Vbrc Summary Pf[1]

8/9/2019 Vbrc Summary Pf[1]

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FINAL REPORT

The hon. Bernard Teague ao ChairPErSON

ronald Mcleod aM COmmiSSiONEr

SuSan PaScoe aM COmmiSSiONEr

ordered To Be PrInTed

July 2010

By autoty

Govenent Pnte o te Stte o Vcto

PP No. 332 Sesson 200610

SUMMARY


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2009 Victorian Bushfres Royal Commission


3/52Souce: Json Sout, coutesy oThe Age.


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Plent o Vcto

2009 Vcton Buses royl Cosson

iSBN 978-0-9807408-1-3

Publsed July 2010

Volue i 978-0-9807408-2-0

Volue ii 978-0-9807408-3-7

Volue iii 978-0-9807408-4-4 Volue iV 978-0-9807408-5-1


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vii

PREFACE

Te buses o Blck Study, 7 Febuy 2009, cused te det o 173 people. Blck Study wote tsel nto

Vctos stoy wt ecod-bekng wete condtons nd buses o scle nd eocty tt tested unendunce. Te lves o ny Vctons wee cnged oeve, nd ny sowed tey e cpble o deeds o get

couge nd copsson. altoug soe countes wee pysclly destoyed, te ebes lso dsplyed

ngenuty, stengt nd esolve n te ce o ts clty. Tee ws lso wdesped devstton o consdeble

es o te scenc oests nd woodlnds tt o pt o Vctos ntul etge.

Egteen onts lte, te lndscpe s elng, fo nd un e etunng, nd ndvduls nd countes

e gettng on wt ebuldng te oes nd lves. We cknowledge te losseso ly, ends, ellow ctzens,

oes, gdens, nls, nd te ny ote tngs tt people old de. We ve seen te pn people ve

endued nd contnue to be, nd we know t wll be long od to ull ecovey o ny. Buse s n ntnsc

pt o Vctos lndscpe, nd te ds ou eoy we sk epetng te stkes o te pst. We need to

len o te expeences o Blck Study nd pove te wy we pepe o nd espond to buses.

Te 2009 Vcton Buses royl Cosson ws n potnt pt o ensung tt tose lessons e clely denednd lent. Te Cosson conducted n extensve nvestgton nto te cuses o, te pepton o, te esponse

to nd te pct o te es tt buned tougout Vcto n lte Jnuy nd Febuy 2009. as Cossones,

we concentted on gnng n undestndng o pecsely wt took plce nd ow te sks o suc tgedy

ecung gt be educed.

in ou delbetons we ensued tt te voces o ected county ebes wee ed. Ou poty ws to

lsten to people dectly ected by te es. We lso ensued tt te Cossons pocesses wee ly bsed n

te county toug open engs (ncludng n egonl towns), web steng so tt people could lsten to te

engs ove te ntenet, publc subssons, te ptcpton o ly wtnesses, te ceton o te Blck Study

Glley, nd te ptcpton o ly nd ends n engs bout people wo ded s esult o te es. Ts

ccess wll contnue: te Cossons webste wll en ctve, nd ll te Cossons docuentton wll be

vlble t te Publc recods Oce o Vcto.

Ts epot s n potnt pt o secung te eoy o te es. Te st volue descbes te ogns nd couse

o te 15 es tt wougt te getest on 7 Febuy nd te esponse to te. it lso tells te stoes o te

173 people wo ded. Volue ii looks t wt lessons cn be lent o tese expeencesow we cn educe

te sk nd pcts o e nd nse e-elted loss o le n utue. Volue iii epots on te Cossons

dnstton nd pocesses. Volue iV epoduces te stteents o te 100 ly wtnesses wo gve pesonl

ccounts o te expeences n te es n lte Jnuy nd Febuy nd n te tet. Te stoes told by

tese people gounded ou wok. Tey contnully ended ll t te Cosson tt buses deeply ect

people nd countes nd tt te needs nd sety ust be t te oeont o govenent polcy.

Te ecoendtons we ke gve poty to potectng un le, nd tey e desgned to efect te sed

esponsblty tt govenents, e gences, countes nd ndvduls ve o nsng te pospect o

tgedy o ts scle eve ppenng gn.

We oe ts epot to te Goveno nd te people o Vcto.

T h. B T ao r Ml aM Ss Ps aM

Cpeson Cossone Cossone


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ix

CONTENTS

PREFACE vii

SUMMARYOFTHEREPORT 122

RECOMMENDATIONS 2337

THECOMMISSIONSTERMSOFREFERENCE 3841

THEPEOPLEWHODIED 42


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Souce: Coutesy o alex ip.

Im 1 T rs f


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1

Summary

CONdiTiONS ON 7 FEbRuARy 2009

Vcto endued one o ts ost sevee nd polonged etwves dung te nl week o Jnuy 2009. Te

tepetue n melboune ws bove 43C o tee consecutve dys o te st te snce ecods d been kept.

Study 7 Febuy ws oecst to ec tepetues n te low 40s, ccopned by stong wnds. in te led-

up to te dy te Pee o Vcto, te hon. Jon Buby mP, descbed te stte s tnde dy. Te County Fe

autoty nd te Deptent o Sustnblty nd Envonent, te Sttes py buse gences, wned tt

oests nd gsslnds wee te dest tey d been snce te as Wednesdy es n 1983.

Te condtons oecst o 7 Febuy wee elsed, s wee peoples wost es wen es boke out coss te

stte. Tepetues wee neng 40C by 11.00 n ny pts o te stte nd lte clbed to te d-40s.

Nueous es endued ecod-bekng xusncludng melboune, wc eced 46.4C. Stong wnds

n te onng gew to sto oce s te dy pogessed, nd wnd cnge oved coss te stte dung te

tenoon, getly ntensyng te es. Te Cosson ws noed tt te CFa nd DSE ttended o ptolled

316 gss, scub o oest es on tt dy. O tese, te Cosson exned n detl 15 es tt cused(o d te potentl to cuse) te getest dge.

Te ost seous consequence o te es ws te det o 173 people. Let bend e les, ends nd

countes stll tyng to coe to tes wt te loss. accopnyng ts loss o le s te es pct on popety

nd te nstuctue tt suppots countes, s well s te substntl envonentl pct, wc wll tke

yes to ully evel tsellet lone be eloted. it s exteely dcult to qunty te cost o dsste lke ts,

but te Cosson esttes t to be oe tn $4 bllon.

Ts ws one o austls wost ntul dsstes. it wll be ny yes beoe ts eects d. Govenents, e

nd eegency sevces gences nd ll ndvduls cn len vluble lessons o tose dys, so tt we gt

educe te sk o suc destucton occung gn. it would be stke to tet Blck Study s one-o

event. Wt popultons t te ulubn ntece gowng nd te pct o clte cnge, te sks ssocted

wt buse e lkely to ncese.

ThE ROyAl COmmiSSiON

in te dys edtely ollowng 7 Febuy te Stte esponded to te consequences o ts dsste. a ele eot

to del wt edte needs ws te st poty. But t ws lso cle tt te county needed to undestnd

ts tgedy nd ow to nse te sk o sl tgedy occung n te utue. On 9 Febuy 2009 te Pee

nnounced te Sttes ntenton to estbls oyl cosson. One week lte te hon. Bend Tegue aO,

Susn Pscoe am nd ronld mcLeod am wee pponted s te royl Cossones.

Te Cossons tsk ws substntl. Te Goveno o Vcto, Poesso Dvd de Ketse aC, ssued te lettes

ptent, settng out te Cossons tes o eeence, on 16 Febuy 2009 (see pge 38). Te Cosson begn

ts wok tt dy, gvng ely poty to county enggeent: between 18 mc nd 8 apl t eld 26 countyconsulttons n e-ected es, seekng to len bout te expeences nd concens o ndvduls ected by

te es. a dectons eng ws eld on 20 apl 2009, nd te eng o evdence begn on 11 my 2009 nd

concluded on 27 my 2010. Dung tt te te Cosson eld 155 dys o engsncludng egt dys o

egonl engs nd 23 dys exnng te 173 e-elted dets.

