The deaths of Stuart John Davidson, Garry Vredeveldt, Christopher John Evans, Jason Richard Thomas and Matthew William Armstrong all occurred at Linton during the evening of December 2, 1998 from the effects of fire. The fire and the deaths occurred in the following circumstances.
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The town of Linton
The wildfire near the township of Linton, which is situated about 30 km south-west of Ballarat, started at about midday on December 2 on a private property in the forested area off Rowlers Rd, Snake Valley which is situated north of the town. Linton has a population of about 630.
The cause and origin of the fire
The fire started on a property owned by Peter James Neyland. The block, Lot 36, is about 64 acres on which Neyland was in the process of building a holiday cottage. During the previous two days Neyland had been burning off rubbish on his property. He had checked as to whether any fire restrictions were in force before commencing the burning off. There were two potential sources of ignition for the Linton fire. Neyland had been burning off rubbish near to his dam and also near a tree some meters east of his partially constructed cottage. At the dam site Neyland had set three piles of rubbish alight on the Monday prior to the Linton fire and, during the day, regularly raked the area. Before going to bed that evening he had made sure these fires were out. During the next day he lit a pile of rubbish nearer to his house. Whilst burning this area of rubbish the bark of a nearby tree began to smoulder and Neyland used buckets of water to douse the tree. This was not successful so he went to a neighbours place and obtained two fire extinguishers. He used the fire extinguishers and a ladder to climb the tree in order to be assured that the tree was no longer alight. During the afternoon he checked on the tree and the general area and did not observe any signs of smouldering.
Mr Neyland left the property on the morning of the fire after having raked and sieved the coals from the area around the dam, again checked the area of the tree, there were no signs of smoke. He raked the ash of this fire into a pile and sieved it through a couple of layers of chicken wire into a garbage bin. "We use this bin full of ash to cover excreta when we use our pit toilet. I filled this bin with fine ash and discarded the larger coals, which by this stage were cold, into the cleared area," Mr Neyland said. On driving up the road, he decided to return, to again check an overhanging branch on the tree. By this time there was already a moderately northerly wind.
The source of the ignition of the Linton fire either began around the area of the dam or from the tree nearer to the partially built cottage. Although, on balance, it was more likely to have been at the site around the area of the dam. According to the Panel of Experts ignition was caused by the wind igniting smouldering combustion from the fires lit by the property owner on previous days. The totality of the experts views on Neylands actions to extinguish the fires, was that he acted reasonably in the circumstances.
The Linton fire was started on 2 December by the wind igniting "smouldering combustion" from Mr Neyland's property. About midday on December 2, the smouldering combustion was fanned by strong northerly winds.
Weather, fuels and general background
The weather on the day was a typical Victorian summer day with temperatures around Linton of the low 30s in mid afternoon with a relative humidity of about 20 per cent. Wind speeds were about 45km/h gusting to 70km/h from the north west during the afternoon. The speed of the wind dropped to about 20 kph in the 30 minutes before the wind change, which engulfed the Geelong City and Geelong West crews at about 8.45 pm.
The fire gradually spread south towards Linton, eventually to burn out about 660 hectares and extended for about 6km with an average width of 1.5 km. Also during the run of the fire two houses and various outbuildings on the outskirts of Linton were destroyed, a caravan and shed situated on the property where the fire started were damaged, a firefighters utility was destroyed, the Geelong West tanker was destroyed and two other tankers were damaged. The majority of damage to private property, with the exception of the CFA tankers, was largely complete by 2.45pm when it crossed the Pittong-Snake Valley Rd to move into the State Forest north of the township. The perimeter of the fire was eventually contained at 1am on December 3.
The initial response by the CFA and DNRE to the fire
The fire was first observed at about 1pm and eventually a number of firefighting tankers from CFA Regions 15 and 16 attended in an attempt to control the fire. DNRE resources also attended in the early stages of the fire. As the fire spread south towards Linton it crossed from private land at the Pittong-Snake Valley Road where the CFA had responsibility to State Forest where the responsibility to manage fire rested with DNRE. The State Forest extended to the outskirts of Linton.
