Operational Debrief Report 2008/09 Fire Season · 2009. 8. 20. · Each fire season presents the...

Operational Debrief Report2008/09 Fire SeasonJames Fox (CFA)Ross Runnalls (DSE)

July 2009

Cover photo courtesy of Chris Mulherin ([email protected]).

Published by the Victorian Government. Melbourne, August 2009

© The State of Victoria 2009.This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Authorised by the Victorian Government, 8 Nicholson Street, East Melbourne.

ISBN 978-1-74242-133-9 (print)ISBN 978-1-74242-135-3 (online)

For more information contact the DSE Customer Service Centre 136 186

DisclaimerThis publication may be of assistance to you but the State of Victoria and its employees do not guarantee that the publication is without flaw of any kind or is wholly appropriate for your particular purposes and therefore disclaims all liability for any error, loss or other consequence which may arise from you relying on any information in this publication.

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DSE/CFA Debrief Report 2008/09 Fire Season

CHIEFS’ FOREWORD History will remember the 2008/09 Victorian fire season for Black Saturday, the most significant bushfire event in Victoria’s history and Australia’s worst natural disaster. Black Saturday, the weeks leading up to and the weeks following saw an extraordinary fire fighting and recovery effort by thousands of DSE and CFA personnel, supported by interstate and international fire crews and management teams. This contributed significantly to minimising the impacts of fires in Melbourne’s water catchments and communities across Victoria. The fires were put out virtually without rainfall, thanks to the perseverance and determination of our people. We are extremely proud of the exceptional courage and commitment that CFA, DSE, the NEO partners and the broader emergency service personnel demonstrated including the way the broader community responded to these fires. Each fire season presents the fire agencies with the opportunity to review, improve and learn from our experiences. Debriefing is a joint agency process to capture learnings on our preparedness programs, how we respond to fires safely and effectively, and migrate into recovery operations. Over 176 debriefs were conducted Statewide. They identify where CFA, DSE and our partners performed well, where improvements could be made and how we can further consolidate our partnership. DSE and CFA jointly considered the key findings in this report and identified 18 issues where we will focus our activities prior to the following fire season. There are some activities that will require DSE and CFA to respond to over a longer period. We would like to thank everyone involved in the various debrief processes. Feedback is an essential part in moving forward. While we recognise that we have come a long way, there is always opportunity to do better. We are committed to continual improvement to ensure that Victoria’s fire agencies provide the best service to the communities of Victoria.

Steven Warrington Ewan Waller Acting Chief Officer Chief Officer, Fire & Emergency Management Country Fire Authority Department of Sustainability & Environment

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PREFACE This is a report prepared for the Chief Officer Country Fire Authority (CFA) and the Chief Officer Fire & Emergency Management Department of Sustainability and Environment (DSE) on operational debriefs for the 2008/09 fire season. The report describes how the debrief process was conducted, emerging issues and presents actions for improving operational performance. In all, 176 debriefs conducted at local, regional and state level were considered in the preparation of this report. This report is based on the debrief information as received. An element of judgement by experienced and skilled fire personnel has been necessary when summarising and prioritising issues. The authors acknowledge that the data could be interpreted differently by others. The State Debrief Coordinators acknowledge the valuable contribution made by members of the project team in the collation, analysis of data and the preparation of the report. James Fox (CFA) and Wing Major (DSE) 2009 State Debrief Coordinators

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TABLE OF CONTENTS

1. EXECUTIVE SUMMARY ............................................................................ 5

2. INTRODUCTION ........................................................................................ 7

3. 2008/09 FIRE SEASON.............................................................................. 8 3.1 Antecedent conditions 8 3.2 Significant fire incidents 9

4. DEBRIEF PROCESS................................................................................ 12 4.1 Purpose of Debriefs 12 4.2 Conduct of Debriefs 12 4.2.1 Local debriefs 12 4.2.2 Centrally Coordinated Debriefs (Regional Workshops) 13 4.3 Collation of Data 13 4.4 Identification of Issues 13 4.5 Risk Analysis 14

5. SUMMARY OF DEBRIEF ISSUES........................................................... 15 5.1 Accommodation 15 5.2 Air Operations 15 5.3 Briefing 15 5.4 Catering 16 5.5 Coordination Centres 16 5.6 Debriefing 17 5.7 Environmental/Cultural Impacts 17 5.8 Financial 17 5.9 Fire fighting equipment 17 5.10 Incident Management 18 5.11 Information Flow 21 5.12 International/Interstate 22 5.13 Legal 23 5.14 Mapping 23 5.15 Occupational Health and Safety 23 5.16 Personal Protective Clothing/ Equipment 24 5.17 Personnel 24 5.18 Plant and Equipment 26 5.19 Preplanning 26 5.20 Records Management 28 5.21 Recovery 28 5.22 Resource Management 29 5.23 Undetermined 29

6. RESPONSE TO DEBRIEF ISSUES ......................................................... 30 6.1 Actions to address key issues 30 ISSUE No. 1: Improve the integrated function of iECC, CFA and DSE state wide coordination and strategic planning. 31 ISSUE No. 2: Ensure appropriate arrangements for liaison and coordination when multiple IMTs are in place, including division of control in a fast moving fire across administrative boundaries. 32 ISSUE No. 3: Develop systems for well prepared and strategically located joint Level 3 ICC facilities. 33 ISSUE No. 4: Develop sufficient preformed IMTs to match extreme conditions. 34 ISSUE No. 5: Continue to improved cooperation between CFA and DSE personnel 35

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ISSUE No. 6: Better integrated and compatible parallel DSE and CFA systems and procedures 36 ISSUE No. 7: Improve the timely and adequate information flow from IMTs to iECC, VBIL and the community 37 ISSUE No. 8: Develop systems for efficient information flow from fire ground, including aircraft, to IMT 38 ISSUE No. 9: Improve and make more concise Incident Shift Plans (ISP), including maps, prepared by IMTs for the fire ground 39 ISSUE No. 10: Ensure clear reporting and management processes for OHS incidents, particularly with international/interstate crews 40 ISSUE No. 11: Minimise injuries and near misses due to falling limbs and trees 41 ISSUE No. 12: Clarify implementation of fatigue management guidelines and frequent breaches of guidelines in first shifts 42 ISSUE No. 13: Consistent understanding of most suitable function and location of Division Commander role 43 ISSUE No. 14: Ensure sufficient skilled personnel to manage fireline situation, communications, personnel, plant and complexity 44 ISSUE No. 15: Improved management of contractor plant 45 ISSUE No. 16: Better adherence to Communications Plans incorporating planned use of UHF radios 46 ISSUE No. 17: Improve efficiency of shift changeovers and adequate briefings 47 ISSUE No. 18: Consistent application and management of road closures that allow access of fire personnel and prevent unauthorised access for non-combatants to the fireground 48

7. REFERENCES ......................................................................................... 49

8. APPENDICES.......................................................................................... 50 Appendix 1 List of Debriefs 50 Appendix 2 Structure and Content of Database 53 Appendix 3 Descriptions of Standard Topics 54 Appendix 4 Risk Assessment 69 Appendix 5 Joint CFA/DSE Standard Topics and assigned risk ratings for issues identified in 08/09 debriefs 70 Appendix 6 Definitions of Terms Used 74

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1. EXECUTIVE SUMMARY Following the 2008/09 fire season, CFA and DSE, as is normal continuous improvement practice, conducted a series of fire personnel debriefs and workshops designed to identify the successes (what should be retained and strengthened) and the problems (things that should be changed or improved) experienced during the fire season. The debrief reports were sent to the CFA and DSE State Debrief Coordinators for collation and analysis. The descriptions of successes and problems contained in the debrief reports were codified using a comprehensive list of standard topics. A short summary of successes and problems were prepared for each standard topic based on the descriptions made in the debrief reports. This particular process has been used by CFA and DSE since the 2002/03 fire season to identify issues for consideration. Areas of operations where improvements adopted following debriefs from previous fire seasons have become successfully embedded into practice include: deployment of large interstate and international contingents, municipal emergency coordination and liaison arrangements, communications infrastructure, logistics of catering and large base camps, local community engagement during fires, briefing culture, safety and survival skills of fire personnel, safety advisor role and incorporation of local knowledge. Areas where improvements have been made, but where there is benefit for further improvement include: the establishment of the integrated Emergency Coordination Centre (iECC), Incident Action Plan processes, shift changeovers, adherence to communications plans, mapping, management of non-combatants on the fire ground, OHS incident reporting, fatigue management and compatible CFA and DSE systems and processes. In some areas, improvements from recent past fire seasons were tested by the unprecedented fire conditions of rapidly moving fires affecting many communities. These include: coordination of multiple Incident Management Teams, the Victorian Bushfire Information Line established following 2002/2003 season, information flow to the community, role of 000 in dispatch and traffic management. While there were many successes achieved in the 2008/09 fire season, the focus of this report is on the problems that can be addressed by CFA and DSE as part of the continuous improvement process. A risk analysis identified 46 standard topics as being in the High Risk category. An analysis of the debrief reports for each of these High Risk issues resulted in 18 key issues being identified. A workshop attended by nominated representatives of CFA and DSE developed detailed actions and timelines to address each of the 18 key issues. The 18 key issues were:

