Massive Failures In Bushfire Command


He’s the state’s chief fire officer, with “ultimate responsibility” for fires under the Country Fire Authority Act of 1958.

He was also isolated, poorly informed and badly out of touch with developing events on Black Saturday, as the Interim Report of the Victorian Bushfires Royal Commission shows.

It’s taken journalists a few days to read over the 300-odd pages of the interim report handed down on Monday, but already Rees’s position looks untenable. In fact, the whole management of Victorian bushfires appears broken. Most frighteningly, given what we now know about the inept and chaotic CFA response to the fires of 7 February 2009, Black Saturday could happen again.

Initial reports about the report stressed that its recommendations were measured and that it did not explicitly lay blame. This is not the case. The report is scathing about the way the fires were handled.

One of the best informed reporters has been Karen Kissane of the Age, who has been covering the Royal Commission and attended many of the hearings. It’s probably no coincidence that Kissane has been among the most strident critics of Rees and the CFA’s performance.

When you look closely at the detail of this investigation, it becomes tragically apparent that the CFA was completely unprepared for a fire of the magnitude of Black Saturday. Its systems were inadequate, especially those for communications, command and control. Astonishingly, because of inept preparation and chaotic organisation on the day, the officer put in charge of managing the Kilmore East fire — which killed 121 people and destroyed 1,244 houses — was not trained for the job. The Incident Control Centre at Kilmore was not properly prepared. It didn’t even have a working fax machine or adequate phone lines.

As a result, neither the state control centre nor local fire brigades were able to communicate with the Kilmore centre properly. Crucial warnings never even made it to the CFA website. People died.

It gets worse. Despite growing alarm, even “dread” from experienced officers at both state headquarters in Nicholson Street, Melbourne, and at a larger divisional control centre at Kangaroo Ground, control of the fire was not transferred from the manifestly inadequate Incident Control Centre at Kilmore to the better staffed Kangaroo Ground facility. As a result, warnings that were drafted at Kangaroo Ground were not released because they could not be approved by the over-stretched Kilmore centre. It was a critical breakdown.

The picture that emerges of CFA boss Russell Rees is damning. Despite being organisationally and legally the man in ultimate command, he abdicated his responsibility on the day, failing to take charge — or even an interest — in the developing Kilmore blaze.

The interim report states that “Mr Rees did not appear to become actively involved in operational issues, even when the disastrous consequences of the fires began to emerge.”

And further, “Mr Rees did not look specifically at warnings concerning the Kilmore East fire nor did he, given his knowledge of the spotting potential of that fire, ask anybody to check whether the Kilmore ICC was producing timely warnings.”

Rees didn’t speak to either the Kilmore or Kangaroo Ground incident control centres which were “controlling” the Kilmore East fire. He didn’t look at any fire prediction maps concerning the Kilmore East fire on 7 February. The reason he gave the Royal Commission as to why he did not inspect prediction maps? “The need for a state overview.”

Strategy is undoubtedly important to the overall management of fire suppression across Victoria, especially on a day like Black Saturday. But what is fire strategy if it is not the prioritising of threats and allocating resources accordingly? Further, strategy cannot be formed without accurate information, which the interim report comprehensively demonstrates Russell Rees did not have, or even ask for. Rees’s strategy was so overwhelmed by the chaos of Black Saturday that he was unaware of the severity of the Kilmore East fire until 5am the next morning. Russell Rees’s strategy failed.

The Royal Commission confirms this. It found that not only did Russell Rees not see the fire prediction maps or know about the severity of the Kilmore East fire, neither did Gregory Paterson, the CFA’s state duty officer on the day and the third most senior officer in the CFA chain of command. The Commission reports that “it is also difficult to understand how Mr Rees could properly carry out a strategic state-wide coordination responsibility or how Mr Paterson could carry out the responsibilities of State Duty Officer and the coordination tasks he described.”

In fact, the CFA’s response to Black Saturday was all too likely to fail because its systems were not up to managing a threat like the one faced on 7 February.

The CFA’s state control centre had only recently moved from Burwood to a co-located facility with the Department of Sustainability and Environment at Nicholson Street. The move caused major disruptions to the CFA’s capacity. For instance, the Royal Commission was told by Gregory Paterson that “[i]f the incident [the 7 February 2009 fires]had been run from the SECC [the old headquarters at Burwood]we would have had up to ten CFA Situation Officers on duty. Instead we had two CFA Situation Officers on duty due to lack of space.” That’s an 80 per cent reduction in capacity. For this alone Rees should be held accountable. But Rees told the Royal Commission that the move from Burwood to Nicholson Street “worked well and was a success”.

The story of the CFA’s bumbling, chaotic response to the Kilmore East fire is a tragic echo of the failures of emergency services and disaster response efforts in other countries. During 9/11 in New York and Hurricane Katrina in New Orleans, US authorities suffered the same sorts of breakdowns in communications and failures of command and control. Indeed, Rees’s disengaged and bumbling performance on the day resembles most closely the performance of the notorious Michael Brown, the incompetent boss of the Federal Emergency Management Agency during Hurricane Katrina. But while incompetence played a role, these tragedies were also examples of what US sociologist Charles Perrow calls “normal accidents“: infrequent but predictable breakdowns in complex systems that lead to disasters.

Black Saturday was another such “normal accident”. In the case of the Kilmore East fire, for example, the Commission found that key staff in the CFA knew how dangerous the fire would be. It found that the CFA knew it would be uncontrollable once it crossed the Hume Highway. It found that the CFA even drafted urgent warnings as early as 3pm for towns like Kinglake — warnings that were never released because of bureaucratic inertia and the organisational chaos that enveloped the CFA at both state headquarters and the Kilmore control centre. The CFA was not as prepared as it should have been for the events of Black Saturday, and, as a result, people died.

But the really scary thing about the official Victorian response to the fires has been the bluff inability of senior CFA managers and their political masters to accept blame. It’s simply not good enough for Russell Rees to repeat the mantra “I did the best that I could.”  It’s not a recipe for the kind of organisational reform so clearly demonstrated by the events of Black Saturday. If the CFA can’t even acknowledge the scale of its errors, how will it correct them?

Russell Rees’s “best” was woefully inadequate on 7 February. He should resign.

There is another man who needs to take responsibility here: Premier John Brumby. The Premier has decided to stand by his fire chief, toughing out the political controversy.

That’s not acceptable either. If Rees won’t resign, Brumby should sack him.

Ben Eltham is New Matilda's National Affairs Correspondent.