decision to race the change by attempting to complete the fire line. There have been examples in the emergency management literature of this tendency to ignore inconvenient information in the hope that all will turn out well, referred to by Weir as the “Biggles factor” p122 (in Hood and Jones, Attachment 25.) also classified by Reason as optimizing violations. P 389. “(b) optimizing violations, in which the individual seeks to optimize some goal other than safety." .”.. “ It must be emphasized that not all violations are necessarily bad or cause accidents. On some occasions, they save lives and earn commendations; on others they go badly wrong and cause accidents.” Reason 1991:41 ISASI Forum Proceedings. Reason had earlier (1987) linked that type of “faulty perception and inadequate decision making” with “group think” when discussing planning in small groups. 32. Slowness to deploy Portable Automatic Weather Station (PAWS). Within the Incident Control Centre there some were concerns for information about the timing, intensity and duration of the wind change. A decision was made to deploy the NRE portable Automatic Weather Station (PAWS) down wind to Lismore. The result was that a fire research officer, Karen Chatto was dispatched to collect the PAWS and then drive to Lismore. This whole action took several hours, perhaps three hours, by which time the change had passed through Lismore and the PAWS information was no longer vital. What was required was wind direction and rough speed estimated from Lismore and / or other similar

87 Statement of O’Rorke. 88 Statement of O’rorke p5.2. Westmere group base gave weather report at 19:50 SW 20?30 gusting to 40kph, no rain. Gave this information to Alice Knight (Comms Officer).

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locations. It would have been much better for Karen Chatto to have driven straight to Lismore and then make manual observations using the Beaufort scale 89until the PAWS arrived. The absence of a fire weather behavior officer at any level of the operation probably did not allow for such information to be collected and analyzed and then input into the planning process or the operations point. 33. Failure to tap the fire station and communication centers weather stations to the west of Linton. Some fire stations and most of the CFA communications centers (usually in private houses) should have access to reasonable quality weather stations. Whilst they mostly would not be expected to meet the exposure or calibration standards of the Bureau of Meteorology they can easily detect when strong changes pass. During fire emergencies these centers and some stations are often staffed by capable volunteers. It is necessary to have people within the group or AIIMS that can receive, interpret and inject this useful information. The state emergency operations room at Tally Ho has large scale information available and should have the capability during serious fire situations to receive, interpret and apply wind change information. It does not appear to have done so for the Linton fire. This is strange because from about 20:00 hrs onwards the conflict between the Bureau forecast for the wind change between 22:30 and 23:00 and the passage of the wind change at Lismore and the aircraft and other observations should have been crying out for urgent resolution. I would question its capability to act in this way and a serious upgrade of meteorological skills at all levels (Tally Ho, group and brigade) is necessary. It is disappointing that the Bureau of Meteorology appears to want to withdraw from the nowcasting needed to ensure safe fire operations and indicates that it expects the fire agencies to undertake this task.90. 34. Unfriendly Communications . The fire management radio plan consists of 161 different frequencies of which 77 are allocated to CFA, 77 to NRE and 6 to VPC there is one other. This is a bewilderingly complex communication system which has apparently undergone a change from “old” to “new” designation see Comparison table (Attachment 48). There must be the most careful communications management at fire incidents and one must consider the possibility of multiple fire events. The certainty is communication confusion and breakdown. Safety depends upon information, analysis and decision. Communication is vital and a communications system of such complexity must collapse under pressure. The problem reaches greater proportions when the users of these channels are volunteers who can be working outside their normal areas, sometime hundreds of kilometers away from their usual operational areas.

89 Attachment 90 See note 41 Bureau of Meteorology Preliminary report on Meteorological Aspects of the Linton fire on 2 December 1998. page 11 .

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Considerable investigation, by human communications experts is required. The operations needs are likely to be for channel access yet there must be capacity to overhear and maintain situational awareness. This is not an easy or trivial task and must not be left to communications engineers who may take only engineering perspective and ignore the human and operational needs. The necessity for people outside the system to overhear (property holders, associated agencies e.g. local government, schoolteachers, police etc) must also be considered, they too are major stakeholders in fire emergencies. The inability of the Geelong tankers to hear the weather warning and maintain situational awareness explains the surprise they received when the wind blew up and the fire behaviour suddenly changed. There is an unanswered question as to why the lead tanker stopped. Stepnell’s statement does not provide the answer. If the tanker had not stopped then they may have cleared the area in time before the change arrived. It is possible that Stepnell saw in front of him through the unburnt fuel, along an unused track the loom of the burning out operations as the SE crew approached. In the dark this would have been most confusing especially as the track turns into the east at that point taking them closer or even into the fire. The confusion would be a good reason to stop and try to make sense of the situation. Time would have allowed him to sort it out but then the change arrived. However examination of the track suggests that the distance was too great to see the loom but the track appeared to turn into the fire. That would cause sufficient uncertainty to require stopping and sorting out. The lack of communication between the dozers and the strike team leader and the consequent inability to maintain situational awareness put the machine operators at considerable risk. In the case of the TD40 dozer the operator was experienced enough to take himself to safety when he saw the threat. One might speculate whether the Geelong tankers would have followed him if they had have known of his withdrawal and the reason for his retreat. He was not able to communicate his actions and reasons because he was not radio equipped; a dangerous condition in itself. 35. Failure to ensure that every firefighter was aware of the imminent wind change. When it was clear that a vigorous wind change was imminent there was no attempt to advise every individual firefighter of the wind change. The communications van did a broadcast to which it did not receive sufficient confirmation of reception but it did not take any other action to communicate that information to the firefighters. Messages to individual tankers do not appear to have been made. Every firefighter had a right to be advised that their relatively safe situation was about to become extremely hazardous and that was not done. There was 45 minutes to do so. The firefighters, all of them, were entitled to be advised of the timing, intensity and duration of the wind change. That included those who were in the “safe” situations adjacent to the burn area. They still had to protect themselves from falling perhaps burning branches, flying sparks, embers and smoke. 36. Apparent unawareness of the location of all firefighters.