1. Improve the integrated function of iECC, CFA and DSE state wide coordination and strategic planning.

2. Ensure appropriate arrangements for liaison and coordination when multiple IMTs are in place, including division of control in a fast moving fire across administrative boundaries

3. Develop systems for well prepared and strategically located joint Level 3 ICC facilities.

4. Develop sufficient preformed IMTs to match extreme conditions. 5. Continue to improve cooperation between CFA and DSE personnel. 6. Better integrated and compatible parallel CFA and DSE systems and procedures. 7. Improve the timely and adequate information flow from IMTs to iECC, VBIL and the

community. 8. Develop systems for efficient information flow from the fire ground, including aircraft,

to IMT.

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9. Improve and make more concise Incident Shift Plans, including maps prepared by IMTs for the fire ground.

10. Ensure clear reporting and management processes for OHS incidents, particularly with international / interstate crews.

11. Minimise injuries and near misses due to falling limbs and trees. 12. Clarify implementation of fatigue management guidelines and minimal breaches of

guidelines in first shifts. 13. Consistent understanding of the most suitable function and location of Divisional

Commander role. 14. Ensure sufficient skilled personnel to manage fire line situations including

communications, personnel and plant complexity 15. Improve management of contractor plant. 16. Better adherence to communications plans and incorporating planned use of UHF

radios. 17. Improve efficiency of shift changeovers and adequate briefings. 18. Consistent application and management of road closures that allow access of fire

personnel and prevent unauthorised access for non-combatants.

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2. INTRODUCTION The purpose of this report is to;

describe the debrief process that was applied following the fire season; summarise the range of issues identified; outline the actions and timelines.

Fire debriefs were conducted in accordance with the Code of Practice for Fire Management on Public Land 2006 (Revision 1 DSE 2006) and the DSE Guidelines, Fire Management Manual 9.1, Recovery, and the Joint CFA/DSE Partnership Guidelines – Performance Monitoring Improvement. The 2008/09 Victorian fire season included 29 significant bush fires with 13 of these occurring on the 7th February 2009. Now known as Black Saturday, this conflagration is the most significant bushfire event in Victoria’s history and Australia’s worst natural disaster. This report is focused on the whole of the 08/09 fire season, not just the events of Black Saturday. The debriefing process provides an opportunity to capture learnings on safety and effectiveness by reviewing all aspects of the fire suppression including identifying where improvements are possible. The learnings are then used to update or amend existing practices. Debriefs are one important source of information for CFA and DSE to consider when identifying areas for improvement. Other information available to CFA and DSE, including that arising from the Victorian Bushfires Royal Commission will also be relevant in determining changes that can be made to improve the operations of CFA and DSE and the service provided to the community of Victoria. The style of debriefing reflects the scale and complexity of the fire suppression effort and may range from a single brief, structured discussion between fire fighters and their supervisors on completion of routine fire control operations, to a detailed debriefing following a major incident. For large or multiple incidents involving many crews and or other agency personnel, a series of debriefings are conducted. In total, 176 debriefs were considered in the preparation of this report from CFA, DSE and its Network Emergency Organisation partners (Parks Victoria, Melbourne Water, Department of Primary Industries, Department of Planning and Community Development and VicForests) and interstate and international fire agencies that provided support to Victoria. In many cases debriefs were conducted jointly by the agencies. Single agency debriefs also occurred ranging from crew levels through to functional groups that operated in various IMTs and at the iECC. These culminated in six joint agency regional workshops where key issues were raised and discussed. The out workings of the regional workshops were considered in the identification of the key issues. This report identifies operational issues impacting at the whole of state level. It does not discuss every individual matter raised, many of which can be, or have been addressed at the local level. Some issues may have been raised by CFA and DSE personnel with the Victorian Bushfire Royal Commission that CFA and DSE are not aware of. For that reason, this report is an important but not the only source of information available to the Chief Officer CFA and the Chief Officer Fire and Emergency Management DSE in considering changes and improvements to be made. Many personnel from CFA, DSE and its NEO partners have contributed to the debriefing process and their commitment is highly valued particularly when many were involved in the recovery processes, planning burning activities and day to day business of their respective organisations following the fire season.

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3. 2008/09 FIRE SEASON

3.1 Antecedent conditions The 2008/2009 joint CFA-DSE pre-season regional briefings, highlighted that South-Eastern Australia remained in the grip of more than ten years of drought. Data provided by the Bureau of Meteorology (BOM) showed that Victoria experienced below average rainfall when viewed over the last three years, last 12 months and last three months. Stream flows (indicators of underpinning dryness) were mostly below 10% of the long term average. The BOM communicated in briefings, was for a neutral rainfall outlook with warmer than average temperatures for South-Eastern Victoria. September and October were very dry months. Spring rainfall totals were below the long-term normal range in most weather districts. There were some good rains during November. Across the State, stream flow levels decreased. From September to November, daytime temperatures were above average in most districts. In some areas, the November rains produced some new growth however pasture was recorded as substantially dry in South West, North Central, and Northern Irrigation regions. By the end of November 2008, Fire Danger Periods had been declared in all municipalities in country area of Victoria. December 2008 was abnormally cool and wet across most of Victoria. Temperatures across the State were about 2 ºC below normal. Many sites in Victoria exceeded their usual December rainfall by more than 25%. Some areas in the south-west of the State received the highest total December rainfall in 20 years. This rainfall led to new vegetation growth. During January 2009, most of the State returned to conditions described as very dry and, at the end of the month, as very hot. The vegetation growth from the rain in December dried out completely. Fuel loads were at very high levels. The last week of January 2009 was exceptionally hot. For example, in Melbourne, temperatures over 43 ºC were recorded on three consecutive days – 28th (43.4), 29th (44.3) and 30th (45.1). Eight Total Fire Ban days were declared in January 2009. Following the January heatwave, a weak change brought some relief, mostly to southern coastal areas from 31st January onwards. However, inland areas remained very hot until 5 February. For example, Bendigo recorded daily maximum temperatures (in degrees Celsius) of 40, 35.5, 34.5, 37 and 40.2 between 1st and 5th February. In early February 2009, weather predictions showed extreme fire danger for the State on 5th and 6th February. The extended weather outlook identified 7th February 2009 as a day of particular concern. The forecast noted that the Forest Fire Danger Index (FFDI) was predicted to be in excess of 80 on 7th February. Very strong winds were predicted, as were temperatures in the low 40 degree Celsius range. FDls were expected to peak early in the day. A cooler change was predicted for the late afternoon, with a marked temperature difference, but strong winds. The three day BOM forecast included predictions of FDI levels of 328 for 7th February 2009. The scale of this weather was potentially unprecedented and prompted CFA, DSE Fire and other emergency services to issue warnings to the Victorian community, through press conferences and media releases. This included urging people to avoid all unnecessary travel and the Premier of Victoria making a public announcement. On the 7th February 2009, Victoria recorded its highest official record temperature of 48.8 degrees Celsius at Hopetoun in western Victoria, while Melbourne recorded a maximum temperature of 46.4 degrees Celsius. Northerly wind gusts were reported at 115kmh.

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Following the early February heatwave temperatures moderated with only two days exceeding 30 degrees Celsius, those being the 23rd and 27th February 2009. Both of these days were declared Total Fire Ban days. The mild weather experienced for the remainder of the month following 7th February assisted greatly in controlling large fire perimeters without substantial addition to fire areas.

3.2 Significant fire incidents Table 1 shows fires attended by CFA and DSE which fall within the significant incident category based on potential community impact, size, location or suppression difficulty and on which most of the comments in the debrief data are based. During the declared fire danger period CFA fire & incident reports indicate a total of 41280 fires and incidents were reported to CFA of which 7109 were grass and scrub fires1. During the same period, DSE was the control agency for 825 wildfires.