To conduct ts nquy popely te Cosson needed to gound ts wok n n undestndng o te elty

o buse nd ts eects on peoples lves. Ts petve peeted te Cossons wok, o te ntl

county consulttons to te publc subssons, te 100 ly wtnesses wo gve pesonl ccounts o te

expeences, nd te nvolveent nd suppot gven to te les wo ttended te engs nto te e-elted

dets. Te Cosson elt tt ts wok could, nd sould, contbute to ndvdul nd county elng, s well

s ccoodte te stong publc nteest n te nquy. Ts cotent to people went beyond te equeent

to ensue ntul justce o epesented ptes nd tose potentlly ected by te Cossons ndngs nd

ecoendtons: s uc s possble, te people wo wee ost dectly ected by te es wee gven voce

nd te stoes nd vews wee ed.

SummARy OF ThE REPORT


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2

Te Cosson vews potecton o un le nd te sety o countes s te gest poty o buse

polcy nd dected ts eots ccodngly. Ts poty guded te Cosson n ts nlyss, te collectono evdence, ts epots nd te oulton o ts ecoendtons. Te ecoendtons ute efect te

Cossons ecognton tt ndvduls, e gences nd Coonwelt, Stte nd locl govenents se

esponsblty o pepng o e nd povng peoples sety. Wle plcng te pesevton o un le t

te et o ts delbetons, te Cosson lso sougt to ensue tt due consdeton ws gven to Vctos

envonentl sustnblty.

Te Cosson ws sked to nque nto nd epot on te cuses nd ccustnces o te es tt buned

n JnuyFebuy 2009, te pepton nd plnnng beoe te es, ll spects o te esponse to te es,

esues tken n elton to utltes, nd ny ote ttes t consdeed ppopte. Te lettes ptent dected

te Cosson to ke suc ecoendtons s t tougt t on pepton nd plnnng o ute e tets

nd sks, lnd-use plnnng nd ngeent, epoong o stuctues, eegency esponse, councton,

tnng, nstuctue nd ovell esoucng.

ThE FiRES

Te es n JnuyFebuy 2009nd n ptcul on 7 Febuyve deeply sced te Vcton people

nd te lndscpe. Te Cosson teeoe begns ts epot wt dscusson o te 15 ost dgng, o

potentlly dgng, es tt buned on 7 Febuy, ncludng tose n wc people ded. mny o tese es wee

sgncnt becuse o te sze nd pct; soe o te slle ones, oweve, povde nsgt nto te deng

ccustnces nd dends o te dy. Te Cosson exned te ollowng es (sown ee n te ode n

wc tey gnted):

Delbun

Bunyp

Kloe Est

hos

Colene

PobonetWeete

Cucll

mundnd

redesdle

Ne Wen: hkwy

Ne Wen: LynbookCol Dve

Ne Wen: LynbookGol Club rod

Uppe Fentee Gully

Bendgo

Beecwotmudgegong.

Tese es wee not te only ones tt occued dung te 200809 buse seson: DSE nd CFa st nd

voluntees ougt undeds o es. Te e seson ws long nd dendng, plcng consdeble pessue on

egtes even beoe te wost es begn n ely Febuy. Fgue 1 sows te extent o te es o Jnuy

Febuy 2009.


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Summary

Fi 1 T JFb 2009 bsfs

Melbourne

Redesdale fire

Bendigo fire

Kilmore East fire

Pomborneit-Weerite fire

Narre Warren fires Bunyip fire

Murrindindi fire

Coleraine fire

Horsham fire

Beechworth-Mudgegonga fire

Churchill fireDelburn fire

Upper Ferntree Gully fire

Vcto s long, soetes devsttng, stoy o e. Te condtons on 7 Febuy gve se to ptcully

destuctve buses. Tese vey ntense es se soe etues tt set te pt o less ntense es. Vey

dy uels nd stong suce wnds esulted n etc e bevou nd te developent o stong convectve ctvty

cpble o ltng ebnds suc s bunng bk g n te convecton colun. Stong uppe wnds tnspoted

bunng bk downwnd o ny kloetes, esultng n long-dstnce e spottng.

Spottng ws n potnt cto n te sped o soe es. Febnds ced by te stong wnds sped o

one dge top to te next n es o boken ten. Tey wee ced coss spse eten-out pstue o eswee gss ws less tn ully cued nd gt otewse ve ested te es sped.

altoug tey ved n te sze nd pcts, te ost sevee o te 7 Febuy es te Cosson exned

sed nube o etues:

rpd e sped ollowed gnton, wc espondng cews could not contn.

Fes cowned n oested es, wc de te possble o gound cews to contol.

Poweul convecton coluns wee geneted bove te es.

Extensve owd spottng occued s esult o te uel type, te wete condtons nd te topogpy.

Lte n te dy wnd cnge lteed te decton o e sped nd extended te eont.


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recognITIon oF The FIreFIghTerS

Te Cosson cknowledges ll tose wo plced te lves t sk to gt te es tt buned n Vcto nJnuyFebuy 2009, nd ptcully on nd te 7 Febuy. its gttude extends to cee egtes o

ll te govenent gences nvolved, voluntees, pvte unts, ndusty bgdes, polce, nd bulnce nd ote

eegency sevces wokes, s well s egtes wo ce o ntestte nd oveses to elp. Wee t not

o te eots te dge nd loss would ve been even gete.

Te Cosson ptcully ecognses te contbuton o voluntees nd te les. Te stengt o te CFa

voluntee bse ws evdent on 7 Febuy; ts ncludes ts suge cpcty, te locl knowledge o ts ebes nd

ts pd esponse. Te Cosson ed o voluntees pepng o te dy, wnng locl esdents nd ssstng

wt te conontng tsk o loctng nd dentyng te ded. Countless oe voluntees took up suppot oles.

altoug not well known, pvte unts ply n potnt ole n egtng n ny pts o Vcto. Tey e usully

opeted by es o lndownes, nd te equpent usully conssts o sll ult-pupose utlty wt

potble tnk nd pup ounted on te e. Opetos gt be ebes o te CFa but ts s not lwyste cse.

Te opetos o oest plnttons bove cetn sze e equed to ve ndusty e bgdes. Tese bgdes

need only potect te plntton ssets, but te plntton opeto cn, nd oten does, pet te bgde to

opete outsde ts desgnted e.

Te Cosson cknowledges te egtng suppot povded by ndusty bgdes nd pvte unts nd

encouges contnued coopeton between publc nd pvte opetos. it s pctcl nd vluble expesson

o sed esponsblty tt stengtens te sttes ovell egtng cpcty.

ThE FiRE-RElATEd dEAThS

Te getest tgedy o Blck Study, nd one o te py esons wy ts royl Cosson ws estblsed,ws tt 173 people ded s esult o te es. Ts exceeded te loss o le o ny pevous buses

ncludng as Wednesdy, n Febuy 1983, wen 75 people ded n Vcto nd Sout austl.

Fve es cled peoples lves. Te getest loss esulted o te Kloe Est e (119 people); t ws ollowed by

mundnd (40), Cucll (11), Beecwot-mudgegong (2) nd Bendgo (1). Te get joty o tese people ded

on 7 Febuy; ou ded n te ollowng dys o weeks s esult o te njues tey sustned on 7 Febuy, nd

one peson, n ntestte egte, ded s esult o njues sustned te 7 Febuy.

Te Cosson ed ny ccounts o people wo suvved te 2009 buses, but t ws only by exnng

te ccustnces o te dets tt t could coplete ts nvestgton o tese es. in ptcul, te exnton

o te ccustnces o te dets elped te Cosson expnd ts knowledge o te wy people undestnd

nd espond to buse. Tese nques lso cst lgt on ts consdeton o ttes suc s plnnng nd buldng

egulton, te need o bod nge o sety optons, nd wt kes oe deendble gnst buse.