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There was not specific knowledge at either the Incident Control Center or Operations Point level of the location of all the firefighters. There is a problem with a short-term fire (this fire effectively lasted about 8 hours) of keeping track of large numbers of firefighters. A lot of radio traffic can be generated in maintaining position reports but for matters of safety as well as operational effectiveness it is essential that the disposition of the fire fighting forces and other resources be known. Taxi style GPS and auto reporting systems may be useful and possibly cost effective. Such systems would certainly remove a lot of traffic from the communication systems and restrict the airwaves to essential messages including safety messages. There has been no mention in statements of pin boards or other means of maintaining knowledge of fire unit dispositions. The staging area may (or may not) have maintained a plot of locations of assignment but that information would rapidly have dated and become misleading as re-assignments and plan changes occurred. Re-crewing, re-supply and repair all need accurate knowledge of fire unit positions. For safety warnings position knowledge and current communication channels are essential. 37. Lack of Bureau of Meteorology follows up on forecasts. One of the wind change charts issued at 19:45 was not reproduced in the joint report. It will be necessary to establish whether this chart was in fact transmitted by the Bureau and at what time. And whether it was received and at what time by either the ICC or the ops point. This forecast may have been prepared but not sent or sent but not received. None of the statements from the NRE officers refer to contact from the Bureau following up the forecasts issued. There was likewise little or no apparent communication from the various fire officers inquiring of the Bureau seeking information or confirmation or expressions of doubt on the accuracy of the Bureau forecasts. Some communication did however occur, at 14:40 as there is a hand written note on the 14:12 spot forecast. It is not clear whether that query was initiated from the fire area or from the Regional Forecasting Centre. The serious wind change forecasting error was allowed to continue without challenge from either end of the forecasting chain. If the forecast had been followed up then the timing error may have been found up to two hours before impact and increased the probability that the fire units would have been warned, taken different action and not been trapped. This is speculation of course but the speculation seems reasonable. 38. No Total Quality Management (TQM) process evident for Bureau spot fire forecasts. There is no information of any TQM processes in place for fire weather forecasts. Perhaps an examination of other Bureau wind change forecasts would be helpful in establishing whether this was a minority oversight or whether the reliability of frontal forecasting is quite low. If it is low then alternative techniques must be developed. The wind change is the single most important factor in entrapment after fuel state. The forecasting must have a very high reliability and critea of accuracy must be developed as well as follow up to forecasts and TQM processes for fires that are important enough to warrant spot fire forecasts.

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It is a puzzle as to why the Bureau, usually a paragon of reliability failed on this occasion to quality control its fire weather forecast. 39. No Challenge to the Bureau and their wind change forecast. From 1700 hours when the 3LO interview (Attachment 42) went to air Greg Leach was expecting the wind change “in a couple of hours” i.e. 19:00. The Bureau was then forecasting the wind change at 01:00hrs. Later aircraft reports were giving the wind change at 19:50 some 70 km to the west and at Skipton (20km west) at 20:30. All this time the Bureau was forecasting the wind change at 23:00 (forecast at 19:53). In the light of these conflicts in information there is no record of the ICC, Operations Point, or anybody within those centers challenging the Bureau’s forecast. If the forecast had been challenged it may have been amended. The effect of an amended forecast could have been to cause a decision to secure the firefighters on the eastern flank before racing to secure the eastern flank itself. It is conceivable that the decision to deviate the bulldozer from the fire edge may have been reversed and the re-watering of the tankers through unburnt country not have been permitted. The spirit of query and challenge of forecasts needs to be encouraged and established as an obligation of all fire managers. The same obligation also applies to other aspects of fire management relevant to safety e.g. fuel data, firefighter skills and training. If there are doubts they need to be resolved and if there are inconsistencies they must be resolved. 40. No request for meteorological outposting service. The Bureau of Meteorology through its Regional Forecasting Centre has an arrangement with NRE for outposting meteorologists complete with a comprehensive range of computer, communication and observation equipment to a fire-fighting headquarters such as the ICC at Ballarat. The program has been very effective in improving communication and perceived quality of fire weather forecasts in difficult fire situations. The Linton fire was a fire early in the season. The fire was of moderate intensity travelling at moderate speed in moderate fuels although they were dryer than expected. Experienced fire managers could have expected to have the fire contained and made safe before the day was out. It is reasonable that a weather outposting operation be not requested. If however the more conservative action was taken of requesting an outposting when the decision to activate AIIMS it is likely that the wind change forecast errors would not have occurred. If a meteorologist were part of the ICC or better the Operations Point and in receipt of the other wind change data they would have resolved the problems and the meteorological information would have been of a much higher quality. It is worth noting that the Berringer fire which had a similar blow up and escape was also underestimated and an outposting was not requested. There was a serious forecast error on that occasion that most likely would have been avoided by an outposting. It seems that there is a natural reluctance on the part of fire managers to put into action the rather large effort entailed in a full outposting.