1 CFA CAD data for the period 01/11/2008 – 01/05/2009

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Table 1 Summary of significant incidents

INCIDENT NAME START DATE CFA

R

EGIO

N

CO

NTR

OL

AG

ENC

Y TOTAL AREA

BURNT (ha)

LOSS AND DAMAGES

Hazelwood Open Cut Mine 14/9/2008 R10 CFA

Sunset 30/10/2008 R18 DSE 10000

Dereel 12/11/2008 R7 CFA 10

Seaford 20/1/2009 R8 CFA 5 Langwarrin 21/1/2009 R8 CFA 12

Drummond North 22/1/2009 R2 CFA 300 Woodend 22/1/2009 R14 CFA 193 Merton 27/1/2009 R23 CFA 40 Delburn 28/1/2009 R10 CFA 6440 30 houses Branxholme 29/1/2009 R5 CFA 475 Lysterfield 30/1/2009 R13 CFA 40

Bunyip 4/2/2009 R8 DSE 26,300 24 dwellings, 50+ sheds, 1 factory, 6 caravans Dargo 6/2/2009 R10 DSE 13640 Murmungee / Beechworth 7/2/2009 R24 DSE 32,300 2 fatalities, 29 dwellings

East Tyers-Thomson 7/2/2009 R9 DSE 1778 CFA Kilmore East /

Murrindindi 7/2/2009 R12 DSE255,300* 159 fatalities, 1639 dwellings

Vectis 7/2/2009 R17 CFA 2,200 13 houses

Coleraine 7/2/2009 R4 CFA 775

Weerite 7/2/2009 R6 CFA 1,300

Churchill 7/2/2009 R10 CFA 24,500 11 fatalities, 247 dwellings

CFA Redesdale 7/2/2009 R2 DSE

9,500

Harkaway 7/2/2009 R8 CFA 180

Upper Ferntree Gully 7/2/2009 R13 CFA 1 House

Maiden Gully 7/2/2009 R2 CFA 330 1 fatality, 58 houses

Lynbrook 7/2/2009 R8 CFA 34

Wilsons Promontory 9/2/2009 R9 DSE 25200 Muskvale 23/2/2009 R15 CFA 2813 Upwey 23/2/2009 R13 CFA 350

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Figure 1 Location of major fires

Source cfa.vic.gov.au/about/documents/2008_2009_Fire_Season_Overview_Map_A3.pdf

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4. DEBRIEF PROCESS

4.1 Purpose of Debriefs The CFA and DSE Partnership Guidelines (Performance Monitoring and Improvement) state that:

(a) All joint incidents will be the subject of a debriefing, ranging from informal to joint debriefing of all Level 2 and 3 incidents. The purpose of the debrief will be to document and resolve all outstanding issues for participants; to identify success factors for future reinforcement and service improvement; and to identify potential for rectification and improvement of future operations. (b) Systematic analysis of operations in significant joint incidents will be conducted to recommend improvements to future operations as agreed by both Agencies. (c) DSE and CFA will develop agreed protocols for action, operation and reporting of a range of performance review programs and these will be implemented in partnership.

The operational debrief process is designed to enable CFA and DSE to review and assess their performance in preventing, preparing and responding to fires. It also assists in identifying areas for improvement from local through to state level.

4.2 Conduct of Debriefs

4.2.1 Local debriefs The range of local debriefs included:

o CFA Brigades, Groups and Regions o DSE Work centres, Districts and Areas o Incident Management Teams for significant incidents o Regional Coordination Centres o Integrated Fire Agency Coordination Centres o Integrated Emergency Coordination Centre Units o Communications Units o Occupational Health and Safety Units o State Aircraft Unit o Information Unit o Interstate/International Agencies

The State Aircraft Unit (SAU) debriefs have been collated and analysed in a separate report, State Aircraft Unit Victoria Debrief of 2008-2009 Fire Season. In response to this report, the SAU will prepare an implementation plan. Only issues which impact beyond the SAU have been considered in this report. At each debrief, participants were asked to identify (a) ‘Things that went well’ (i.e., should be retained and strengthened), and (b) ‘Issues that need improvement’ (or changed). Participants were asked to consider all aspects of the operational response, including preparedness, deployment and ongoing support at the home location and not just the incident. After extensive discussion at debriefs, participants were asked to record their findings on the Debrief Record Sheet (Joint Agency Incident Management Toolbox 2008/09 version) and the

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final records were collated by the State Debrief Coordination Team. Participants at debriefs were encouraged to engage in frank discussion without laying blame or criticising performance. This is a strength of debriefs as it allows all to participate freely. It is also the case that some views expressed by individuals may not be debated or validated by others or reflect a consensus view. It was therefore the role of the State Debrief Coordinators to consider the issues and synthesise them in this report. Local debriefs were largely completed by 20 April 2009.

4.2.2 Centrally Coordinated Debriefs (Regional Workshops) After the completion of local debriefs, six regional workshops were convened by the 2009 State Debrief Coordinators where issues of strategic importance raised at field debriefs were discussed among invited personnel. About 40 personnel were invited to each regional workshop, taking into account their participation in fire fighting operations and strategic issues that they may have identified as requiring discussion. The regional workshops were held between 11 and 29 May 2009. Like other debriefs, participants considered issues in relation to two main focus questions – ‘What worked?’ and ‘What didn’t work?’ Following extensive discussion, participants were asked to identify what they thought were priority issues and group these into themes. These were recorded and forwarded to the State Debrief Coordination team. At the conclusion of each workshop, participants were asked to identify issues that they could move forward on immediately and develop an action plan for local implementation. Debriefs from which reports were received and analysed by the State Debrief Coordination Team are listed in Appendix 1. A number of individual Brigade, Group, District and Work Centre debriefs are included in addition to the Region, Area, IMT and functional unit debriefs.

4.3 Collation of Data Completed debrief reports were received and the matters raised were transferred to a database to facilitate efficient management and analysis of the debrief data. The structure and content of the database used is outlined in Appendix 2.

4.4 Identification of Issues To assist with the identification and description of the major issues emerging from the debrief data, a list of standard topics previously developed to analyse debrief data for the 2002/03 fire season (Woodman & Roughead, 2003) was used. These Standard Topics are described together with examples of inclusions and exclusions in Appendix 3. During the process of examining the database and assigning the Standard Topics, it became necessary to develop four additional Standard Topics to accurately reflect the specific issues reported. These additional Standard Topics were Coordination Centres State – induction/training, Coordination Centres State – staff engagement/ rostering, VBIL and Undetermined. Each debrief entry (record) in the data base was then assigned to a Standard Topic.

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A search of the database was then conducted to locate all the entries (records) for each Standard Topic that related to ‘Areas that needed improvement’ and ‘The things that went well’. These records were examined to identify the common problems and the significant but less common problems for each Standard Topic.

4.5 Risk Analysis Each Standard Topic was assigned a risk rating according to the combined likelihood and consequence of the problems identified in the debrief process. The consequence of the problem was assessed against each of five consequence areas of: financial, human, business interruption, environmental and reputation and image. The risk analysis process used is consistent with AS/NZS 4360:2004 Australia/New Zealand Risk Management. The risk assessment matrix is in Appendix 4. The risk rating of all Standard Topics for the 08/09 debrief is included as Appendix 5.

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5. Summary of debrief issues This section summarises the problems and successes identified in the analysis of the debrief reports in relation to each Standard Topic (see Section 4.4). In cases where only a few comments were received or minimal problems were raised, the Standard Topics have been combined and described together. Greater emphasis is deliberately given to problems rather than successes in order to identify potential sources of improvement. Comments have had to been taken as received without judgement or validation.

5.1 Accommodation 1. Accommodation at fire

There was generally favourable comment regarding the quality of accommodation, particularly from interstate and international teams. It was not possible to provide motel standard accommodation for all fire personnel close to the fire. This highlighted issues in relation to travel time and less comfortable camp accommodation, such as the standard of bedding, tents and ablutions (hygiene), and the difficulties of sleeping due to noise resulting from aircraft, fork lifts, trucks and foot traffic. The considerable effort required to establish base camps was not always appreciated.

5.2 Air Operations 2. Air Ops - airbase operations 3. Air Ops - coordination State/Regional 4. Air Ops - deployment/tactics 5. Air Ops - standards

State Aircraft Unit conducted a series of debriefs around the state and engaged an independent person to facilitate those sessions and recommend actions for improvement in a separate report. The following issues arise from debriefs of generally non - aircraft unit personnel. Aircraft operations were free of major safety incidents and provided valuable support to ground crews in asset protection and fire suppression. Fire ground personnel experienced difficulties in communication with aircraft, possibly due to the amount of radio channels monitored at any time by aircraft. Logistics sections at times were not able to service the needs of aircraft in the required timeframe. Communications between Air Operations and Operations could have been better in understanding limitations on aircraft use and in obtaining best value from aircraft. Some interstate personnel felt their air operations skills could have been better utilised.