RESPONdiNg TO buShFiRE

Te esponse to te es on 7 Febuy ws cctesed by ny people tyng te best n extodnly dcult

ccustnces. Tee wee ny exples o people wo et te cllenge dbly. Neveteless, soe poo

decsons wee de by people n postons o esponsblty nd by ndvduls seekng to potect te own sety.

Te Cosson s conscous o te pessue nd dcultes people ced on te dy, but t would be neglgent

t ovelooked te sotcongs: we need to len te lessons so tt pobles cn be voded n te utue. Te

Cosson teeoe exned te polces, systes nd stuctues needed to ensue tt govenent, e nd

eegency sevces gences nd ndvduls ke noed, eectve decsons bout te esponse to buses

n wy tt potects le nd nses loss.


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Summary

VIcTorIaS BuShFIre SaFeTy PolIcy

as te es o JnuyFebuy 2009 buned e gences nd ndvduls de cucl decsons n te contexto n ovecng polcy o county sety n buses. Tt polcy d becoe known colloqully s sty o go

but s oe ccutely descbed by ts ull ttle, Pepe, Sty nd Deend o Leve Ely.

as esult o ts nques te Cosson concludes tt te centl tenets o te sty o go polcy en sound.

Te 7 Febuy es dd, oweve, seveely test te polcy nd exposed weknesses n te wy t ws ppled.

Levng ely s stll te sest opton. Styng to deend well-peped, deendble oe s lso sound coce

n less sevee es, but tee needs to be gete epss on potnt qulctons.

Te polcy s now n tnston. Snce 7 Febuy te Stte s poved te polcy nd te county educton

cpgn tt ccopnes t, ncludng n esponse to te Cossons nte ecoendtons. Te Cosson

consdes tt, ltoug te cnges te Stte s de to dte dvnce te polcy, ute cnge s needed.

Te sty o go polcy led to llow o te vtons n e sevety tt cn esult o deng topogpy, uel

lods nd wete condtons. in ptcul, t dd not dequtely ccount o te eocous es expeenced onBlck Study. a buse sety polcy ust be cpble o delng wt te ct tt evey e s deent nd ust

deentte potentl estos o ost buses. Te ost ece es cll o deent ppoc to county

sety, o deent dvce, suppot nd esponses o e gences. On suc dys, te ntl ttck ls to contn

e, te opetonl ocus nd ndset o e gences sould ove to povdng noton nd ttendng to

county sety te tn e suppesson.

Te sty o go polcy tended to ssue tt ndvduls d e pln nd knew wt to do wen wned o

buse tet. But ny people dd not ve well-tougt-out pln nd wee let to ke te own decsons

wtout te benet o ssstnce o te utotes. in ddton, wnngswen tey wee gvenwee too

now: tey wee dected t gettng people to enct te e plns, te tn gvng oe specc dectons

o dvce. Te Cosson ed tt ny people wt nd see wt ppens beoe levng n esponse

to one o oe o nge o tgges, suc s e beng n te e, te stuton becong dngeous,

o beng pesonlly told to leve. Fo tese people te lck o ltentveste povson o seltes nd euges

o evcutonbece ctcl s llbck opton. any polcy ust encouge people to dopt te lowest sk

opton vlble to te, wc s to leve well beoe buse ves n te e. Te Cosson cknowledges,

oweve, te elty tt people wll contnue to wt nd see, nd copeensve buse polcy ust

ccoodte ts by povdng o oe optons nd deent dvce.

Te Stte s ccepted tt te polcy optons o levng ely o styng to deend do not ully cove te need o

contngency plns, but t stll ppes eluctnt to pleent ltentves, gung tt te vlblty o sute o

optons could dscouge soe people o levng ely. Te Cosson s concened tt te Sttes eluctnce

s efected n te slow pogess wt county euges nd buse seltes. it sply does not ce te elty

tt te ele bny polcy ppoc dd not elp ny people wo, o vous esons, dd not nd ete opton

cceptble n te ccustnces.

advce bout buses ust lso be povded to te county n wy tt engges te. Te populton

exposed to e on te ubn nges s gowng nd te deogpcs e cngng. it s essentl tt tee be

contnued ocus on povdng nk nd enngul dvce bout te sks nd wt s equed to dequtely pepe

o nd suvve buse. Locl plnnng nd eegency ngeent pocesses e lso cucl to te oulton

o ts dvce. Te ct tt not ll ouses e deendble n ll ccustnces ws ecognsed beoe 7 Febuy.

in te Cossons vew ts essge needs to be conveyed oe oceully. an potnt obsevton o te

ccustnces o ny o te e-elted dets s tt deendblty s ected by te suoundng envonent

not just te lnd nd vegetton edtely djcent to ouse. Beng close to evly oested e cn ncese

te eocty o n ppocng e nd te lkelood o evy ebe ttck, kng t de to deend ouse.

Deendng ouse lso eques t lest two ble-boded, t nd detened dults wo e pysclly nd entlly

peped to wok long nd d n duous nd dngeous condtons. Te gous o ountng deence n te ce

o es suc s tose on Blck Study cugt ny by supse. Te Cosson nds t ptcully woyng tt

nely l o te people wo ded wee clssed s vulneble becuse tey wee ged less tn 12 yes o oe

tn 70 yes o becuse tey wee sueng o n cute o conc llness o dsblty.


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County educton ust contnue to stess tt styng n e-pone es on dys wen condtons e s sevee

s tose on Blck Study nvolves gve sk to ones le.Te polcy ppoc lso needs to ecognse te potnt undelyng pncple o sed esponsblty. a undentl

spect o te Cossons ecoendtons s tt eveyonete Stte, uncpl councls, ndvduls, ouseold

ebes nd te bode countyust ccept gete esponsblty o buse sety n te utue nd tt

ny o tese esponsbltes e sed.

Te Cosson uses te expesson sed esponsblty to en ncesed esponsblty o ll. it ecoends

tt Stte gences nd uncpl councls dopt ncesed o poved potectve, eegency ngeent nd

dvsoy oles. in tun, countes, ndvduls nd ouseolds need to tke gete esponsblty o te own

sety nd to ct on dvce nd ote cues gven to te beoe nd on te dy o buse.

Sed esponsblty does not en equl esponsblty. Te Cosson consdes tt n soe es te Stte

sould ssue gete esponsbltes tn otes; o exple, te Stte nd ts e utotes e lkely to be oe

ble tn ndvduls to denty te known sks bout buse. it s lso necessy o te Stte, uncpl counclsnd les to ecognse te specc needs o vulneble people, wo gt need ely wnng, ssstnce o

septe consdeton ptcully on code ed dys.

T t pi

Te Cosson undestnds te ttcton o n uncoplcted polcy ewok tt pesents two cle optons

sty o gobut suc n ppoc s splstc. relstc dvce s unvodbly oe coplex nd eques subtlety.

as consequence, ltoug te Cosson suggests etnng te eectve eleents o te exstng polcy t lso

ecoends ugentng nd povng te polcy n nube o es:

coveng te ull nge o eswt ptcul ecognton o te egtened sk ssocted wt te ost

eocous es on te wost o dys

stengtenng wnngs nd povng te telness nd dssenton

povdng oe pctcl nd elstc optons suc s county euges, buse seltes nd evcuton

ncludng sssted evcuton o vulneble people

povng te qulty nd vlblty o dvce on e bevou nd ouse deendblty nd clely conveyng

te essge tt ong te sks o styng to deend e det nd seous njuy.