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Equipped with only a good quality lap top computer and printer a meteorologist can if a telephone line is available provide most of what a fire manager should require. If even a reduced service had been available then a happier outcome may have ensured. 41. Insufficient qualifications in OICs and team leaders . The literature of fire-fighting including the reports on the Storm King fire and an examination of the work practices of forest crews indicate that the crew leader is a very important component of crew safety. The statement of William Bell of NRE illustrates the broad range of experience and knowledge that resides in this level of supervision. The NRE crew leaders often have decades of experience in the bush and in using and dealing with fire. In difficult situations this experience can be the difference between a safe operation and a disaster. This level of experience is necessary in forest fire situations to maintain high levels of safety.91 Neither the strike team leader nor the crew leaders on the Geelong City or Geelong West tankers had sufficient experience in forest fire fighting. Their skills lay elsewhere. Scarf the strike team leader states that he had only one forest fire under his belt and that was the Dandenongs Fires of 1997. It is not stated what his role was but only attendance at a forest fire may not increase the experience base by very much. Stepnell, Geelong City leader was an urban firefighter who claims to be involved in three major forest fires but does not state which ones or his experience gained. Clearly, Stepnell was more experienced than Scarf but probably would be judged insufficient for crew leadership by NRE. Using leaders without sufficient experience in such a difficult position could not be considered good practice and places the leaders in very difficult and stressful positions and the capacity for errors is large. In this case the decisions to re-water through un-burnt country, misinterpretation of the weather situation, agreeing to a deviation in bulldozer track away from the fire edge could be attributed to lack of experience at the line leader and crew leader level. 42. Deviation of bulldozer line away from fire edge. Instructions were given for bulldozer fire control lines to be made adjacent to the fire edge in a direct attack. This is a standard and safe operation if the fire intensity is low adjacent to the bulldozer as it was up to the wind change. Any unburnt fuel on the fireside is then burnt out. If the bulldozer (or hand) trail moves away from the fire edge then the attack becomes indirect and requires back burning to remove the intervening fuel and prevent later fire spread. If a wind change occurs before the burnout fire has reached the fire line; fire intensity will increase especially in junction zones and threaten to break through the fire line threatening people caught on the firebreak or on unburnt fuel. Indirect attack can be used if fire intensities are too great for direct attack, the terrain too difficult and there is sufficient time and resources to achieve a burnout before the fire danger increases. With the deviation of the bulldozer away from the fire edge the resulting breakaway of the fire was certain when the gusty change finally arrived. The burning out of 60 – 80 meters between the fire and the proposed deviated track in the dark could not be guaranteed to prevent a breakaway, as too little time remained to complete the burnout. If the bulldozer had maintained

91 Cheney discuses the loss of this experience (Attachment and the difficulties this can make for fire management.

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work on the fire edge the breakaway would have still occurred although it would have been smaller. The deviation of the bulldozer was bad fire management practice. 43. Failure to withdraw firefighters before wind change. Firefighter deaths occur mostly with a sudden increase in fire intensity due to a sudden wind changes or intensification, or the fire arriving at increased and dangerous fuels or a run up a slope. When any of these occurrences can be foreseen and the fire predicted to exceed the survivable limits then the firefighters must be withdrawn to a safe location. Experienced firefighters can achieve a fair degree of safety by being on or contiguous to completely burnt ground. In the case of increased threat due to wind changes such locations cannot be classified as completely safe. The wind is now blowing harder in the fire area due to fire effects and loss of forest friction can and does cause trees and limbs to fall. Sometimes this falling timber is also burning making it doubly dangerous. Greatly increased airborne embers and sparks are very uncomfortable, likely to cause small burns and can create eye damage. There is always the danger that inexperienced firefighters when being subjected to this wind may make bad decisions and put themselves in further danger by moving away from the fire edge. The time taken to withdraw can be significant and I would estimate that a completely safe withdrawal to the cemetery would have taken 20 – 30 minutes all going well. The withdrawal to the fire edge could take 10 minutes to ensure that all the firefighters were accounted for. It would be most important in a withdrawal to ensure that nobody became lost and was caught on unburnt ground. I have been unable to find any direction to withdrawal in any of the statements. The only actual withdrawal that I could find was the withdrawal of the bulldozer driver initiated by him. 44. Exposing crews to unburnt fuels Even when fires are burning quietly and the situation seems benign it increases risk by exposing firefighters to unburnt fuel. One must be very sure that the fire intensity and rate of spread cannot increase to dangerous levels during the exposure time. Checks must be made of the weather, fuels and slopes. In this case there appears to be no attempt to undertake these checks. The weather was not requested by the strike team leader, the fuels and slopes were not inspected. No risk assessment appears to have been made and documented. Exposure to unburnt fuels in any area where fires are burning is a serious increase in risk and must be considered carefully and analysis made before a decision. 45. Tanker protection systems There is considerable literature and interest in tanker protection systems for burn overs 92. A visit was made to inspect the NSW tanker protections and it is hard to escape the conclusion that the CFA tankers are inadequate in their safety features. Heat shields that rely upon the thermal properties of polyester resins (plastic and fiberglass) are probably safe up to a radiant impact of about 8 kilowatts per square meter. Previous studies of radiation in fires suggest that design safety thermal loads of 100 kilowatts per square