5.3 Briefing 6. Briefing - process 7. Briefing - standards Briefings were of adequate content and frequency but could take a lot of time at the start of a shift which slowed crews getting to the fire line. The use of the SMEACS briefing format was well received. There were cases of some crews missing out on a briefing, particularly for swing shifts and during hectic times. The most important briefings were considered to be the briefing on arrival at a fire and changeover briefing on the fire line with outgoing counterparts. The inclusion of specialist advice in briefings was appreciated.

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5.4 Catering 8. Catering - food standards and quantities 9. Catering - processes Quality and quantity of catering often undertaken by contractors, was good, although there were some comments on delays in delivering food to the fire line, the catering for special dietary needs and the lack of variety in base camp drinks.

5.5 Coordination Centres 10. Coordination Centres Regional - role/procedures 11. Coordination Centres Regional - standards and facilities There were differing views regarding Regional coordination. Concerns were raised relating to communications from the RECC to groups; putting together strike teams to go away; inadequate use of volunteers in the RECC; and the ‘000’ overflow impact. The lack of space and the layout of facilities were reported as problems, as well as the inability of ‘phone and IT systems to cope during operations. The lack of resources such as data projectors and photocopiers was reported to be a problem at specific sites. There were few concerns raised in relation to CFA or DSE RECCs. February 7 highlighted their crucial role in mobilising and assisting IMTs at ICCs until an IFACC was established. February 7 also highlighted the need to clarify the roles of RECC and iECC in the division of control of a fire that rapidly moves beyond the reasonable control of an IMT and into an area where a further Division or IMT could be established. The function of Municipal Emergency Coordination centres (MECCs) received less comment than in the past. While their role is generally better understood, they were clearly focussed on community recovery after February 7. Where one ICC covered a number of MECCs, a single liaison person was able to represent all relevant MECCs. DSE’s panel contract for plant reduced the need for MECC involvement in plant engagement. Management of road closures was a significant issue, given the extensive road network in fire areas, management of local and fire ground traffic and crime scene requirements as well. 12. Coordination Centres Regional - IFACC There was poor understanding of the relationships between the roles of ICC, RECC, IFACC, MECC and iECC, leading to confusion around the most appropriate application of the IFACC role.

13. Coordination Centres State - induction/training 14. Coordination Centres State - role/procedures 15. Coordination Centres State - staff engagement/rostering 16. Coordination Centres State - staff roles 17. Coordination Centres State - standards/facilities The operation of a joint iECC was initiated for the 2008/09 fire season, located in the former DSE ECC at Nicholson St. It was tested by the events of February 7 and the following weeks. The facility was cramped and noisy due to the numbers of staff involved from CFA, DSE, and a range of support agencies, along with media interest. The volume and tone of feedback comments in relation to working in the iECC pointed to a lack of consistency in IT and ‘phone systems, procedures and roles, particularly at the State Duty Officer, State Coordinator and Chief Officer level in both CFA and DSE, which made it difficult for staff to work together efficiently in areas of logistics, resources, situation and planning.

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In a significant and prolonged emergency situation such as experienced in 2008/09 a large number of staff were introduced to and rotated through the iECC. The constant turnover and lack of experience drew comments from those regularly dealing with the iECC on the need for pre season, training and scenario exercises and thorough induction. Identification/security ID of people (iECC staff and people moving through the iECC), and the building (daily passes, name tags, security of server room) were also identified as concerns.

5.6 Debriefing 18. Debriefing standards and processes Thorough debriefs were not always conducted at the end of the shift within teams, and between teams and the IMT. There was a view that previous post fire and season debriefs have failed to address perennial issues.

5.7 Environmental/Cultural Impacts 19. Environmental/Cultural Impacts There is apparent conflict between the retention of vegetation and fire protection requirements, particularly along roadsides. Environmental values need to be considered by IMTs during fire suppression, and works at the time need to be recorded to inform recovery works undertaken following the fire. Vehicle hygiene was readily ignored during fire operations. The inclusion of culturally sensitive areas identified on maps was favourably received.

5.8 Financial 20. Finance and Accounting – processes Purchase order processes need to be better communicated and adhered to in the various agencies. Reimbursements of money during operations should be delegated, operational arrangements with suppliers should be reviewed (e.g. for bulk purchases), finance personnel should be incorporated at the iECC and ICC at an early stage, and efforts should be made to move to an electronic system for financial transactions. Corporate card spending limits were easily exceeded at the height of operational activity and cost recovery for volunteer’s out of pocket expenses (e.g. ‘phone calls, travel, and food) through the petty cash system was overtaxed by constant use.

5.9 Fire fighting equipment 21. Fire fighting equipment – maintenance International / interstate crews appreciated the support they received in the provision of vehicles, equipment and maintenance. An appliance fault list being maintained at staging areas, and the pre-location and operation of CFA District Mechanical Officer resources worked well. In some cases appliances and equipment returned from the fire ground in poor condition at shift changes and to home base.

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22. Fire fighting equipment - security standards 23. Fire fighting equipment – standards The new design appliances with features such as twin cabs, diesel pumps and crew protection systems, the use of private appliances, bulk water tankers, thermal imaging cameras and quick fill pump were all well received. There was dissatisfaction with the manoeuvrability and lack of power of Nissan Patrol vehicles, the lack of GPS in DSE vehicles, non-emergency vehicles without radios and contractors with no emergency warning lights were reported. It was also mentioned that LED emergency warning lights were too bright when travelling in convey or working near them at night.

24. Fire ground - identification and signage Instances were mentioned of fire ground crews not wearing tabards or having their role identified in some way, inadequate fire ground signage for roads and water and emergency vehicles being used without lights or markings, and not fitted with radios. 25. Fire ground Supervision - non combatants Non-combatants were less of a problem than in previous seasons. Management of media crews on the fire ground was still a challenge, including the need for escorts. Some media on the fire ground took advantage of their agency issued personal protective equipment (PPE) to gain unauthorised access to the fireground. Ambulance access to the fire ground was inconsistent. Some accessed the fire ground without an escort, while others would not attend unless an escort was provided.

5.10 Incident Management 26. Incident Management - AIIMS – Processes 27. Incident Management - AIIMS – Roles 28. Incident Management - AIIMS – Structure The AIIMS system is generally well understood, so there were few concerns with its application. At the height of the fire season, the number of IMTs in operation at the one time led to larger than desirable size sectors and divisions. The size of IMT was not always matched to a changing fire situation. Many sector commanders and strike team leaders thought that IMTs showed a lack of confidence in them by not delegating decision making to them. Back burning was used as a common example. This is possibly a reflection of lack of poor information flow between fire ground and IMT. Information flow from Operations to Situation Unit was enhanced by having Situation personnel in the Operations room. There is confusion around the most appropriate use of Division Command and Operations Points. CFA tend to use fire stations or Group HQ as Division Operations Points as fires scale up. DSE tend to use Division Commanders when the number of sectors dictates, and they operate mobile rather than from a fixed location. Both models work well in certain situations. While there are concerns about Division Operations Points working in isolation as mini IMTs, they can overcome some of the problems associated with distance of IMT from the fire ground, particularly where co-located with a base camp. The Safety Advisor role continues to be variously applied along with its relation to the Medical Unit. Medical units appeared over resourced until an incident occurred.

29. Incident Management - changeover briefings and processes 30. Incident Management - changeover fire ground/staging area

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31. Incident Management - changeover ICC Changeovers worked better than in recent seasons, possibly due to fires being less remote from ICCs. Changeover crews were however often delayed getting to the fire ground. Time was consumed with IMT briefings resulting in rushed changeover briefing on the fire ground due to outgoing crew fatigue management requirements. Changeovers worked well where the sector commander arrived at the fire ground and were briefed before crews arrived. Crews were reluctant to depart the fire ground if fire was active, and particularly if replacement crews were not in place. Quality of briefings both on fire ground and in ICCs was variable, in part due to the time available. Bussing strike teams to the fire ground allowed tankers to stay on the fire ground. Concerns were raised about changing over in the dark, particularly when new to the sector. Length of change over due to distance from base to fire ground, and changeover of both day and night IMTs on the same shifts were less prevalent than in previous seasons. Swing shifts assisted in retaining fire ground continuity during normal changeover periods and allowed crews to become familiar with the fire ground in daylight.