To be eectve tese cnges need to be pt o well-desgned long-te county educton pog tt

cptues peoples ttenton, kes llownce o locl needs nd ccustnces, nd s egully evluted nd

poved. muncpl councls sould tke oe ctve ole n plnnng o buse, ncludng plnnng o evcuton

nd selte optons n te uncpltes.

aong te eleents o te polcy tt sould be etned e te ollowng:

te pncple o sed esponsbltytt tee e legtte nd potnt oles o bot ndvduls nd te Stte

encougeent to leve ely s te sest opton

styng nd deendng stll beng sound coce n less sevee condtons nd es, povdng cetn pecutons

e tken

epss on pepton, wete styng to deend o levng ely

sound dvce o ndvduls, ouseolds nd countesncludng x o specc nd genel dvce

delveed toug vous odes nd ed.

it wll not be esy to ntn te ocus on buse sety ove te. County eoy o eocous es cn de

becuse o te eltve nequency o suc events. in tese ccustnces tee s sk o ndvdul nd collectve

undeestton o te sknd possbly coplcency. indvduls ust en vglnt, nd te Stte sould use

county educton nd publc weness to bek te cycle o coplcency. Tecng buse stoy nd setyn scools s potnt o ntnng county eoy nd weness.


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Summary

Im 2 T Bi f

Souce: Coutesy oThe Bendigo Advertiser.

Fnlly, ndvdul plnnng nd cton o buse sety cn oten nvolve d decsons. Fo exple, egtng

equpent nd nstuctue e expensve, nd soe people n buse-pone es wo wnt to deend te

oes gt not ve te nncl ens to pepe te oe ully. Dles suc s ts sould be dscussed

n educton pogs unde te evsed buse sety polcy.

Te evsed polcy needs to cllenge people to tnk bout wt tey would do buse tetened on wok

dy, dung scool oldys o wen tey d ote plns (suc s pty). Tey lso need to sk teselveswete tey e pysclly nd entlly stong enoug to cope wt te dends o sustned egt, wt

would tey do te plns l, nd ow would tey potect te pets nd lvestock o would tey leve te.

People need to ce te ct tt buses do not necessly ve t convenent tes. Te plnnng needs

to efect ts elty.

eMergency and IncIdenT ManageMenT

Te Sttes eegency ngeent ewok povdes o plnnng, pepton nd coodnton n te

ngeent o cses nd ntul dsstes. On Blck Study new stte-level opetonl ngeents wee

beng tlled by te CFa nd DSE. Ts ws te st e seson (200809) tt te gences d been co-locted

nd opetng o te ntegted Eegency Coodnton Cente n melboune. Te pupose o te ECC ws

to ceve eectve sttegc plnnng nd coodnton, bette noton sng nd ste decson kng.

People wo woked t te ECC ovewelngly consdeed tt te outcoe o te es would ve been wose d te gences not been co-locted.


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8

Te Cosson gees wt ts concluson but ute concludes tt te stte-level eegency ngeent

ngeents stll lteed becuse o conuson bout esponsbltes nd ccountbltes nd soe potntdecences o ledesp. Tue ntegton ws not ceved: te CFa nd DSE ollowed opetng pocedues tt

wee not ully consstent, used septe tecnology systes, nd n ny cses peoed duplcte unctons.

Te Stte s cknowledged soe o tese pobles, nd snce 2009 systes t te ECC (now te Stte Contol

Cente) ve been upgded nd te centes lyout cnged. Te Cosson endoses tese poveents

nd suppots te contnued use o te Stte Contol Cente o ntegted eegency ngeent.

Te expeence o 7 Febuy lso glgted sevel es n wc g-level stte ngeents need eo.

On Blck Study te oles o te ost seno pesonnel wee not cle, nd tee ws no sngle gency o ndvdul

n cge o te eegency. Te Cosson notes cnges de s pt o te new coodnton, cond nd

contol ngeents but consdes tt oe sould be done. it ecoends tt te oles be cled, ncludng

toug ognstonl cnge.

Even wen te gt polces nd systes e n opeton, stong nd eectve ledesp s essentl. On 7 Febuyte ledes ulttely esponsble o te opetonl esponse to te eegency wee te Ce Oce o te CFa,

m russell rees, te Ce Fe Oce o DSE, m Ewn Wlle, nd te Ce Cossone o Polce, ms Cstne

Nxon. altoug ny o te unctons ssocted wt ec ndvduls ole gt ve been delegted to

subodntes, tese people wee stll ulttely ccountble. Te Cosson concludes tt soe eleents

o te ledesp povded on 7 Febuy wee wntng. m rees nd m Wlle ougt to ve done oe n elton

to wnngs (ts ws delt wt n te Cossons st nte epot), suppotng ncdent ngeent tes nd

sttewde plnnng. Te Cosson consdes tt ms Nxons ppoc to eegency coodnton ws ndequte.

ms Nxon esel cknowledged tt levng te ntegted Eegency Coodnton Cente nd gong oe t

bout 6.00 p on 7 Febuy ws n eo o judgent. Te Cosson ses ts vew.

altoug te Cosson concludes tt te mnste o Polce nd Eegency Sevces cted popely beoe

nd dung te buses t consdes tt e sould ve sed te opton o declng stte o dsste wt

te Pee. Te ccustnces clely et te cte o suc consdeton. Even pctcl coss-gency nd

county coopeton ws ledy n evdence nd no ddtonl coecve powes wee needed, suc declton

would ve ecognsed te gvty o te stuton nd gt ve spened eegency gences ocus on

county sety nd wnngs. in te Cossons vew, ccustnces potentlly stsy te cte o declng

stte o dsste, te opton o kng suc declton sould be dscussed wt te Pee.

Te Cosson not only looked t stte-level ngeent but lso t te ngeent o ndvdul ncdents.

Ovell, aiimS (te austlsn inte-sevce incdent mngeent Syste) ws well undestood nd ccepted by

e gences. Te Cosson suppots ts contnued use wt soe no odctons to ncese te pole o

te inoton Unt nd ecognton o te potnce o locl knowledge wtn level 3 ncdent ngeent tes.

at te locl level, te peonce o ndvdul ncdent ngeent tes ved on 7 Febuy, nd te expeence

o te dy deonstted ow potnt eectve pepton s to good peonce. it ws nvbly tose imTs

tt wee well peped, sted by people wt te ppopte tnng nd expeence, nd well pctsed tt

nged dcult es well. Te Cosson coends tese goups o te plnnng nd pepton. Pobles

tt ose wee ts dd not occu led te Cosson to ke ecoendtons bout povng pepton,

tnng nd stng, noton fows nd gency ntegton, so tt oe imTs ve te cpblty, copetence

nd suppot needed to peo well n utue es.

in te led-up to 7 Febuy te Stte, ncludng e gences, ecognsed tt te dy d te potentl to be

ctstopc nd begn plnnng nd notyng te county nd pesonnel ccodngly. Pe-desgnted ncdent

contol centes wee dvsed to be edy o ot stt. in pctce, oweve, te stte o edness o te iCCs

nd te level 3 ncdent ngeent tes tt sted te ved. agn, te Stte s poved ts pocedues

snce 7 Febuy, ncesng te nube o pesonnel equed o ull level 3 imT nd estblsng stndds o

pe-postonng tes. Te Cosson s concened, oweve, tt te evsed stndds do not go enoug,

nd t poposes tt n ll es wee code ed e dy s oecst ull imT be n plce o 10.00 .addtonlly, e gences sould pescbe nd udt nu nube o jont tnng execses o level 3 imTs.


19/52

9

Summary

On 7 Febuy not ll te imTs ngng level 3 ncdents wee sted by people wt level 3 tnng, nd cltes n

te ncdent contol centes o wc imTs opeted wee n soe cses decent. Te Cosson ecoendedn ts st nte epot tt pe-desgnted level 3 iCCs be popely sted nd equpped. in esponse, te Stte

llocted $28 llon to upgde level 3 iCCs nd dvsonl cond ponts, te upgde beng sceduled o

copleton by 30 June 2010.

Fute, te Cossons exnton o sotges o level 3 incdent Contolles eveled jo deences between

te DSE syste o ccedtton (ol ssessent o cnddte gnst known cte) nd te CFa syste o

endoseent (nonton o ppovl o peson to peo ptcul ole). Snce bot gences povde ebes

to jont imTs, t s gly desble tt tee be uno stndd nd selecton pocess, to ensue tt ec

incdent Contolle, egdless o gency, s sl expeence nd copetence. Te Cosson consdes tt

DSEs ccedtton pocess s goous nd tooug nd s sutble o use by bot DSE nd te CFa. Te CFas

pocess s oe subjectve nd less tnspent. Te Cosson poposes tt uno, objectve nd tnspent

ccedtton pocess o level 3 incdent Contolles nd syste o peonce evew be dopted nd tt

tneesp scee be used to pogess people o level 2 to level 3 postons.