At about 2pm CFA and DNRE representatives began to establish an Incident Management Team at Ballarat in a State Government office block called the Glasshouse. The IMT was jointly set up by the two firefighting agencies in accordance with a Multi-Agency Incident Management Agreement signed by their respective Chief Officers earlier in November 1997 whereby the agencies agreed to operate under a specified incident management system. Among other things this system is intended to ensure the safety of all firefighters on the fire ground. The IMT was part of the management structure established under this incident management system which is called the Australian Inter-Service Incident Management System (AIIMS). AIIMS has an Incident Control System known as ICS. Once the IMT was established at Ballarat it was intended that the fire be jointly managed by the two agencies under the AIIMS system of incident management. The fire agencies had agreed that in multiagency incidents, one incident organisational structure would be adopted for all personnel present at the incident. The agencies are to ensure that there is no duplication of structure and the incident organisational structure will follow AIIMS/ICS principles. On the day, it was agreed between representatives of the agencies that the CFA would become the lead agency and a CFA officer Greg Leach, would take on the role of incident controller. John Sanders from the DNRE eventually became his Deputy. Other senior positions in the AIIMS management structure were progressively filled by a mixture of CFA and DNRE personnel.
It should be noted that the CFA also had a system known as the group system, which permitted various local brigades and their parent regions to join together for the purpose of managing wildfire incidents. This system was progressively being supplanted by AIIMS. Unfortunately, the Linton fire was managed under both systems AIIMS and the Group. The old group system was operated by CFA Region 15 in parts of the eastern flank of the fire and in the northern section by Region 16. Mr Roche, the CFAs chief officer, indicated that the change from the old group system, first envisaged in the early 1990s, was undertaken because:
"Experience of incidents during the course of the 1970s and 1980s had exposed weaknesses in the system of incident management based on brigades and groups, particularly when faced with larger incidents crossing group or regional boundaries or between public and private land."
The fire at Linton crossed both these boundaries. Mr Roche also indicated:
"The group system has been shown to be incompatible with inter-agency operation. It is impossible effectively to coordinate the resources of two (or more) agencies during an incident, without a system of command and control that effectively supplants the different hierarchies operating within those agencies."
At no stage did management in the IMT at Ballarat take control to ensure that the ATIMSICS management system applied throughout the fire. One group, Region 16, was not aware of the fact that an IMT had been established at Ballarat. IMT management did not ensure that either a written incident action plan or communications plan was distributed to the command structure working on the fire ground. This was required under AIIMS. On the eastern flank, where the Geelong strike team were working, the relevant CFA volunteer divisional and sector commanders were not trained in AIIMS-ICS principles and managed their part of the fire under the old group system. In turn they were managed from the forward operations point which had been established in the Linton Shire Offices.
The officer in charge of the forward operations point was Bob Graham, a DNRE employee. Graham was managing the resources on the fire ground, which included DNRE and CFA personnel. CFA personnel included both full time and volunteer firefighters. However, the CFA resources were largely made up of volunteers. On the fire ground, where CFA resources were concerned, management was taken from a mixture of full-time and volunteer personnel.
There was no system to ensure that only competent firefighters attended at the fire ground. In this sense, competence is defined as training plus experience for the specific task. The CFA relied on the "home brigade" to make up the crew without any knowledge of the task the crew would be required to perform once reaching the fire ground. Eventually, perhaps the most inexperienced team, which was from Geelong, was tasked to potentially the most dangerous work on the fire ground building a control line on the eastern flank with a forthcoming wind change due at some time from the south-west.
The CFA relied on a radio "general message" system for the delivery of important messages (like wind change) to firefighters on the fire ground. This is in spite of the long recognised difficulties with radio communications during previous wildfires, the AIIMS-ICS system of supervision and control. The CFA operations guidelines, established with AIIMS principles in mind, were the operative guide for its personnel. Briefly, the guidelines state that it "is vital to carry warning of the actual or estimated wind change to all personnel involved in the firefighting operation."
There some was confusion between CFA and DNRE management about the meaning of the Multi-Agency Incident Management Agreement. The CFA was of the view that the nature of the operation was "incident based" and not "agency based" with lines of responsibility in accordance with the AIIMS structure. DNRE were of the view that responsibility could be delegated. For example, DNRE argued that the officer-in-charge of the forward operations point could delegate his responsibility to CFA officers.
Under AIIMS principles and the Multi-Agency Incident Management Agreement the officer-in-charge of the forward operations point could delegate a duty but not relinquish responsibility.
The critical distinction is that the occupant of the functional role has specified duties and responsibilities under the AIIMS-ICS system.
That individual may seek to carry out those duties and fulfil those responsibilities in a number of ways. One of those ways is to engage a deputy and task that person to carry out various actions. If the deputy fails to carry out the action to the extent necessary for the occupant of the functional role to have discharged his or her responsibilities, that person (the occupant of the functional role) has not fulfilled the duty. A deputy does not assume the responsibilities of the functional occupant under AIIMS-ICS.