32. Incident Management - Communications Plan – adherence 33 Incident Management - Communications planning Communications plans and planners were well established at most incidents. Fire personnel became frustrated though when they could not communicate by radio either due to the amount of radio traffic that occurred at active times, or when designated channels in the communications plan were not effective due to black spots. They then reverted to whatever worked, be that “go to” conventional channels, trunking, mobile phone, or UHF radio. The expanding coverage of mobile phones has actually freed up radio by less use of trunk radio, but complicated communications planning. UHF is widely used by plant contractors. In the absence of sufficient trunk radios, mobile phones and UHF radios need to be considered in communication plans. There were instances of insufficient portable radios to allow for communication for crews away from vehicles. 34. Incident Management - continuity objectives and strategies 35. Incident Management - coordination and management of personnel 36. Incident Management – demobilisation International and interstate crews were generally pleased with their demobilisation arrangements. The need to capture IMT documentation including logbooks in an orderly manner was emphasised. Some large base camp establishments required considerable time and resources to effectively close down, pack up and appropriately rehabilitate the site. 37. Incident Management – Incident Action Plan (IAP) standards and processes IAPs were generally of a high standard, timely and adaptable to changing circumstances. At times there was too much detail in IAPs and not enough IAPs to go around. The recent development of the briefer Incident Shift Plan (ISP) form of the IAP was not broadly adopted for the 2008/09 season, possibly due to concerns about not having maximum possible information and technical problems in using the joint agency ISP template. Due to time constraints, up to date and high quality IAP maps were a common concern and are addressed in more detail elsewhere. There were challenges in delivering IAPs and ISPs to Division Operations Points. Portions of the ISP could be better prepared at Division level without duplicating IMT functions.

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38. Incident Management – ICCs ICC facilities often did not fully cater for IT, telephone, privacy and close access for the entire IMT. At times of high fire stress IT and phone systems struggled to cope. Noise was a common issue particularly around radios. The mechanism for transfer of fire control to another location when a fire crosses a certain “boundary” proved difficult and needs review. An instance of a necessary change of location of ICC during a fire was a stressful task for those involved. 39. Incident Management - integration of local knowledge While local knowledge was actively incorporated into IMTs, many comments were still received about local input being ignored by IMTs and Sector Commanders, particularly when the control agency was DSE. Local guides for visiting strike teams for their first shift at least were appreciated. 40. Incident Management - interagency integration The emergency agencies generally worked well together, especially where the agencies had worked together on preparedness activities. This extended from DSE and CFA to also include SES and VicPol. There were negative comments from CFA generally at Group level in relation to DSE when DSE was the control agency for a Level 3 incident. 41. Incident Management - management of local resources Fire fighting personnel whose homes and families were impacted by fires were carefully managed, given that they still wanted to be involved with fire response. In one instance after the first week, local strike teams were placed on standby to deal with flare ups. Local group liaison in IMTs was of considerable assistance to visiting IMTs. Excessive shift lengths and self deployment of local resources did occur. 42. Incident Management - objectives and strategies 43. Incident Management - resource coordination plant equipment 44. Incident Management - split IMTs/Strike teams/resources Strike teams were often tasked to an incident or sector, and then not fully utilised. This led to some self deployment where a need was identified elsewhere. Army crews were difficult to fully utilise due to their lack of appropriate fire fighting accreditations, and coordination of industry brigades was at times affected by their focus on the protection of their forest assets. 45. Incident Management - staging area standards 46. Incident Management - staging areas procedures Staging areas generally worked well. Time was lost with staging areas located at considerable distance from the fire ground, pressure on refuel facilities at shift start and IMT briefings. More “hot changeovers” on the fire ground using shuttle buses was suggested as a way of saving time. Co-location with base camp contributed to noise while crews were trying to sleep. District Mechanical Officer requirements and PPE stores were not always part of staging area planning. 47. Incident Management – tactics The number of fires that were contained on the 7th February reflected strategies of strong initial attack. The use of Fire Behaviour Analysts; existing fire breaks and thermal imaging cameras assisted IMTs.

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There were sometimes differences between the strategies of day and night shift IMTs. Day shift IMTs are larger due to air operations and information requirements, and consistency of strategy occurred where day shift IMT set the fire strategy and the night IMT performed a valuable complementary role, but were often able to achieve much in operations and planning when fire activity was quieter. 48. Incident Management - traffic management VicPol responded well to unprecedented demand for road closures to be implemented during fire escalation. There was a deal of frustration at the inconsistent and sometimes very restrictive application of crime scene full road closures and partial road closures, which prevented residents and fire fighters returning home, and plant contractors and power company personnel getting to work. A road block pass system organised for contractors at one IMT with approval delegated by the Incident Controller, worked well. The extensive road network under closure meant that not all roads could be secured and motorists with satellite navigation instruments could find often unsafe detours. Internal traffic management should have been implemented where a fire control line that was also access to other sectors carried a lot of traffic under often smoky conditions.

5.11 Information Flow 49. Information Flow - community awareness The feedback from CFA and DSE personnel was that the fire agencies relationship with the ABC, well conducted and resourced community meetings, use of community radio stations and the use of technology such as Facebook were appreciated, but on 7th February there was inadequate, inaccurate or outdated information to the community about the locations of fires and their potential impacts. This was complicated by varying information about the same events from different sources (e.g. police, radio callers, DSE/CFA, iECC). There were concerns about the importance given to the provision of community information within ICCs and the resourcing required to adequately run an Information Unit. It was felt that the attendance of Operations staff at public meetings would have assisted public confidence. 50. Information Flow – Emergency Services Telecommunications Authority (ESTA) Pager systems were reported to be too slow or completely failed. Multiple messages were received for the same incident, and some brigades were paged when they had no available resources. The volume of calls on the 000 system led to unanswered calls. ESTA operators were said to be very busy and hard to understand. A failure to ask sufficient questions led to calls being misdirected by ESTA. After hours calls to DSE locally from ESTA for fires on public land were not received.

51. Information Flow – Victorian Bushfire Information Line (VBIL) The main challenge reported was a perceived ‘breakdown’ in information flow between the iECC and the VBIL in terms of tracking queries and answers, and handling high volumes of queries. It was also noted that VBIL was not accessible from outside Australia. 52. Information Flow - fire ground to IMT Information that was available, or should be known on the fire ground did not get to the IMT in some cases. This was considered due to ICCs being too remote, or Divisions or sectors too large, or IMT members not sharing information. An inability of

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the fire ground to contact IMT/ICC because telephones were engaged or not answered, or radios were congested, was also reported. 53. Information Flow - from IMT There were reports that some IMTs did not provide sufficient information to the MECCs, RECCs, groups and the local community. Divisions, Sector Commanders and staging areas reported the same problem. Concerns were also raised regarding information flow between adjoining IMTs. 54. Information Flow - from media There were complaints from CFA and DSE personnel that the media distributed unsubstantiated information (‘myths’) which confused the public. ABC radio mixed emergency information with callers from the public, therefore confusing its role as an emergency information provider and a talk back radio program. 55. Information Flow – interagency Several systems provided information leading to different versions of the same event. The currency, detail and variety of the information reflected inefficiencies. 56. Information Flow - IT systems Computer access was expected at all sites as basic personal working tool. Different CFA, DSE, Parks Victoria and Melbourne Water Web and IT systems led to problems with login (access) to applications and extra time and effort in information exchange. Numerous sources and versions of information made information flow more difficult than it should be. 57. Information Flow - to media

Feedback suggested that the Media and Information personnel need to be physically located together within the information unit. Media personnel need to be managed by CFA/DSE staff, which can place extra strain on available resources. Spokespersons should be the preferred source of comment to the media rather than involving senior incident management personnel. The use of CFA and DSE spokespersons talking about the same fire can risk mixed and inconsistent messaging. Many specific issues regarding the media and information management in the iECC were reported. A common request from the media was for information on the total resources (appliances, crews) committed to a fire, but this was often difficult to provide. It was also noted that ABC radio advertised an 1800 number and hotline but this went unanswered. 58. Information Flow - within IMT Communication within an IMT was awkward where some IMT members were located in another building, or from Operations to Information / Situation Units (Planning), particularly when trying to capture mapping information. Staging areas and base camps were often left out of the information flow channels.