Tose imTs tt wee pooly peped o dd not ve ccess to ully quled st lso oten d te getest

dculty ngng noton fows, wc e cucl to te ssung o publc wnngs nd nong egtes

o cngng condtons nd potentl dnge. in te lgt o te evdence, t s pln to te Cosson tt eectve

tnng s essentl. Te tnng needs to povde noton on te sevces vlble t te Stte Contol Cente

suc s speclsts tned n wete oecstng, e bevou nlyss nd pedctve ppngnd to stess

te potnce o pepng tely wtten ncdent cton plns (bsed on stndd teplte) wtn ou ous

o epoted gnton o e.

in ddton, sklled oces need to be suppoted by obust, consstent nd coodnted noton nd systes

o tckng e vecles nd ppng es. Wen te Sttes ppoc to gtng eocous es s so gly

dependent on coss-gency coodnton t s uncceptble tt eectve coodnton o noton systes

s not been ceved.

Fnlly, odblocks ply n potnt pt n ntnng publc sety dung buse nd te buse cn

potect elt nd sety o cltte e nvestgtons. On nd te Blck Study oe tn 4,500 odblocks

wee estblsed to egulte tc on ods ledng nto nd ound e-ected es. Te evdence eveled

nube o systec pobles wt te wy te odblocks opeted, ong te nfexblty, poo councton

nd denyng ccess to egtes. Snce Blck Study new gudelnes ve been elesed tt pove te

opeton o ull nd ptl odblocks, llow n incdent Contolle to delegte esponsblty o te estblsent

nd opeton o odblocks wt te suppot o Vcto Polce, nd olse syste o wstbnds to denty

people wo cn pss toug odblock. Gudnce s lso povded on ow polce sould execse dsceton t

odblock. Te Cosson welcoes te new epss Vcto Polce gves to copsson nd coonsense

n te execse o dsceton.

FIreground reSPonSe

Successul esponse to e eles on n eectve blend o pesonnel, esouces nd pocesses. On 7 Febuy

ny opetonl systes woked well, ptcully consdeng te wete condtons. Fo exple, te Cosson

ed ew coplnts bout egtng equpent, wc s been poty o CFa nvestent n ecent yes.

mny cews wee on stndby edy o ntl ttck, nd soe successully contolled es tt wee potentlly

vey dgng.

Te best oppotunty to bng buse unde contol s t o ne te pont o gnton, wen te e s sll. Te

ole o st ttck s to contn te e swtly nd nse te sk to le nd popety. Ts s ptcully potnt

on dys o extee e dnge, wen ntl ttck gt be te only oppotunty o contnng e. act e n

ntegl pt o ntl ttck nd, togete wt gound cews, povde contnung suppot dung n extended e.

Dependng on wee tey e sttoned nd te dsptc potocols, ct cn oten get to e nd stt te

ntl ttck beoe gound cews ve.


20/52


10

Im 3 Fis Kik

Souce: Coutesy oThe Herald & Weekly Times.

Dung JnuyFebuy 2009 ct plyed n potnt ole n te esponses to es. On 7 Febuy, oweve,te use nd eectveness wee lted by te wete, wc n ny cses de fyng unse. Tee wee ote

pedents, too. Fo nstnce, te pocess o dsptcng n ct eques equest o te ct to pss

toug tee lyes o utoty beoe t s cleed by te Stte a Desk. Te syste s cubesoe nd n soe

cses delyed te esponse. altentve etods o pd dsptc e used elsewee n austl nd oveses,

but Vcton gences ppe eluctnt to consde te opton o ste esponse syste. Te Cosson

poposes tt stte polcy be cnged so tt ll pesonnel equed to fy ct nd suppot ttck e on

stndby on code ed dys nd tt ct e utotclly dsptced to g-sk es n desgnted es.

Te Coonwelt owns nd contols ct tt could be used o egtng. Beoe te 200910 e seson

t eld n opetonl beng, outlnng ts esouces nd cpbltes to te sttes nd tetoes. Te Cosson

consdes, oweve, tt coopeton between te Stte nd te Coonwelt would be stengtened by n

geeent tt llows Coonwelt el esouces to be utotclly ncopoted n te Sttes pepedness

plnnng nd, wee vlble, used on dys o g e sk.

moe bodly, eectve ccess to nd use o tecnology s potnt to eectve detecton nd ngeent

o es nd tckng o esouces on te gound. as noted, vous pobles bece evdent wt noton

tecnology t ncdent contol centes, ncludng becuse te CFa nd DSE used deent systes nd ncdent

ngeent te st soetes d dculty gnng ccess to bot systes. Ts nbted te use nd tnse

o noton suc s wnngs, ps nd stuton epots. Te Cosson notes tt te CFa nd DSE e

nvestng n systes ed t ectyng ny o tese sotcongs, ncludng toug te extensve upgde

o level 3 ncdent contol centes.


21/52

11

Summary

resouce tckng s oten nul nd te-consung pocess. it s essentl incdent Contolles know te

locton o vecles, pesonnel, equpent nd ct so tt e ngeent cn be plnned nd dected ndctcl noton, suc s ed fg wnngs, cn ec tose on te egound wen tey need t. Te Cosson

dented two es o concen. Fst, te CFa nd DSE use deent systes nd te CFa syste, by te CFas

own dsson, s not kept up wt eegng tecnology. Second, on 7 Febuy tee wee wdesped pobles

wt dos nd pones nd cews not llng n te equed ppewok, wc de t dcult to tck egtes

nd vecles. Te Cosson kes specc suggestons o povng noton nd tckng systes nd

poposes tt stnddsng tese systes be poty.

Counctons systes on 7 Febuy wee lso ndeed by poo covege, lck o nteopeblty between

eegency sevces gences, nd nsucent nvestent n new tecnologes. Fo exple, te tnssson speed

o te pgng syste d been educed n ode to expnd ecepton covege, nd ts cused seous delys n

ote tn te ost ugent essgng. Tee wee lso councton dcultes between etopoltn nd egonl

polce becuse o ncoptble do systes. Fute, do blck spots ent tt ecepton ws poo o non-

exstent n soe es, nd tee ws cnnel congeston nd nsucent cnnel vlblty. Tese pobles weeexcebted wen e dged o destoyed do nd telecounctons nstuctue.

Te Stte s begun wok to esolve tese pobles, notbly toug te new Eegency Sevces Counctons

Sttegc Fewok, wc s sx potes: seless sttewde councton, cll tkng nd dsptc,

consstent sttewde qulty o sevce, poved dt sevces, locton-bsed sevces, nd county

councton. Untl te sttewde counctons syste envsged by te new ewok becoes elty,

te CFa sould contnue to pove ts exstng counctons syste, ncludng by esolvng covege decences.

Tee sould lso be ute esec nto soke nteeence wt counctons systes nd equpent, nd

ts poble sould be ecognsed n CFa nd DSE tnng o counctons plnnes.

Fift st

Te CFas nd DSEs ngeent o egte sety deseves coendton. Te nube o es tt neededto be tckled sultneously, nd te ntensty, ceted enoous cllenges nd sks o egtes on Blck

Study. at tes condtons wee cotc on te egound, counctons wee dcult, nd supevsos nd

cew ledes wee equed to nge n extee condtons. Te ct tt tee wee no egte dets dung

egtng ctvtes on 7 Febuy speks volues o te epss te CFa nd DSE d gven to tnng nd

sety weness.

ipovng egte sety s ocus o te CFa nd DSE, especlly snce te Lnton nquy nto te det o

ve egtes n 1998. in te dys beoe 7 Febuy tee ws stong epss on egte sety, ncludng

gvng cews sety bengs. a nube o cews psed te equpent nd sety esues vlble to te dung

te bunoves on Blck Study.