Reference also needs briefly to be made to Exhibit 7 1D. This is a document prepared and tendered by the DNRE during the course of the Inquests for the purpose of identifying and clarifying issues which NRE considers to be of importance.
DNRE stated:
"The Incident Controller must be a competent person from the agency in overall control or a suitably qualified person agreeable to both agencies. At all fires that are operating under the Multi-Agency Incident Management Agreement, the Deputy Incident Controller shall come from the other agency. This is to highlight to all fire fighters that the operation will be fully integrated in decision making and implementation."
The DNRE paper then goes on to state:
"It is not unusual, nor is it outside the principles of AIIMS-ICS, to have sectors or divisions fully resourced by personnel from the one agency."
It appears difficult for DNRE to argue, in this case, that it was not in a sufficient position of control over the system of work employed at the fire ground to give rise to a potential responsibility for the safety of DNRE
officers, CFA employees and volunteers, and any others involved in the Linton wildfire at the fire ground.
Specifically, in this particular case, it had a DNRE officer-in-charge at the forward operations point who had control over the firefighters on the fire ground, and was responsible for the safety of the personnel and to supervise the CFA divisional commander. In turn the divisional commander supervised the sector commander, and so on.
Four "at risk" incidents prior to the Geelong West entrapment
During the early stages of the run of the Linton fire a number of additional incidents occurred whereby many firefighters lives were put at serious risk. All told there were four such incidents, commencing at about 2.45pm. The last of incidents occurred at approximately 4 pm - more than four hours before the two tankers from the Geelong strike team were trapped and the five volunteers lost their lives.
None of these earlier incidents resulted in any changes to the perception of firefighters on the ground of the
Report of the Investigation and Inquests into a Wildfire and the Deaths of Five Firefighters at Linton on 2 December 1998 dangers that this fire presented. There was no system in place within the CFA to ensure that incidents occurring during a running fire, where firefighters lives were put at risk, were reported to the Incident Management Team. None of the incidents were reported to the IMT in a timely way to enable them to re-assess and re-evaluate what was happening on the fire ground and the risk it constituted to the safety of firefighters.
The Sector and Divisional Commander, Messrs Lightfoot and Phelan respectively, both volunteers from Region 15, who ultimately came to be in charge of the Geelong strike team, were either directly or indirectly involved in at least two of these prior incidents.
Thus at least some individuals in a management role had warnings of the erratic behaviour of the fire on its short run through the forest.
The AIIMS-ICS Incident Control System manual provided personnel should:
"Report Special Incidents and Accidents
* Indicate the information required:
nature of event
location
magnitude
personnel involved (no names to be broadcast over radio)
initial action
subsequent action
* Obtain information from:
subordinates
personal observation
ground or air observers
* request assistance needed, such as helicopter, ambulance or tow truck
*submit report to incident controller."
Messrs Lightfoot and Phelan were not trained by the CFA in managing a fire by AIIMS principles. Clearly they both had little perception of the risk that this fire presented on the day.
The CFA had no system to ensure that these incidents (or near misses) were immediately reported through the chain of command to the IMT. DNRE had introduced an incident reporting system a few months before Linton.
The earlier incidents on the fire ground probably occurred in the following order the Pittong-Snake Valley Rd burn over, the Snake Valley A entrapment, the incineration of sector commander Lightfoot's utility and the Madden Flat Rd extension burn over. An additional, potentially compounding problem was posed by the risks to firefighters by what is now known as the Hadler burn.
As the head of the fire approached the Pittong-Snake Valley Rd between 10 and 12 CFA tankers lined up on the road in an attempt to stop the fire. As the fire moved up hill towards the road it intensified, fanned by the north wind, and crowned in the tops of the trees crossing the road. Some of the tanker crews had to either activate their fog sprays for protection or beat a hasty retreat.
At about 2.30pm the Snake Valley A tanker moved into a bush paddock south of Pittong-Snake Valley Road having observed spot fires ahead of the main front of the fire. When the spot fires became more intense and the head of the fire travelled over the road the tanker almost became trapped in amongst the trees and mine shafts that littered the area. The six crew on the Snake Valley A tanker were lucky to escape with their lives. One crew member received burns to the hands, which required hospital treatment. The whole crew was relieved from further work as a result of exposure to the fire.