5.12 International/Interstate 59. International/Interstate induction and deployment International/interstate crews provided a significant ongoing contribution to fire suppression resources. They were keen to be brought up to date with local differences in fire management, geography and culture so that they could do the best

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job possible. The scale of deployment of visiting crews represented a considerable liaison role at iECC and at ICCs. The non-specific nature of resource requests made it difficult to match resourcing with tasks. Also, it was suggested that International/interstate Liaison Officers needed to be assigned to IMTs and embedded in the strike team. Briefings tended to vary significantly between crews and needed to match the tasks and expertise within the crews. For instance, the briefing for the Burned Area Emergency Response team (BAER) should be different to that given to fire fighters. Local knowledge was not always available for interstate/international crews; and the introduction of some interstate/international crews to the fire line after dark was a concern. Assistance with the passage through customs, general logistic arrangements, issue of telecards, rosters and rotations, integration with local crews and use of the buddy system were all appreciated by international crews. The most challenging aspects to become familiar with included: the CFA/DSE relationship, CFA/DSE land tenure, how Victorian IMTs are chosen, Victorian terminology, Australian expressions (slang), FDI and how it works, Victorian road rules, and Australian creatures that bite. Both international and interstate crews were limited by their knowledge of CFA appliances and particularly safety systems, trunk radios, and induction for non-operational roles. Fatigue management guidelines made smooth interchange of interstate taskforces with varying tour lengths difficult.

5.13 Legal 60. Legal Personnel were concerned about their legal position in relation to: the management of records (collection, collation, and note-taking), the road worthiness of DSE slip-ons when unloaded due to 600 kg minimum load capacity, the recognition of DSE vehicles as emergency vehicles, and the Chief Officer’s powers of delegation to interstate agency personnel.

5.14 Mapping 61. Mapping - standards and processes As the ability to produce large quantities of tailored high quality maps has increased, so have expectations of users. There were many complaints about the availability and quality of maps, as well as the extent of detail (too much or too little). The accuracy of large scale maps was often compromised in order to give broader coverage at smaller scale. The lack of a single CFA/DSE mapping system was noted, and it was reported that deficiencies existed in GIS mapping systems, particularly DSE Firemap. Also, there were no operating manual to guide external mappers / GIS operators. Mapping could have been assisted by more GPS units, both handheld and satellite navigation units for vehicles; and reinstatement of property owners’ information in CFA map books and directories.

5.15 Occupational Health and Safety 62. OHS - briefings/safety officers There were some concerns raised other than the inconsistency between fire agencies other than CFA and DSE in relation to the use of field safety advisers, and that the safety component of briefings was taken more seriously after significant incidents occurred.

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63. OHS - fatigue – general 64. OHS - fatigue - Tour of Duty standards 65. OHS - fatigue - work shift standards The scale of fire activity on 7th February highlighted the impact of many personnel working a stressful long first shift overnight. Revised DSE fatigue management guidelines were not universally well understood and considered difficult to implement.

66. OHS - near miss incidents Reporting of OHS incidents including near miss incidents occurred, but there were difficulties in carrying out investigations on all reports. CFA and DSE use the same field reporting cards but do not have compatible electronic follow up recording systems. Falling trees caused serious injuries and were also responsible for a considerable number of near misses.

67. OHS - safety first culture 68. OHS – standards There is a strong culture of safety first, although there were a number of reports of unsafe practices generally in relation to vehicles and plant operation. Ambulances were not always able or prepared to access injured personnel on the fire line. 69. OHS - use of welfare personnel CIS peers generally were appreciated, but some concerns that the service was overdone and at times not well coordinated with the medical unit in the IMT. 70. OHS - warnings and warning procedures This issue is confined to warnings to fire fighter personnel, not community. Few comments were received on warnings other than concerns that warnings of a wind change may have been too late, and red flag warnings not getting through on radio or pager.

5.16 Personal Protective Clothing/ Equipment 71. Personal Protective Clothing/Equipment - usage The availability of replacement PPE at staging areas and helmet fitted torches were appreciated. It was suggested that personnel need to come prepared and not rely on base camp stores for personal protective equipment. Visiting crews commented on lax application of PPE.

5.17 Personnel 72. Personnel - availability of accredited personnel Some personnel were considered to be working in positions and at a level for which they were unsuitably accredited, while international and interstate personnel were potentially not used to their full capability and accreditation level. An apparent shortage of accredited personnel in IMT support roles and Information Units was reported. Uncertainty around agreements with DPI and VicForests was also thought to impact on the availability of accredited personnel. Alternatively positive feedback was received regarding the gradual progression from deputy roles to lead roles, e.g. Deputy Incident Controller then to Incident Controller. 73. Personnel - continuity of business

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No issues were raised in debrief reports. 74. Personnel - discipline and personal conduct Many single issues were reported of a local nature. A lack of respect for brigade property, and the personal property of others were reported. The time taken to obtain photographs rather than ‘concentrating on the job’ was also noted. A lesser but perennial problem mentioned was litter left on the fire line. 75. Personnel - ICS roles, systems, procedures No significant issues were reported. 76. Personnel - Industrial awards There was a need for supervisors to recognise various hours of work clauses in Industrial Awards in managing shift lengths. 77. Personnel – leadership

There were instances of strike team leaders and sector commanders focusing on immediate concerns and not managing all issues. 78. Personnel - return to work No significant issues were reported. 79. Personnel – training The implementation of minimum skills received strong support as did the consistency of skills across brigades/crews. Personnel felt a need for more refresher training and exercises. There was an expectation that Information Officers could fill the role of Media Officers and the lack of IRIS operators was reported. 80. Personnel - training communications Poor discipline leading to congestion on radio channels and a lack of training for staff to deal with transferred 000 calls were the key problems reported. 81. Personnel - training driving The lack of 4 wheel drive skills became evident when strike teams from flat country were assigned to mountainous locations. 82. Personnel - training fire behaviour/suppression There was a poor understanding of mopping up techniques, the risks associated with fire suppression near power lines and the value of fire behaviour analysts. 83. Personnel - training ICS roles/systems/procedures AIIMS IMT roles and relationships were not always commonly understood or consistently interpreted, particularly the Information Officer role. There were instances of poorly trained sector commanders and untrained WICEN radio operators.

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84. Personnel - training/induction The only comment was that new people were not well inducted into a wide range of roles and facilities. 85. Personnel - training mentoring/experiential training There was a lack of experienced staff in supervisory roles and an unpreparedness to mentor staff to ‘fast track’ potential leaders in severe fire situations. It was felt mentoring should be embraced and enforced. 86. Personnel - training technical skills/systems DSE crews were not trained in asset protection and structural fires. There was a lack of formal training and accreditation in hazardous tree recognition following fires, DSE staff lacking knowledge of CFA IMS, and ground observers not working for fire behaviour specialists. A lack of skills, experience and confidence to manage contract machine operators on the fire line was also noted. 87. Personnel - welfare issues/miscellaneous There was a high standard of medical support including the provision of massage facilities in some areas and the level of welfare support to crews when injuries occurred. Where fire fighters were involved in the search for bodies there was an unwillingness of some personnel to seek trauma support. Some interstate crews brought with them their own first aid and paramedic support.

5.18 Plant and Equipment 88. Plant/Equipment - management/operating standards Some contract operators were poorly skilled for forest and mountain work, which could be addressed if operators were accredited based on terrain experience and skills. The need for supervision of untrained plant contractors took DSE personnel away from fire fighting duties. Other problems related to incompatible tanker hose fittings (DSE/CFA/Interstate), incompatible dozer engagement (contract) arrangements, contracted operator’s PPE, and the engagement of contractors by other means than through the IMT. Contractors in DSE PPE caused some confusion. It was suggested that more GPS transponders in DSE and contract dozers/excavators would greatly assist tracking of plant. It was also suggested that the management of machinery by sector commanders (not ICC plant unit) needed to be confirmed, and training modules reviewed to reflect this.

5.19 Preplanning 89. Preplanning – communications Most communication issues are raised under Communications planning. Matters that arose before communications plans were put in place included the inadequacy of pagers and phone texting on 7th February. The lack of portable radios and incidence of critical radio black spots are pre-planning rather than Incident communications planning issues. The lack of state wide computer network log-in hampered network access for CFA personnel. Local trunk radios were issued to interstate strike teams and taskforces, which addressed previous season issues of radio compatibility with interstate agencies.