Despte ts, te Cosson ed tt tee s ute scope to pove egte sety. altoug no-one ded

dung egtng ctvtes, egettbly two egtes dd de n Febuy 2009. One egte ded on 7 Febuywen e let s cew to elp eltve, nd n ntestte egte ded on 17 Febuy te beng stuck by llng

tee. Tee wee lso nueous occsons on wc egtes wee n extee dnge nd soe wee njued.

Fegtes cugt n bunoves oten lcked te ccute nd tely noton tey needed to vod sk.

indequte bengs, councton nd councton equpent, ps nd wete noton wee coon

concens. Te Cosson lso dented sevel decences n sety nvestgtons nd poposes tt te CFa

nd DSE end te pocedues o nvestgtng sety ncdents nd ne sses. Fe gences sould lso ocus

on ensung tt tey ve tooug pocesses o dentyng nd ppovng ptcully dngeous ctvtes suc

s bck-buns. Te Cosson ecoends tt ts be suppoted by tnng o ll pesonnel, to ensue tee

s cle undestndng o te esponsblty o te incdent Contolle n ppovng suc ctvtes.


22/52


12

Te Cosson s lso dspponted t te low poty gven to te ppontent o sety dvses, despte suc

dvses beng ndtoy o level 3 ncdents unde te CFa nd DSE jont stndd opetng pocedues. Tesepesonnel ensue tt sety s poty nd dvse, gude nd suppot te ncdent ngeent te n dentyng

nd delng wt sety concens. On 7 Febuy tee wee bout 200 tned DSE nd CFa sety dvses but

only two wee pponted to ncdent ngeent tes.

Gven te lue to ppont sety dvses nd te dngeous stutons tt cugt nube o egtes

unwe on 7 Febuy, te Cosson es tt n oce esponsble o sety ust be pponted to ll level

3 ncdents. in ddton, sety dvses sould be ened sety ocesconsstent wt ecoendtons o

te Lnton nquy nd consstent wt te ttle gven to ote key pesonnel n n ncdent ngeent te.

REduCiNg ThE NumbER OF FiRES

it s xotc tt te ost eectve wy o educng buse dge nd potectng un le s to pevent es

o sttng. it s obvously possble to elnte buses, but t s possble to educe te sk nd ncdence

o es stted s esult o un ctvty. Nne o te 15 es te Cosson exned wee stted s dect

o ndect esult o un ctvty; ve wee ssocted wt te lue o electcty ssets, nd te cuses o ou

wee tougt to be suspcous.

Bode dt suggest tt bout one-td o buses n Vcto gt be lt by people ctng wt scevous

o cnl ntent. altoug te popoton o es tt e cused by electcty nstuctue s lowpossbly bout

1.5 pe cent o ll gntons n nol ccustnceson dys o extee e dnge te pecentge o es lnked

to electcl ssets ses dtclly. Tus, electcty-cused es e ost lkely to occu wen te sk o e

gettng out o contol nd vng dedly consequences s getest.

Vctos electcty ssets e geng, nd te ge o te ssets contbuted to tee o te electcty-cused es

on 7 Febuy 2009te Kloe Est, Colene nd hos es. Dstbuton busnesses cpcty to espondto n geng netwok s, oweve, constned by te electcty ndustys econoc egultoy ege. Te ege

vous te sttus quo nd kes t dcult to bng bout substntl eo. as coponents o te dstbuton

netwok ge nd ppoc te end o te engneeng le, tee wll pobbly be n ncese n te nube o es

esultng o sset lues unless ugent peventve steps e tken.

Te Cosson consdes tt now s te te to stt eplcng te geng electcty nstuctue nd to ke

jo cnges to ts opeton nd ngeent. Te seousness o te sk nd te need to potect un le

e petves Vctons cnnot gnoe. Te nube o e stts nvolvng electcty ssets ens uncceptbly

gt oe tn 200 ye. altoug t s not possble to elnte te sk posed by electcty ssets, te Stte

nd te dstbuton busnesses sould tke te oppotunty to nvest n poved nstuctue nd substntlly

eove one o te py cuses o ctstopc es n Vcto dung te pst 40 yes.

in vew o te sze o Vctos electcty dstbuton netwok, ny eplceent pog wll tke yes to copleteeven t begns edtely. it s teeoe necessy to consde nte esues o educng te buse sk

ssocted wt te cuent netwok nd te Cosson suggests wys by wc ts could be done.

Te Cosson consdes tt Enegy Se Vcto needs to tke oe poctve ole s te electcty ndusty

sety egulto. in te pst t s tken lgely pssve ole, ocusng on conng dstbuton busnesses

buse tgton plns nd lne clence plns. it s not ssessed n detl wete sety objectves contned

n te Electricity Safety Act 1998 e ctully beng ceved. Te Electcty Sety mngeent Scee ege

s undegone potnt cnges ecently. it s now copulsoy o te dstbuton busnesses to ptcpte n te

ege nd specy ow tey wll eet te oblgtons unde te Electcty Sety act. Enegy Se Vcto sould

now lso ve ccess to oe o te dt needed to ssess te ccustnces o es cused by led dstbuton

nstuctue nd ne sses, so tt t cn denty tends nd tke tese nto ccount n te developent o

buse peventon stteges.


23/52

13

Summary

Ovell, te Cosson s stongly o te vew tt Enegy Se Vctos egultoy powes nd esouces need

to be stengtened, ncludng te ognstons blty to pply snctons o non-peonce. it poposes ttEnegy Se Vcto ve cle ndte to pevent nd tgte electcty-cused buses nd powes to ull

tt ndte.

Te ote jo buse cuse lnked to un ctvty eltes to es tt people delbetely o ccdently lgt.

Delbete e-settes consttute only sll popoton o te populton, yet te ctons cn cuse enoous

dge to ndvduls, countes nd te envonent. Te evdence beoe te Cosson suggests tt

tee s good del o peventve ctvty unde wy t te locl, stte nd ntonl levels. Tee ens, oweve,

consdeble scope to pove te evdence bse on delbete e-settng nd so pove polcy nd pog

developent; te extent nd cuses o ts bevou e not well undestood.

Te Cosson notes tt tdtonlly Vcto Polces ppoc to son s ocused on cnl nvestgton

nd eegency ngeent, te tn ce peventon. Ts ppes to be cngng. Vcto Polce s

cknowledged tt t s necessy to bette undestnd sonsts nd te bevou nd otvtons n ode

to pove peventon nd contol. it dvsed te Cosson tt snce 7 Febuy 2009 t s getly ncesed

te ttenton t pys to son peventon. Specclly, t s ntoduced sttewde son peventon nd detecton

sttegy nd sttewde Opetons response Unt, wc wll, ong ote tngs, ncese vsble polce ptols

n g-sk loctons dung peods o extee buse sk.

Te Cosson welcoes te ocus on esec nd evluton o cuent nd poposed stteges. it uges

Vcto Polce to contnue to pusue coodnted sttewde ppoc to son peventon nd to evlute ts

ppoc te te st e seson n wc t opetes, to detene wete sucent suppot s beng gven

to locl nttves.

Te Cosson lso welcoes te ntonl ocus on son peventon by te mnstel Councl o Polce

nd Eegency mngeent. it encouges te Coonwelt, stte nd tetoy govenents to ensue

tt te Ntonl Wok Pln to reduce Buse ason s sutble ocus on evlutng cuent nd poposed

pogs to encouge te developent nd sng o best-pctce ppoces nd gves poty to poducng

ntonlly geed ewok o dt collecton.

REduCiNg ThE dAmAgE CAuSEd by FiRE

Fe s n ntegl pt o te austln envonent, nd te sttes n te sout-est e ost pone to buses.