At about 3.30pm a strike team led by Mr Hadler (who had also been involved in the Pittong-Snake Valley Road line-up) began to light up bush on the west side of Madden Flat Rd (which runs north south from Pittong-Snake Valley Rd to Possum Gully Rd). Over the next 15 minutes about 1.2km of fire line was lit up. At this time Lightfoot (who later became the sector commander in charge of the Geelong strike team) was taking another strike team a little further south on Madden Flat at the intersection of Possum Gully Rd to burn out another section of bush. There was no planning for the first burn (the Hadler burn), which could easily have put at risk Lightfoot and his team. At the time of his undertaking Lightfoot was unaware of the Hadler burn. It is noted that the IMT became aware of the Hadler burn, undertook some preliminary investigation by air and advised them to stop the work. However, the fire had already got away.
During Mr Lightfoots operation, he and another volunteer firefighter were both lucky to escape with their lives when Lightfoot's utility became bogged in a mineshaft, while he was reconnoitring in front of the head of the fire. The advancing head of the fire destroyed the utility and Lightfoot and his colleague had to run for their lives. They both took refuge in the Hardies Hill tanker which, along with a number of other tankers from the Buninyong strike team immediately had to activate their fog sprays for survival as the head of the fire also engulfed their trucks. One tanker beat a hasty retreat with fog sprays operating. Parts of this incident were filmed at a distance by a media-crew, who were advised by DNRE to leave. As indicated, this strike team, under the command of Lightfoot, was conducting a backburning operation around the Madden Flat Road extension and its intersection with Possum Gully Road to pinch the head of the fire. The fire head of the fire had already crossed Possum Gully Roads at the time of the back-burn.
Each of these incidents demonstrated that those fighting the fire did not fully appreciate the fire behaviour as it related to fuel-loads, topography and weather. The fire was spotting ahead of the main front and the tactics adopted were inappropriate.
Conclusions
The Linton wildfire was ostensibly being managed by the CPA and DNRE, jointly by agreement, under the AIIMS-ICS system of incident management. In fact, two systems of incident management operated side by side during the management of the fire AIIMS and the CPAs old group system. This led to dysfunctional command and control. Vital safety information was not efficiently and appropriately disseminated. Many firefighters and operational managers working on the fire ground did not know of the existence of the IMT.
Both agencies, aware as they were of the potentially dangerous and hazardous nature of the work being conducted, did not ensure that their joint management of the operation provided to the Geelong strike team, working on the eastern flank of the fire building a control line, the necessary level of supervision, information and instruction to enable them to operate safely.
The agencies did not ensure that the AIIMS system of incident reporting applied in this fire. Had competent fire officers stationed at the IMT even briefly been told in a timely way of the incidents (the Snake Valley A and the Lightfoot utility incineration), it is likely that the problems with safety and operational management would have been identified. The dangerous nature of the Linton fire would have been recognised and more careful attention to supervision and safety would have been likely to alter the eventual outcome with the Geelong strike team.
The DNRE officer-in-charge of the forward operations point, in view of the dangerous nature of the work, did not check to ensure that the Geelong strike team were adequately supervised, actually received the information on the wind change and were properly instructed on the work to be performed on the arrival of the change. As indicated, DNRE was involved in jointly managing the fire with CPA and it had a responsibility to ensure that the management systems actually in operation at the fire provided the required level of supervision, information and instruction to firefighters on the fire ground relevant to the task to be performed. Specifically in this case, a DNRE officer was in a position of command at the Forward Operations Point and had control of a number of aspects of work on the fire ground.
In summary, the DNREs employee, the Forward Operations Point Officer, failed to properly supervise the Divisional and Section Commanders in charge of the Geelong Strike Team.
In the case of the CFA, it did not ensure that its Strike Team Leader had sufficient training to recognise the nature of the forest fuel load with which he was working and the level of risk that created when combined with topography and changes to weather. It had no system to ensure that inexperienced firefighters and managers were not tasked to potentially dangerous areas of a fire ground. Having tasked inexperienced personnel, it had no systems to ensure inexperienced crews, crew leaders and strike team leaders were appropriately monitored when working on the potentially dangerous eastern flank of a wildfire pending a south-westerly wind change. It also did not have systems actually working to provide the necessary level of supervision, information or instruction relevant to the wind change and the dangerous work of its firefighters on the eastern flank
In summary CFA failed to properly supervise Mr Scharf. In the circumstances that prevailed at Linton proper supervision involved:
* Mr Phelan (Divisional Commander) supervising Lightfoot in the performance of his duties as Sector Commander;
* After receiving the Wickliffe message, Messrs Graham, Phelan and Lightfoot should have
met to determine:
- the relevance of that message to the arrival of the wind change on the fire ground;
- the need (if any) to change the existing tactics; and;
- Safety instructions that needed to be given to Mr Scharf.