92 Paix 1999 and US Forest Service . Attachments 16 and 38.

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meter are required 93. Recent US experiments94 are suggesting loads of up to 170 kilowatts per square meter. An estimate made in this report 95 suggest loads of 28 kilowatts per square meter for this fire. Under these loads the fiberglass shields are not only ineffective but also dangerous, as they now become a very effective fuel. Empty fiberglass tanks add to the risk. The plastic content of the shields and tankers make up a secondary fuel load that once ignited would ensure little survivability for any crew who escaped the initial radiation from the wild fire. Unprotected tyres96 without cooling sprays also greatly decrease the survivability of the current design of tankers. Crew protection in the bus shelter behind the cab is most unlikely to be effective in a severe fire. Reliance on hand held sprays for radiation and cooling protection is primitive and uncertain. Simple woolen blankets are helpful but heat reflective properties are required. The inability to put up heat screens to protect window glass is also a weakness in current tanker design. 46. Lack of PPE and last resort procedures Whilst the firefighter clothing supplied is of good design, the lack of multiple layers and hoods as now on issue in NSW would suggest that there are improvements possible. It is recognized that there is a balance between dissipating metabolic heat and protection from external radiation.97 The NSW and SA approaches seem to be desirable. The metabolic heat in volunteers who are mostly tanker based would be much less than for hand trailing NRE crews and so their level of protective clothing could be increased. When entrapped there is no time to devise last resort procedures. The actions for the crew must be well practiced after careful research to delineate what are the appropriate procedures when caught suddenly. The subject is complex and all that can probably be achieved is an increase in the probability of survival rather than a certainty. 47. Use of large tankers in forest areas. The large tankers supplied by the CFA to their brigades are unsuitable for use in forest fire fighting. The appropriate equipment is what is currently used by NRE who have developed fire fighting equipment and techniques throughout the last fifty years. Large, heavy tankers could be considered dangerous in use on bulldozed fire trails. It is appropriate to use them in many other fire-fighting roles. It is doubtful that they should be the main fire-fighting vehicles used in initial attack.

93 Fireman. “Heat Shielding for CFA appliances”. Attachment 39. 94 “Surviving Fire Entrapments”. Attachment 38. 95 Attachment 44. 96 King and Walker, Attachment. 97 Budd. “Heat and the Wildland Firefighter”. Wildfire, Dec 1997, 14-19. Attachment 40.

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An analysis of initial attack both from the theoretical point of view and from the empirical approach of Tolhurst98 show that the most effective time for fire fighting on bad fire days is in the first few minutes when the fire is small and of controllable intensity. Very fast initial attack is the best strategic and tactical approach. Large and heavy tankers are not capable of very fast initial attack. Small, four wheel drive maneuverable vehicles are required. They are also lower in capital cost and easier to position at volunteer residencies to ensure a much improved coverage and response time for initial attack. The lack of manourvability prevented the Geelong tankers from turning around easily and going for water via a safer route. The heavy units also slowed the bulldozers considerably by requiring a better quality trail, wider with more turnarounds. 48. Re-supply of water. It seems strange that the tankers were required to travel out of the fire area to be refilled. The fire was some six hours old when the strike team tankers needed refilling. The access to the north end of the bulldozer track at Possum Gully road was good and that is a very obvious location for a water re-supply vehicle. Two other tankers from the strike team were moving around the fire area also looking for water. 99 49. Run-out of tanker water The 15 page mini booklet “Wildfire safety and Survival Guide CFA 1997, page 12 (Attachment 55) devotes four lines to the use of water as a survival measure “keep a reserve of water in the tanker for protection and safety of the crew” and “Turn on external water sprays or fog patterns”. There is no other guidance on how much water was to be retained how it was to be used, when it was to be activated and how effective it could be expected to be. Some approximate calculations 100 would suggest that as little as 200 litres of water applied as a film to a tanker cab would absorb all the radiant heat from this fire. The capability of water sprays and fogs in absorbing radiant heat is recognized but by how much is unknown. Paix (Attachment 16) has reviewed tanker burnover incidents and found quantities of water between 700 liters and 3600 litres have been used successfully in survival situations. It is highly likely but not certain that if the Geelong West tanker had some water available, how much is unclear, their survival chances would have been improved. If residual water for self defense is necessary then its quantity must be carefully monitored and its maintaince a matter of high priority. There was not a great deal of emphasis placed upon residual water as the CFA booklet cited above only gives 4 lines out of about 350 to the subject. The effect of wind changes on safety receives 15 lines (page7) or about four times the amount given to safety water. In the absence of careful tests and trials it is uncertain what level of safety water sprays provide. Certainly they can do no harm and until evidence to the contrary the NSW systems (if 98 McArthy and Tolhurst. Effectiveness of Fire-fighting First Attack”. 99 Statement of Buckland p2.4. 100 Attachment 43.