Te sks ssocted wt buses e lso potentlly ncesng s esult o populton gowt n te ulubn

ntece nd te pobble eects o clte cnge. Te esult s tt, ltoug t gt be possble to educe

te nube o sevee es nd to be bette peped o e, buse wll neve be elnted o te austln

lndscpe.

recognsng tt t s not possble to stop ll es, te Cosson consdeed wys o educng te loss o le

nd dge cused wen e does occu by educng exposue to e, elpng to ke oes oe deendble,educng te ntensty nd sped o e, nd elpng people ecove o te pct o e.

PlannIng and BuIldIng

in ll, 2,133 ouses wee destoyed s esult o te JnuyFebuy 2009 buses n Vcto. Te Cosson

ed ny ccounts o people wo ted to deend well-peped ouse nd led. mny o te

173 people wo ded s esult o te es d been tyng to deend te oe, nube o wc d been

peped n ccodnce wt CFa dvce. Tese esults deonstte tt wee people lve, te stndd o te

buldngs n wc tey lve, ow tose stndds e ntned nd, teeoe, plnnng nd buldng contols

e cucl ctos ectng sety n buse.

Te potecton o un le sould lwys be te ovedng objectve. altoug t s not possble to guntee

tt ny buldng wll suvve buse, ptcully eocous one, te Cosson consdes tt tee e soees wee te buse sk s so g tt developent sould be estcted.


24/52


14

Im 4 lki t Mb m t Kik rs

Souce: Dvd Gegty, coutesy oThe Herald & Weekly Times.

Te ppoc te Cosson poposes cknowledges te coplexty o te plnnng syste nd seeks to

stengten consdeton o buse tougout te plnnng pocess by gvng gete ecognton to buse sk

wtout posng uncceptble bodvesty costs. Ts s te ost eectve wy o ntnng te cpcty to ssessec developent on ts ets, wle ensung tt suc ssessent ttces sucent wegt to te sk nd

pcts o buse. Te Cosson teeoe poposes tt te Vcto Plnnng Povsons eltng to buse nd

te CFa gudelnes o ssessng pet pplctons n es o g buse sk be ended n ode to gve poty

to potectng un le nd to ensue tt developent does not occu n es n wc ete te buse sk o

te envonentl cost o kng people se s too g. Te eectveness o tese contols sould be evewed t

lte stge to detene wete te objectve o substntlly ltng te constucton o oes n es o g

buse sk s been ceved. i not, oe pescptve contols sould be ntoduced.

in ddton, te Cosson kes detled poposls bout te plnnng ege n ode to pove noton

nd undestndng o buse toug bette ppng o bot buse sk nd Vctos bodvesty. it lso

ecoends tt buse sk be ccounted o n te pplcton o contols on cleng ntve vegetton nd tt

te constucton o ouses be estcted on g-sk blocks tt e too sll to enble deendble spce to be

ceted nd ntned.


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15

Summary

in elton to buldng stndds, te Cosson concludes tt constucton stndds o buse-pone es

do not dequtely cove ll te potnt coponents o buse sk. it ecoends povng stndds ndclyng objectves to edess tese decences. Te g sk to ny oe tt s bult n te Fle Zone nd s

teeoe lkely to be subject to dect contct wt fes ust lso be ecognsed. Deeed-to-stsy constucton

stndds e not ppopte o suc dwellngs. Becuse o te sk, ec buldng ust be desgned specclly

to espond to te condtons on te ste.

Fute, buldng egultons do not dequtely cove te constucton o non-esdentl buldngs used by vulneble

goupso exple, scools, osptls, cld ce centes nd ged ce cltesn buse-pone es. Te

buldng egultons need to contn specc stndds o te constucton o suc buldngs.

applyng lnd-use plnnng nd buldng contols to nse o educe buse sk pesents cllenges. in ptcul,

te plnnng nd buldng systes opete pospectvely nd ve lttle cpcty to del wt pst decsons nd

exstng settleents o buldngs n buse-pone es, so tey cnnot ccount o people wo e ledy lvng

n es o exteely g sk. Te Cosson teeoe poposes tt cton be tken to elp people ove wy

o tose es wee ote buse sk-tgton esues e not vble. in ptcul, te Stte sould

develop nd pleent volunty etet nd esettleent sttegyncludng non-copulsoy lnd cquston

o exstng developents n es t uncceptbly g buse sk.

Even wen buse sety s ebedded n plnnng nd buldng decsons t cn be dcult to ensue tt te

stndds tt ppled t te te o subdvson o constucton e ntned. Tee s need o ecnss

desgned to ensue tt buse sety contnues to be poty o buldng ownes. Te Cosson puts owd

nge o poposls ed t clttng contnued ntennce o stnddsncludng endng te Sale of

Land Act 1962 to eque tt vendo stteents nclude noton tt wll elp potentl buyes undestnd

te buse sk o popety beoe tey nlse te pucse.

land and Fuel ManageMenT

Pescbed bunng s one o te n tools o e ngeent on publc lnd. it cnnot pevent buse, but tdeceses uel lods nd so educes te sped nd ntensty o buses. By educng te sped nd ntensty

o buses, t lso elps potect fo nd un. ionclly, ntnng pstne oests untouced by uel educton

cn pedspose tose oests to gete destucton n te event o buse.

about 7.7 llon ectes o publc lnd n Vcto s nged by DSE. Ts e ncludes ntonl pks, stte

oests nd eseves, o wc lge poton s oested nd pone to buse. DSE buns only 1.7 pe cent

(o 130,000 ectes) o ts publc lnd ec ye. Ts s well below te ount expets nd pevous nques

ve suggested s needed to educe buse nd envonentl sks n te long te.

Te Cosson ecognses tt pescbed bunng s sky, esouce ntensve, vlble only n lted te es,

nd cn tepoly ve dvese eects on locl countes (o exple, educed qulty). Noneteless, t

consdes tt te ount o pescbed bunng occung n Vcto s ndequte. it s concened tt te Stte s

ntned nlst ppoc to pescbed bunng despte ecent ocl o ndependent epots nd nques,

ll o wc ve ecoended ncesng te pescbed-bunng pog. Te Stte s llowed te oests to

contnue ccuultng excessve uel lods, ddng to te lkelood o oe ntense buses nd teeby plcng

egtes nd countes t gete sk.

Te Cosson poposes tt te Stte ke cotent to und long-te pog o pescbed

bunng, wt n nnul ollng tget o nu o 5 pe cent o publc lnd ec ye, nd tt te Stte be

eld ccountble o eetng ts tget. DSE sould ody ts Code o Pctce o Fe mngeent on

Publc Lnd so tt t s cle tt potectng un le s gven gest poty, nd sould epot nnully on

pescbed-bunng outcoes.

To ensue contnung envonentl potecton, te Stte needs to pove ts undestndng o te eects o

deent e eges on fo nd un. Te Cosson poposes tt DSE expnd ts dt collecton on te eects

o pescbed bunng nd buse on bodvesty. mntennce nd extenson o dt collecton on Vctos fo

nd un ssets s not been g poty. it needs to be poved so tt oe noed nd scentclly-bseddecson kng cn ccopny te developent o pescbed-bunng eges tt eet consevton objectves

s well s ccoodtng buse sety consdetons.


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mngng cleng long odsdes s ptcul cllenge o uncpl councls. Te councls e esponsble o

buse peventon nd tgton nd bodvesty ngeent long locl nd soe tel ods; Vcrods ssl esponsbltes o ul eewys nd tel ods. in soe cses tese odsdes contn te only ennt

ntve vegetton n n e nd oe potnt wldle codos nd selte. Consequently, deng objectves o

od sety, bodvesty potecton nd buse peventon cn be dcult to econcle.

in te cse o buses, ods nd odsdes cn be potnt uel beks, so od nges need to educe

te uel levels n pepton o te e seson. rods e lso essentl o people seekng to escpe es nd

o eegency sevces seekng ccess to es. Snce te 2009 es lnd nd od nges nd te CFa ve

dented g-sk ods nd e cyng out uel-educton wok to educe te utue sks o buse.