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90. Preplanning – community awareness The feedback from CFA and DSE personnel was that there was generally a poor appreciation by the community of the fire risks of living in rural areas judging by attendance at Community Fireguard and Fire Ready Victoria meetings. Attendance at community fire awareness meetings increased when there was fire in the area. There is concern that the ‘stay and defend or go early’ advice may be questioned given the number of fatalities in the fires. There were numerous comments regarding the extension of CFA’s arrangements with ABC radio to other commercial and community radio networks. 91. Preplanning – Emergency Management Arrangements The role of the MECC and VicPol is not well understood at lower levels in both CFA and DSE. The events of 7th February raised the issue of fire refuges and concern about what instructions to provide to the public. It was reported that relief centres were too close to fire stations and staging areas. ICC footprints and their relationship to Wildfire Response Plans are not well understood. The Defence Forces could have been of better value with appropriate Basic Wildfire Awareness accreditation. 92. Preplanning – facilities There were not enough facilities prepared with suitable space, power, and telephone and internet connections to rapidly serve as ICCs for large and fast moving fires. Many Group Headquarters can serve as Level 1 and 2 ICCs or as Level 3 Division Operations points, but are not suitable as Level 3 ICCs. Some staging areas and base camp locations were limited in their capacity to handle larger scale incidents. 93. Preplanning - fuel management There was evidence of fuel reduced areas of land assisting in fire control over the summer months, and an acknowledgement that there has to be a high level of preparation to take advantage of the burn window in autumn and spring to achieve burn targets on public land. The effectiveness of Municipal Fire Prevention Committees was queried given the municipal impediments to achieving roadside burns and less roadside vegetation works by Vicroads, PV and local government. It was noted that road easements serve as fire wicks as well as habitat links. 94. Preplanning – interagency Most of the issues raised under Incident Management – interagency integration have a significant component that could have been addressed with greater effort directed to pre season pre planning. They relate to systems, procedures, equipment and relationships. SES was helpful in filling a number of roles whilst meeting their own statutory responsibilities. 95. Preplanning – personnel Most of the issues raised under Personnel and resource coordination have a significant component that can be addressed in pre season planning. They relate to training, accreditation, mentoring and resource planning. Pre-planning paid dividends in the successful deployment of “pre formed” IMTs and associated resources. Volunteers could assist in a range of RECC and ICC support roles, particularly community information. An active evaluation of personnel in AIIMS roles would assist in fast tracking succession planning.

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96. Preplanning – procedures Most of the issues raised under State and Regional Coordination – roles/procedures, Incident Management – processes and OHS - processes have a significant component that can be addressed in planning. Feedback received identified issues with the concept of pre formed IMTs, burn over drills, procedural relationship between iECC, IFACCs and ICCs and RECCs. Community warning procedures were considered to be inadequate. Resource escalation triggers were also questioned. 97. Preplanning - resources and equipment Most of the issues raised under Fire fighting equipment and Resource management have a significant component that can be addressed in pre season pre planning. There were requests for more slip on units instead of tankers for mountain fires, chainsaw operators on strike teams, handheld GPS units, handheld radios and Information Unit kits.

5.20 Records Management 98. Records Management There was a lack of conventions around the naming and storing of electronic files (such as ‘L’ drive for DSE). Problems were also reported regarding the management of the Information Unit email, the recording of actions, and issues about the recording of OHS incident reports by members of the medical unit.

5.21 Recovery 99. Recovery - community In areas where significant losses of life and property occurred, local CFA personnel were faced with the huge task of providing initial recovery services as they were the only personnel capable of entering burnt areas. There was distress in the community about obstacles to returning home after the fires and confusion regarding restrictions on entering burnt areas (crime scenes, health hazards). There was also no clear position about letting those residents who had left return to their homes, or those who had decided to stay during the fire to leave and get supplies and return to their homes. 100. Recovery - rehabilitation standards/planning Despite experience in previous seasons, excessively wide cleared fire lines still created a major rehabilitation task. This was considered to have resulted from incident management/tactics and the poor supervision of (contract) dozer operators. There was difficulty in re-establishing old firebreaks when piles of logs were placed at right angles to roads/tracks. When base camps on municipal land were not rehabilitated, this lead to a substantial invoice from the municipality for clean-up works. There was also difficulty in determining whether fences burnt during back burns or wild fires were subject to DSE replacement. 101. Recovery - transition from response Community recovery was able to commence as soon as the main fire had passed and this was supported with good interaction with the community by fire crews. The lack of financial management staff during fires meant that financial matters became a post fire issue. The lack of a clear transition from response to recovery lead to confusion internally and externally. The presence of specialists from the USA

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Burned Area Emergency Response teams highlighted the lack of resources to address the rehabilitation/recovery phase in a fire season like the one just experienced. Response and recovery phases occurring simultaneously meant that Department of Human Services and MECC personnel were involved in human welfare matters while the fire response was in progress.

5.22 Resource Management 102. Resource management – systems Separate agency resource tracking systems complicated matters for IMT Resources teams along with inconsistent use of IRIS and “T” Cards and the pilot Resource Tracking system. The logistics function and stores were well managed, although the procurement process was long and convoluted and both agencies found it difficult to fill logistics roles over a long period. Accounting for assets during and following de-mobilisation of some ICCs and Base Camps was difficult.

103. Resource management – transport Transport and logistics arrangements generally worked well with some delays still experienced. There was concern where Strike Team Leaders did not travel on buses with their team which hindered good communications. Baggage limits were considered too light for fire fighting PPE and where crews were travelling by commercial aircraft.

5.23 Undetermined 104. Undetermined This categorisation (code) was applied when records (entries in the database) contained insufficient information to enable the problem (issue) to be determined.

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6. RESPONSE TO DEBRIEF ISSUES Forty six Standard Topics received a high risk rating according to the severity of the problems grouped under each Topic. The problems under these high risk Standard Topics were examined further to identify key issues, as problems were often raised under more than one of the 104 Standard Topics. The outcomes of the regional and other state wide workshops were incorporated into this exercise, where they identified both issues that could be acted on immediately at local field or unit level, and priority issues for consideration by the State Debrief Coordination Team. In identifying 18 priority key issues, the team focussed on high risk, state wide, joint agency issues, some of which may not have been readily apparent, but were the basis of a range of the problems raised in debriefs. Representatives of CFA and DSE at a Theme Owners Workshop held on 1 July 2009 worked in groups to develop detailed actions and timelines to address each of the 18 key issues, often drawing upon work already underway since the 2008/09 fire season, such as the funded Bushfire Preparedness Program. The actions addressing the identified key issues are listed below then described in more detail in the following tables. The high risk standard topics pertinent to each action are shown by number for each response.

6.1 Actions to address key issues

1. Improve the integrated function of iECC, CFA and DSE state wide coordination and strategic planning.

2. Ensure appropriate arrangements for liaison and coordination when multiple IMTs are in place, including division of control in a fast moving fire across administrative boundaries.

3. Develop systems for well prepared and strategically located joint Level 3 ICC facilities.

4. Develop sufficient preformed IMTs to match extreme conditions. 5. Continue to improved cooperation between CFA and DSE personnel. 6. Better integrated and compatible parallel CFA and DSE systems and procedures. 7. Improve the timely and adequate information flow from IMTs to iECC, VBIL and the

community. 8. Develop systems for efficient information flow from the fire ground, including aircraft,

to IMT. 9. Improve and make more concise Incident Shift Plans, including maps prepared by

IMTs for the fire ground. 10. Ensure clear reporting and management processes for OHS incidents, particularly

with international / interstate crews. 11. Minimise injuries and near misses due to falling limbs and trees. 12. Clarify implementation of fatigue management guidelines and minimal breaches of

guidelines in first shifts. 13. Consistent understanding of the most suitable function and location of Divisional

Commander role. 14. Ensure sufficient skilled personnel to manage fire line situations including

communications, personnel and plant complexity. 15. Improve management of contractor plant. 16. Better adherence to communications plans and incorporating planned use of UHF

radios. 17. Improve efficiency of shift changeovers and adequate briefings. 18. Consistent application and management of road closures that allow access of fire

personnel and prevent unauthorised access for non-combatants.