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water was available) may have assisted the Geelong West crews to survive this medium intensity fire.

FUTURE FIRE SAFETY THREATS There are considerable threats to fire fighter safety in the future:

? Increasing rural/urban interface ? Severely decreased resources for public land management ? Steadily increasing fuel loads that have now reached the highest level since human

occupation. ? Loss of bushcraft ? Badly informed public resistance to fuel and forest health management through

burning ? Excessive reliance on technological fixes ? Decrease in rural populations.

RECOMMENDATIONS

This review has prompted several recommendations all aimed at making the fire-fighting task safe. There is no reason why any one should perish in the process of fire-fighting. The recommendations span a considerable range of interests from organisational structure to choice of materials for fire tanker construction. Some of the recommendations need much further review and analysis for example changing the structure of fire management in Victoria would not be an activity undertaken lightly. Improving the focus and improvement of fire research is also a most complex matter that would require further and serious analysis and study. Likewise making fire communications system more user-friendly will also take considerable effort but will be necessary for a safe fire-fighting environment. Some of the recommendations are very expensive but not as costly as continuing to have life loss and damage as a result of insufficient fuel management. Some recommendations require improved training and experience building over a considerable span of time. Some of the recommendations have been around for some time and a study of the Stretton101 and Barber Royal Commissions and the Auditor General’s Report102 will prompt a further number of recommendations. There is a lot to do and even though we may escape another Black Friday or Ash Wednesday this year or next there will surely come a January or February that will have a host of extreme fire danger days with the capacity to wreck havoc on Victoria in a way unimaginable by most people.

101 Attachment. 102 Attachment.

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The Recommendations 1. Review the structure of rural fire management in the State of Victoria. The review should

consider removing some of the organisational confusion and conflicts by restructuring fire fighting in Victoria into three agencies.

City Fire: to manage fire and fire risk in our cities and towns. Forest Fire: to manage fuel and fire on public lands and plantations. Rural Fire: to manage through its resources of volunteers, fires and community threat in the rural area including small towns, villages and hamlets.

2. Rural fire protection to be overseen by fire and community protection officers backed with legislation and a system of inspection similar (but of course smaller in scale) to work, road, aviation and marine safety agencies. Such an organisation could maintain quality supervision of the fire management agencies and ensure that fuel hazards in Victoria that threaten people, property and the environment are dealt with. A safe fuel environment alone would remove almost all risk to community, state assets and fire-fighters.

3. The community as well as fire-fighters, volunteers, associated emergency agencies should

be represented fairly and equitably on the boards and councils of the fire agencies. 4. The agency with responsibility for land management of a fire area is the agency with

responsibility for fire management. The disparity of techniques needed for forest, grass, rural interface and heathlands are so different as to make interagency systems unworkable and maybe unsafe.

5. The volunteer brigade and group system must be restored and fostered. The rural

community is well served with its volunteers acting through community spirit and they have developed the world’s best first attack, and group fire management system. When a fire exceeds first and second attack then it may be the time for incident management systems to be set up.

6. The Australian Interagency Incident Management System (AIIMS) be subject to critical

and impartial review and examination and its applicability be properly assessed for Victoria’s rural fire threats.

7. An independent and rigorous needs analysis for fuel management to ensure a safe

environment for Victoria be conducted immediately. The needs analysis can then lead to a rational investment strategy to ensure that Victoria can cope with its fire threat.

8. NRE to be resourced sufficiently (subject to the needs analysis) to be able to use

machinery under its control and crewed with its own employees for fire-fighting. 9. Any contract equipment must be crewed with operators that have NRE levels of training

and accreditation. In the Linton fire the contractors did excellent work but the scope for unsafe practices exists.

10. Private plantations to be audited for their fuel and fire control capabilities and be required

to be able to meet the risk.

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11. Volunteers be not used outside initial attack for fires on public lands or plantations, unless

they have been trained to the same level as NRE fire-fighters and under the direction or control of an NRE or VPC officer and CFA is paid by NRE or plantation owners at full award rates for the volunteers. The income to be dispersed equally to all rural brigades above their normal allocations.

12. Legislation similar to the Florida Indemnity for fuel management by burning be introduced

in Victoria. 13. Workplace safety including Safety Map techniques be introduced for all CFA operations

and that a culture of work safety, challenge and audit be introduced immediately. Safety programs similar to those for aviation be instituted for fire-fighters especially volunteers.