After discussion had been made about these matters Mr Scharf should have been re-briefed. It is reasonable to conclude that Scharf would have taken instructions as he had earlier promptly responded to DNRE officer Schergers advice to build a turn-around and alter the direction of the
control line.
The strike team leader, Mr. Simon Scharf (a full time firefighter) was not sufficiently trained by his employer, the CFA, to the skill level to enable him to sufficienfly assess the high fuel loads in the area and to recognise the potential danger for the Geelong and Geelong West crews of sending them out to obtain water along an unburnt track, in the event of a wind change. However, by directing the two fire crews to drive out along a bush track he placed the Geelong strike team (perhaps the most inexperienced team at the fire) was placed in the potentially most dangerous section of a wildfire creating a control line on an eastern flank facing an imminent wind change from the south west. From the time the strike team was tasked to the control line to the entrapment, there was no external supervision from those managing the fire. The strike team leader of the Geelong strike team had not worked in this situation previously. In addition, the bulldozer driver working with the Geelong strike team, who was building the mineral earth break for the control line, had not been trained nor had he experienced this type of work previously. He therefore could not offer assistance or guidance to the Geelong strike team.
The strike team was not provided with detail on the expected time of arrival of the wind change from the south-west. Nor was it given instruction as to the work to be performed when the wind change arrived. Information on the wind change arrival was delivered by General Message over the radio and not received by the Strike Team. Although reliance was placed on a general message system for important messages, the AIIMS-ICS system of work provided for a system of supervisors delivering such messages. This was not followed in the case of the Geelong Strike Team. By contrast the experienced DNRE team, also working on the eastern flank, was contacted and provided with the information from the Forward Operations Point at Linton. Earlier, it was given instruction on what to do when the wind change arrived. In view of potential danger in the nature of the operation on the eastern flank and with previous knowledge of communication difficulties, both agencies working jointly to manage the fire operation, should have ensured that the Geelong Strike Team received the necessary level of supervision, information and instruction as to what to do when the wind change arrived. This did not occur. It is noted that had Mr Scharf received just the Wickliffe message and no instruction, there is no certainty that the circumstances would have changed. His training and experience did not give him the tools to understand the danger he was in.
In view of Mr Scharf's response to Scherger's instructions on building a turnaround and in changing direction of the control line, it is reasonable to conclude that he would have taken instruction on the management of his strike team on arrival of the wind change. He received neither the benefit of instruction as to the work to be performed on arrival nor advice about the expected time of arrival of the
wind change. Other than Schergers instructions, Scharf received no supervision from operational managers from the time he commenced work on the control line. He had not previously worked in the dangerous area of an eastern flank constructing a control and facing a westerly wind change. At the minimum he should have been given a mentor and supervised with proper instruction. In reality, because of the shortcomings in his training he should not have been there. This comment also applies in respect of the
inexperienced Geelong strike team.
At Linton, acknowledgments were sought with the radio message on the wind change and only one was received. There was no system for acknowledgments to be requested and no system for dealing with a lack thereof. Also the message, that the wind change was at Wickliffe, was meaningless to many on the fire ground as they did not know where Wickliffe was. In addition, the Fire Agencies were aware of the fact communications difficulties occurred in the management of previous wildfire incidents and there were problems with delivering messages via the radio system. The CFA should not have permitted this system of delivery of important safety information to operate in the potentially dangerous wildfire environment.
Mr Neyland was involved in burning off rubbish on his property for about two days prior to Linton. He took every reasonable precaution, within his knowledge, to ensure that the rubbish fires were extinguished. Eventually a smouldering cinder from one of the rubbish fires ignited the forest. It is likely that the cinder ignited with the hot north wind. Neyland caused the fire. Neylands involvement must also be seen in the context of a significant failure of the fire agences applied systems of work and intervening factors which could not reasonably have been anticipated. As to the deaths of the five volunteers, there are too many intervening factors occuring throughout the managenement of the wildfire to extend the causal link for the deaths to Neyland. From the ignition of fire to the deaths the introduction of the significant failures in the system of work has the effect of breaking the chain of causation.
During the relatively short but violent run of the Linton wildfire numerous firefighters lives were put at risk during incident after incident. One expert, Dr Neil Burrows, wrote in his report to the Coroner on the
Linton fire:
"Frankly, it was a miracle that only five lives were lost at this fire given the numerous other near misses..."
Contribution
Mr Peter Neyland contributed to the fire.
The State of Victoria by its agent the Department of Natural Resources and Environment contributed to the deaths.
The Country Fire Authority contributed to the deaths.
Mr. Simon Scharf, Country Fire Authority fire officer and strike team leader, Geelong strike team, contributed to the deaths.