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ISSUE No. 1: Improve the integrated function of iECC, CFA and DSE state wide coordination and strategic planning. ACTION OWNERS: CFA: Deputy Chief Officer Emergency Management DSE: Assistant Chief Officer Operations Support Related Appendix 5 high risk Standard Topics numbers: 14, 59, 91, 92 Action Detail/intent Due date Improve the model for emergency co-ordination between CFA and DSE for 2009/10

Document clear Mission and Role Statements for all iECC units and positions For International/Interstate Liaison Unit, address personnel and equipment standards, de/briefings and tour management of foreign crews Take into account VicPol review of part 3 of Emergency Management Manual Victoria

30/09/09

Improve operating arrangements for iECC

Document procedures for operation of integrated emergency co-ordination centre For State Duty Officers address alignment between agencies Train all iECC personnel according to role statements (Bushfire Preparedness Program)

1/10/09

Upgrade facilities at iECC in 8 Nicholson St

Upgrade the telephony, IT and physical facilities at the iECC in accordance with information flows and operating processes (Bushfire Preparedness Program)

1/11/09

Improve the model for co-ordination of emergency strategic planning for 2009/10

Review joint strategic planning requirements Determine charter and outputs for strategic planning including links to State Emergency Strategy Team Document draft joint SOP for strategic planning unit (Bushfire Preparedness Program)

1/11/09

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ISSUE No. 2: Ensure appropriate arrangements for liaison and coordination when multiple IMTs are in place, including division of control in a fast moving fire across administrative boundaries. ISSUE OWNERS: CFA: Deputy Chief Officer Emergency Management DSE: Assistant Chief Officer Operations Support Related Appendix 5 high risk Standard Topics numbers: 10, 12, 35, 91, 96 Action Detail/intent Due date Define circumstances under which a further level of coordination is appropriate between the Chief Officers and IMTs

Review effectiveness of operation of IFACCs in recent seasons Consider span of control of IMTs, duration of level 3 incidents, VicPol Division multi agency emergency coordination needs and the need to be flexible with geographic area of control Review and consider US and UK models for managing liaison and operations where multiple agencies are involved in major or multiple incident management

31/08/09

Develop and implement arrangements for coordination of multiple IMTs

Review and revise if necessary, Joint Standard Operating Procedures for IFAC and IMT to provide a clear ‘chain of command’ from Chief Officer to Incident Controller for Level 3 incidents that includes an ‘overview level’ to assist with prioritising preparedness, risk analysis and resource allocation Inform personnel in pre season briefings of any change in function of IFAC and IMT coordination Include Municipal Coordinators and MECC reps in pre season briefings and exercises (Bushfire Preparedness Program)

30/09/09

31/10/09

31/10/09

Develop protocol for the division of a fire into Divisions or more than one ICC

Protocol to consider: span of control being exceeded or being ineffective, effectiveness of established Divisions, and speed, direction and potential community risks of the fire.

30/09/09

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ISSUE No. 3: Develop systems for well prepared and strategically located joint Level 3 ICC facilities. ACTION OWNERS: CFA: Deputy Chief Officer Operational Policy and Planning DSE: Assistant Chief Officer Capability Related Appendix 5 high risk Standard Topics numbers: 11, 26, 38, 92

Action Detail/intent Due date Develop a joint CFA/DSE agreement regarding ICC facility infrastructure requirements

ICC facility requirements to include: Location Space and privacy Radio and telephone communications IT Power, including contingency Vehicle parking Ablutions

15/08/09

Determine strategically ideal ICC locations

Analyse past incidents to assist in determining optimal ICC locations Investigate potential access to suitable ICC sites managed by local government, state and federal agencies and private owners Consider radio communication plan requirements in reviewing effectiveness of Level 3 ICCs catchments or footprints

31/08/09

Upgrade Level 3 ICC facilities

Complete upgrade works on priority ICC facilities Complete upgrade works on remaining ICC facilities (Bushfire Preparedness Program)

31/10/09

30/06/10

34


ISSUE No. 4: Develop sufficient preformed IMTs to match extreme conditions. ACTION OWNERS: CFA: Deputy Chief Officer Emergency Management DSE: Assistant Chief Officer Operations Support Related Appendix 5 high risk Standard Topics numbers: 28, 35, 96, 97 Action Detail/intent Due date Develop a joint CFA/DSE agreement regarding pre-formed IMTs

Agreement to consider: Trigger FDIs IMT size Location Agency composition Facility requirements Escalation triggers

31/10/09

Implement Pre-formed IMTs as part of Mutual Aid Plans

Mutual Aid Plans to consider pre formed IMT locations, team membership and conduct of pre-season briefing and exercising for pre-formed IMTs

30/11/09

Arrange for supplementary IMTs from interstate and overseas

Develop agreements with interstate and international fire management agencies for rapid deployment of IMTs and specialist roles during periods of predicted extreme conditions (Bushfire Preparedness Program)

30/11/09

Appoint one Incident Controller per tour of duty of both day and night IMTs

Draft a set of principles and procedures for approval by Chief Officers CFA and DSE for the deployment of one Incident Controller per tour of duty

31/08/09

35


ISSUE No. 5: Continue to improve cooperation between CFA and DSE personnel ACTION OWNERS: CFA: Chief Officer DSE: Chief Officer Related Appendix 5 high risk Standard Topics numbers: 40, 94

Action Detail/intent Due date Confirm the cooperative arrangement between the 2 agencies

Recognise and respect that each organisation has different governance and statutory responsibilities Respect and support for the best parts of DSE and CFA cultures without wanting to create a monoculture Recognise that, for Incident Management, CFA and DSE are ‘co-dependent’ Acknowledge where cooperation results in good fire outcomes

Identify opportunities to improve cooperation

Regularly reiterate the shared values of CFA and DSE Provide more forums for meeting and working together at Group level Promote joint projects and operational exercises (e.g. fuel reduction burns) throughout the state Extend formation, training and deployment of Joint IMTs further across the state Deal with behaviours that do not reflect the shared values of CFA and DSE

1/11/09

Understand the circumstances which assist cooperation

Commission social research on the attitudes and drivers for firefighters in each agency

30/06/10

36


ISSUE No. 6: Better integrated and compatible parallel DSE and CFA systems and procedures ACTION OWNERS: CFA: Deputy Chief Officer Operational Policy and Planning DSE: Assistant Chief Officer Capability Assistant Chief Officer Operations Support Related Appendix 5 high risk Standard Topics numbers: 40, 55, 56, 96 Action Detail/intent Due date Maximise production and use of Joint Standard Operating Procedures (SOPs)

Promote use of existing joint SOPs Identify areas of operation where joint SOPs are not being consistently applied Identify areas of operation where further joint procedures are appropriate without impairing each agency’s core business Produce joint SOP for fire role accreditation that initially addresses Level 3 positions Develop further joint SOPs

30/09/09 30/09/09 30/09/09 30/11/09 30/06/10

Maximise use of shared systems through Web based integrated IT

Activate joint agency ICT Committee Define scope for shared IT systems between CFA and DSE Investigate and report on practicality of generic log on and e-mail addresses by IMT role for both agencies for 2009/10 fire season Investigate and report on practicality of reciprocal system access, particularly for resource tracking and situation reporting for both agencies for 2009/2010 fire season Conduct third party audit of systems and risk exposures of current parallel systems

15/08/09 30/09/09 31/10/09 31/10/09 30/06/10

37


ISSUE No. 7: Improve the timely and adequate information flow from IMTs to iECC, VBIL and the community ACTION OWNERS: CFA: G Brennan, Manager Community Development DSE: C. Douglass Related Appendix 5 high risk Standard Topics numbers: 49, 50, 51, 56, 90

Action Detail/intent Due date Develop a one source one message web site for community access to fire information

Information source for fire and fire warnings is to be available to DSE, CFA and a range of other websites as negotiated. Web site to have a tool to ensure multiple entries of warnings is possible from a variety of locations. (Bushfire Preparedness Program)

31/10/09

Improve service provided by VBIL

Review and document 2008/09 Service Level Agreement for funding arrangements and improved service delivery standards Upgrade redundancy and overflow arrangements to Centre link or other provider Improve telephone systems and hardware requirements (Bushfire Preparedness Program)

31/10/09

Improve accuracy and timeliness of fire information

Identify sources that can promote the importance of delivering timely and accurate information into the community, including new media options such as Twitter and geographic domain name sites Review, document and implement protocols and procedures for review and initiation of warnings by Information officers to remove impediments and improve accuracy (Bushfire Preparedness Program)

31/10/09

38


ISSUE No. 8: Develop systems for efficient information flow from fire ground, including aircraft, to IMT ACTION OWNERS: CFA: Deputy Chief Officer Operational Policy and Planning DSE: Assistant Chief Officer Operations Support Related Appendix 5 high risk Standard Topics numbers: 52, 58

Action Detail/intent Due date Improve procedures for accurate, timely and succinct information flow from field command to IMT

Identify and document information pathways into and withi

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Operational Debrief Report 2008/09 Fire Season · 2009. 8. 20. · Each fire season presents the...

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