14. Safety officers with veto rights be part of every fire fighting operation. 15. The Bureau of Meteorology inculcate a “duty of care” culture for its fire weather

operations and services. 16. The services provided for fire management be increased to ensure that every fire-fighter

(after initial attack) has information in a written form of weather, fuels, topography, structures, strategies and communications.

17. No fire-fighting activity after initial attack will continue unless a risk assessment to

community, fire-fighters and assets has been made and is subsequently approved by the fire agency safety officers.

18. The limits for direct attack and success probabilities are established. Guidelines with

adequate technical information be made available throughout the fire management community. During any fire and on every fire danger day the limits be calculated and made known to the whole Victorian community and to the fire management community specifically.

19. The limits for back burn and burn out operation be similarly established and promulgated. 20. Fire behaviour prediction must be made for all fire situations even initial attack and if it

exceeds the capability for attack then alternative strategies implimentated. 21. There be a total review of the communications systems used for fire management. The

emphasis to be placed upon designing a fail safe, redundant system that meets the needs of fire-fighters and the rural community. Human communication psychology and communication practices in critical activities (aviation, marine) to be major inputs to the system review.

22. Fire weather information to be available through broadcast systems as in the US and

aviation services established in Victoria. Other safety warnings can also be incorporated. Each fire unit equipped with suitable alerting receivers. This would not replace confirmed transmissions through the fire management network but provide some degree of redundancy.

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23. Mobile phones be permitted and perhaps encouraged for volunteers engaged in fire control. They provide another redundant communication channel.

24. Fire weather skills need to be improved within the volunteer and paid staff at both CFA

and NRE. Similarly fire management skills need to be improved for fire weather meteorologists who are unlikely to manage fires but must have a first hand and experiential understanding of fire management.

25. The Bureau of Meteorology greatly improve its system for forecasting cold fronts and

wind changes in Victoria and achieves for fire weather a forecasting and nowcasting ability sufficient to avoid any more entrapments by ill timed wind changes. Monitoring of these changes must be maintained at a high level during fire events including large fuel management burns.

29 A culture of challenge and safety audit be established for all fire-fighters in both agencies. 26. No person should be involved in fire fighting, who has not reached the required level of

knowledge, skill and experience. It is recognised that community protection will always depend upon who and what is available at the time and the lesser skilled and casual fire-fighter will always be necessary. The education of fire managers for unexpected or unusual fire conditions must be expanded. The once in a lifetime fire should be anticipated. Long experienced fire managers and fire-fighters must be valued and integrated into the fire education and management system.

30 Fire research be greatly increased. Fire research is currently totally inadequate. There is a

lack of freedom to enquire and rigour within the research. It has been troubled with a serious lack of resources and a lack of peer co-operation.

The recommendation aims to: ? Strengthen the research effort in all agencies that have a responsibility for fire management to 2% of total staff. ? Establish a jointly funded but independent fire research centre based somewhat on the structure and policies of the National Centre for Atmospheric Research in Boulder, Colorado or the Intermountain Fire Research Laboratory in Missoula, Montana. ? Have available a fund to support postgraduate research at any of the Universities with a capacity for contributing to fire knowledge. ? Develop a culture of co-operation, challenge and enquiry amongst the fire research community. ? Develop a relevant focus for research with out maintaining strangleholds.

Amongst the subjects where more information is urgently needed (and this is not exhaustive) is fire behaviour, fire and fuel physics and chemistry, strategies and tactics, fuel management, community and policy, fire weather and climate

31. All crews to be briefed before being engaged in fire control activities. Even in the initial attack phase. In post initial attack phases the briefing must include hard copy information on weather, fuels, locations, maps, communications, management structure. Initial attack briefing must include those subjects but may be given slowly over the radio to permit transcription. Each unit must be equipped with suitable maps and communication channel charts and placarded watch outs and emergency procedures.

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32. The flow of meteorological information and the provision of weather skilled officers and volunteers within the NRE and CFA structures need to be increased. Each forest district and each CFA group have a person with observing, interpretation and nowcasting skills and with sufficient communications to ensure that no fire operation including fuel reduction and initial attack takes place with out meteorological (and fuel) input.

33. The CFA and the NRE upgrade their manual weather observing equipment such that each group headquarters has temperature, max and min temperature, relative humidity, wind speed and direction and recent rainfall available. World Meteorological Standards for observation stations should be complied with where possible. Each CFA group headquarters and each NRE district office to have Internet with Bureau of Meteorology Fire Weather Access and a printer for downloading current and forecast fire weather.

34. NRE to upgrade and increase the reliability of the Infra red line scan mapping equipment and to publish reports on each fire scanned.

35. Some additional AWS stations to fill holes in the Victorian fire weather network especially in the northwest and around Westmere. Serious consideration be given to an anchored station south west of Mt Gambier in the Southern Ocean.

36. Fire behaviour officers in each NRE district office and each CFA group headquarters should use current information and Bureau forecast information to predict fire behaviour for briefing to all responding fire-fighters and to guide strategy and tactics and ensure operational safety.

37. The Bureau of Meteorology to increase efforts to provide nowcasting and forecasting services to all fires that have not been declared safe.

38. The Bureau of Meteorology to be pro active in the provision of out- posting services and not to await invitation of the fire agencies. They must truly become part of the fire management team or the fire agencies to employ their owm meteorologists. 39. Any significant change in the weather situation must be transmitted to each fire unit or crew and acknowledgement of receipt obtained. Any failure to acknowledge must result in actions to withdraw that fire-fighting unit immediately. 40. The NRE district or the CFA group must be aware of the location of every unit and machine after the initial attack period has finished. They should know the location of all units and machines during the initial phase if possible.

41. The Bureau of Meteorology should follow up spot fire weather forecasts until the fire for which the forecast was requested is declared safe. A white board in the Regional Forecasting Centre with active fires listed (as determined from spot fire forecasts requests) would be helpful.

42. Fire-fighters to be safely secured and confirmed at least 20 minutes before the passage of any known or forecast wind change at an active fire. Other agencies that are known to have personnel in the area to also be advised to secure e.g. Police, Ambulance, Agriculture, communities’ etc.

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43. Fire units to have their heat shields immediately abandon fibreglass heat shields immediately and replace them with aluminium or other suitable metal and to have a program of replacing fibreglass water tanks within the next three years. Fire tankers to have a water spray system with at least 200 litre of dedicated water fitted within the next three years. Water sprays to protect tyres to be installed immediately. Heat reflective curtains and the removal of toxic plastic from units to be investigated immediately.

44. Improved woollen blankets with reflective properties to be investigated, developed and provided within one year. The use of balaclavas as now issued in NSW be adopted immediately.

45. Large tankers not to be used in forest areas off formed roads and the CFA to consider the provision of faster, lighter tankers to improve their operating range and speed of response in first attack.

46. Fire towers be manned during active fires and equipped with sufficient radios (even hand held if necessary) to ensure a constant source of fire information, radio relay assistance and weather intelligence.

HELP

In my investigations of the Linton fires I have been greatly assisted by the visits to the site of the entrapment. The visit to Bushfires NSW and the Australian Emergency Management Institute and the content of the joint CFA/NRE report, the Bureau of Meteorology’s interim report and the various interviews conducted by the Police and WorkCover.

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LIST OF ATTACHMENTS

1a Reason, J., (1993). Organizations, Corporate Culture and risk. Human factors in Aviation. The 22nd technical Conference, Montreal 4-8 October 1993. I.A.T.A., Montreal and Geneva.

1b Reason, J., (1992). Identifying the Latent Causes of Aircraft Accidents Before and After

the Event. Proceedings of the twenty –second International Seminar of the International Society of Air Safety Investigators, Canberra, Australia, November 4 – 7 1991. The International Society of Air Safety Investigators. Vol 24 (4), 39-45.

1c. Wagenaar, W.A., and Hudson, P.T.W. and Reason, J.T., (1990). Cognitive failures and

Accidents. Applied Cognitive Psychology, 4, 273 – 294. 2. Notes upon reading Report of the Operations Review of Linton fire/Midlands fire #15 on

Wednesday 2nd December 1998 (CFA-NRE). 3. Notes on Reviewing Bureau of Meteorology, Preliminary report on Meteorological

Aspects of the Linton fire on 2 December 1998, Melbourne, July 1999. 4. Turner, B.A., (1978) Man-made Disasters, Wykenham Publications (London) Ltd. 5. Getting the low-down on industry brigades. The Fireman, Sept. 16 1998, page 4. 6. Mitchell, B., (1999) Integrating emergency services, How WA is merging fire and

emergency services agencies. Australian Journal of Emergency Management, 14(1), 2-5. 7. McCarthy, G.J., and Tolhurst, K.G., Effectiveness of Firefighting First Attack

Operations by the Department of Natural resources and Environment from 1991/92 – 1994/95. Research Report No. 45. Fire Management Branch , Department of Natural Resources, Melbourne.

8. Reducing the Risk of Entrapment in Wildfires, A Case Study of the Linton Fire. CFA

July 1999. 8a. Notes on reviewing “Reducing the risk of Entrapment in Wildfires, A case Study of the Linton Fire, CFA July 1999.”

9. NRE (1998), Basic Wildfire Awareness. Department of Natural Resources and

Environment Fire Management. 10. Linton Bushfire Investigation, Operation Hierarchy Chart. Victoria Police. 11. Campbell, F., Bushfire Deaths: The Gallipoli Syndrome, Wildfire Feb 1998 p7 also

Campbell, D., Our Heros are our Future, Wildfire, March 1996 p54.With Dennis 12. Various Letters to Wildfire prompted by Frank Campbell’s Article, Wildfire, March, 1998.

4-6.

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13. Conservation and Natural Resources (1995). Code of Practice for Fire Management on Public Land.

14. Incol, R. (1995) Aircraft and Firefighting in Victoria, Australia. Wildfire, December, 37 – 43, (1995).

15. Cheney, N.P., (1998). The Safety of Bushfire Fighters. Australasian Fire Authorities Council Conference, Hobart, October 1998.

16. Paix, B., (1999). Improving Burnover Protection for Australian bushfire Appliances. Bushfires 99, Albury.

17. Krusel, N., and Petris, S. Staying Alive: Lessons learnt from a study of civilian deaths in the 1983 Ash Wednesday Fires. Hotsheet (now Wildfire) , 2(1), 3 – 19.

18. McCarthy, G.J., and Tolhurst, K.G. and Chatto, K., (1998). Overall Fuel Hazard Guide. Research Report No.47, Natural resources and Environment and Centre for Forest tree Technology.

19. Robinson, C.J., Packham, D.R., and Powell, J.M., Cleaning Up the Country. Wildfire, March 26 – 30 and Thomas, J.W., Concerning the Health and productivity of the Fire-Adapted forests of the Western United States. Wildfire march 1995, 18 – 21.

20. Two papers from Wildfire on Crew management.

21. Linton Fire Management Plans, CFA/NRE.

22. Extract from CFA Pamphlet . Volunteer Compemsation.

23. Safety Map. WorkCover Victoria.

24. Cook, J.(1995). Fire Environment size-up; Human limitations Vs superhuman Expectations. Wildfire, 49-53.

25. Hood, C. and Jones, D.K.C., (1996). Accident and Design, contemporary debates in risk management. Selected papers.

26. Leggett, T., (1996) Meteorological Aspects of the Berringa Fire of 25-26 February 1995. Bureau of Meteorology, Victorian Regional Office.

27. Notes on reading “Meteorological aspects of the Berringa fire of 25-26 February 1995”.

28. Berringa-Enfield Fire 25 – 26.02.1995. Analysis of CFA Fire Management Strategies. CFA Risk Management and headquarters Operations, Melbourne.

29. Notes on reading “CFA Report, Berringa-Enfield Fire 25-26.02.1995. Analysis of CFA Fire Management Strategies”.

30. The Occupational safety and Health Administration’s investigation of the South Canyon Fire, February 8, 1995. Wildfire, March. 1995.

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31. Report of the Interagency Management Review Team South Canyon Fire. Wildfire, December 1994.44-47.

32. Vaughan, D., (1997). Targets for Firefighting Safety: Lessons from the Challenger Tragedy. Wildfire, March, 1997 27-38.

33. Beaufort Wind Scale.

34. Photocopy from notebook, calculations of wind change.

35. Fire Weather Forecasts Linton Fire 2/3 December. 1998. Bureau of Meteorology.

36. Babbitt, B., (1999). Making Peace with Wildland Fire. Wildfire, January 1999, 12 – 17.

37. Bennett, R. (1997). Are we Being Held Accountable? Wildfire August 1997, 15-18.

38. Mangan, R., (1997). Surviving Fire Entrapments, Comparing Conditions Inside Vehicles and Fire Shelters. Report 9751-2817-MTDC, Forest service, UD Dept. of Agriculture. Missoula, Montana.

39. Garvey, M.F. (1986). Report of Tests Heat Shielding for CFA Appliances. The Fireman, Operations No.166, July 16. And Letters to the editor Query on CFA Research and Response from Author.

40. Budd, G.M., (1997) Heat and the Wildland Firefighter. Wildfire, December. 14-19.

41. Firefighter Safety, King and Walker (1964) .

42. Media Monitors. Part Interview 3LO, 2.12.98.

43. Calculation of amount of water required to protect a tanker from full fire immersion.

44. Calculation of Radiant intensity on Entrapped Trucks.

45. Pre-fire Aerial photographs. Originals with Dennis.

46. Sketch communications chart.

47. Fire Observations at Linton.

48. Comparison Table for CFA Radios. August 1998.

49. Requested meteorological information to enable a post fire weather analysis.

50. Email concerning the Florida and Tasmanian burning legislation.

51. Conservation and natural resources. Fire and public Land management. Brochure.

52. NRE. (1999). Research Publications.

53. Mangan, R. (1999).Wildland Fire fatalities in the United States, 1990 to 1998. Report 9951-2808-MTDC. Forest Service, US Department of Agriculture. Missoula, Montana.

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54. Notes on Significant papers in Wildfire.

55. CFA (1997) Wildfire safety and Survival. A Guide for Firefighter Safety. And Wildfire safety and Survival, Hints for Firefighters.

56. Meteorological information available on the Internet to fire services and others.

57. Tassios, S. and Packham, D.R. (1984). An Investigation of Some Thermal Properties of Four Fabrics Suitable for use in Rural Firefighting. Technical Paper No. 1. Chisholm Institute of Technology.

58. Investigation of wildfire Entrapments, US Forest Service. 9551-2845-MTDC

59. Annotated list of Articles on Entrapment from Wildfire.

60. Meteorological information Available from The Bureau of meteorology home page for fire agencies.

61. Department of Conservation, forests and Lands. Fire Protection Instructions.

UNDER SEPARATE COVER

1. Pre-Fire Aerial Photographs

2. NRE Annual report 1997-1998

3. CFA Annual report 1997-1998

4. Bureau of Meteorology. Preliminary report on Meteorological Aspects of The Linton Fire on 2 December 1998.

5. CFA/NRE Report of the Operations review of Linton/Midlands fire #15 on Wednesday 2nd December 1998.

6. Victoria Police. Chronology of Events, Linton Bush Fire.