Te Cosson s we o te unesolved tensons between tgton o buse sk nd envonentl

consevton n te ppoc to odsde cleng nd te legsltve coplextes to do wt od sety, bodvesty

nd buse sk tgton tt ect odsde ngeent. Tese concens would be educed te Sttes

plnnng povsons wee ended to cltte bod nge o odsde woks to educe buse sk, uncpl

councls eceved bette gudnce to elp te esolve copetng envonentl nd buse ngeent

objectves, nd Vcrods pleented systetc sttewde ssessent o buse sk o ll ods.

relIeF and recoVery

Te destucton wougt by te buses o JnuyFebuy 2009 esulted n one o te lgest ecovey eots

seen n austl. Te Cossons obsevtons on te ely ele nd ecovey eots e bsed on ccounts

o peoples ndvdul expeences nd noton t exned. recovey o people, countes, locl econoes

nd te envonent s dcult nd eques long-te ppoc. Ts pocess s beng cltted by te Vcton

Buse reconstucton nd recovey autoty, estblsed on 10 Febuy 2009.

in vew o te scle o te dsste, te Cosson consdes tt ovell te ntl ele nd ecovey eots wee

well nged. muncpl councl ele centes wee genelly ctvted quckly. Tey povded ssebly ponts nd

plces o euge o people dsplced by te es nd elped to ly oundton o te pogessve buld-up o elend ecovey sevces. Te Cosson ed ny expessons o gttude o people ected by te buses

o te ce nd ttenton tey eceved t ele centes. Te Stte nd Coonwelt Govenents ele nttves

wee genelly popt nd well coodnted. Te mnste o Polce nd Eegency Sevces coodnted ecovey

eots t te Stte Cbnet level, s would be expected.

People o locl countes, nd ten te wde county, esponded geneously to te obvous need o

suppot to be povded to people endeed oeless nd dslocted by te es. Food, clotng nd beddng fooded

n to ele centes, nd get debt o gttude s owed o ts geneosty.

But te cos cused by dsste o ts scle nevtbly ent tt unntcpted stutons ose nd soe plns

led. Te Cosson ecognses tt ele nd ecovey pocesses e coplex nd e de oe so wen te

eegency s pdly escltng nd occung t ultple loctons. Contnung es, nccessble ods nd loss

o powe nd telecounctons ndeed ele eots nd nteeed wt councton nd oblty. Ts stesson te syste bougt nto ocus soe county concens bout ntl ele nd ecovey pocesses:

Te egstton pocess n ele centes ws usttng to ny s ecovey gences septely collected

pesonl noton o buse-ected people, ddng to te tu nd slowng te gences blty

to espond. it took soe te o coodnted collecton o noton to becoe eectve.

medcl sevces wee not lwys vlble loclly, nd ntlly tee ppeed to be poo coodnton o soe

st d sevces.

Post-e wele cecks wee not well coodnted, especlly o sll, solted countes nd ndvduls

wo ened on te popetes.

rodblocks wee souce o ustton nd dculty o locl esdents, Vcto Polce, te Deptent

o Py industes, CFa voluntees nd otes coodntng ele eots.


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17

Summary

Im 5 Msvi ts t mmb Bk St

Souce: Coutesy oThe Age.

Non-nsunce nd unde-nsunce ve peded te ebuldng pocess.

Fencng bodeng publc lnd ens poble becuse o te equeent tt pvte lndownes be

te ull cost o estong dged encng between te popety nd publc lnd.

Te coodnton o nl ele te te es ws gented.

Te Stte s snce ntted cnges to pove ny o tese pocesses.

Te Cosson consdes t too ely to coent n detl on te edu- to long-te ecovey nd econstucton

eot, but t encouges te evew nd evluton o nttves to suppot lenng o expeence.


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buildiNg ON CuRRENT kNOwlEdgE

altoug tee s uc to len o te expeences o Blck Study, te Cosson uges ll nvolved n

developng nd pleentng buse polcy to look to te long te. Govenents need to cete n envonent

n wc ndvduls, countes nd e gences buld on cuent knowledge n te lgt o utue noton nd

expeence. To ke people lvng n buse-pone es se, Vcto needs fexble polcy tt tkes dvntge

o new tecnology nd cnges ngeent pctces to cptlse on potentl poveents. adptve tnkng

nd pocesses e best suppoted by good ognstonl stuctues, goous esec, nd contnuous polcy

evluton nd poveent.

organISaTIonal STrucTure

in te Cossons vew, dsste o te scle o 7 Febuy wll lwys put pessue on ognstonl

pocesses nd stuctues. in ts cse t glgted seous decences n top-level ledesp s esult o dvded

esponsbltes, nd te opetonl esponse ws ndeed by deences between gences systes, pocesses

nd pocedues. indvdully, te pobles dented gt be esolved by cngng wokng ngeents between

te CFa nd DSE, nd wok s ledy unde wy towds ts. But, wen consdeed collectvely, te pobles

llustte systec lngs tt led te Cosson to conteplte ognstonl cnge. Te Cosson does not

consde tt te sotcongs dented n connecton wt Blck Study cn be ovecoe sply by dong oe

o te se, even t s done bette.

mny o te concens dented elted to opetonl ttes suc s contol, nteopeblty nd ntegency

stndds, ledng te Cosson to conclude tt ocus on povng opetonl cpblty s equed. in

consdeng te ole o ognstonl cnge n espondng to tese concens te Cosson sougt wde

nge o vews o wtn Vcto, o ntestte nd oveses, nd o te polcy, opetonl nd cdec

pespectves. a dvesty o vews ws pesented. Tee ws no consensus bout te best ppoc to ognstonl

ngeents o Vctos e sevces gences. No ws copellng odel put owd.

in wegng te vous opnons, te Cosson ws not convnced by te Sttes vew tt stuctul cnge s not

needed nd tt te ocus sould be on eneent o exstng ngeents. Fo ny o te opetonl pobles

te Cosson dented, pevous ttepts to pove coodnton ve led. Typclly, pogess s been slow

o ncoplete o s not ceved te level o nteopeblty equed. Nete s te Cosson pesuded tt

dcl eo, suc s ovng to sngle e sevce, s necessy o desble t ts te. Tee gt be n ntutve

ttcton to egng gences, but tee s sk tt te ege tsel becoes te py ocus o eot, wc could

esly dstct ttenton nd ocus o te opetonl poveents te Cosson consdes to be te poty.

Fute, t wee not done ceully, subsung ll eleents nto one gency could undene te stengts o

ec gency. Fo nstnce, DSEs speclst expetse n oest egtngwc s cucl gven te e sk tt

ccteses Vctos oestsust be ntned nd stengtened. addtonlly, tee wee no copellng

ctcss o te govennce stuctues o te e gences, nd te Cosson teeoe poposes tt te exstng

govennce ngeents en uncnged.

Te bsolute poty s to pove opetonl peonce. in suppot o ts, te Cosson ecoends

odest nd tgeted ognstonl eo s ctlyst o cnge. Ts would nvolve poveents to coon

opetonl polcy nd stndds, stonge coodnton nd unbguous cond nd contol, gete

nteopeblty, nd stengtened cpcty to povde n ntegted esponse.

in keepng wt tese potes, te Cosson sees te edte ppontent o ull-te Fe Cossone

s necessy st step. Te Fe Cossone would be n ndependent sttutoy ppontent nd te seno

poessonl e oce n Vcto. Te poston would not entl govennce o ngeent esponsblty o te

tee e gences (te CFa, DSE nd te metopoltn Fe nd Eegency Sevces Bod). Te Ce Oces

o te gences would, oweve, be dected by te Fe Cossone on opetonl ttes n pepton o nd

on extee nd code ed dys nd o level 3 es. Te Fe Cossone would be esponsble o te ollowng:


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19

Summary

developng nd buldng opetonl cpcty to pepe o te gest sk dys

te contol o level 3 esstndng delegtons o level 3 es would est wt te Ce Oces o te CFa,DSE nd te mFB, wo would lso etn opetonl contol ove level 1 nd 2 es

ledng pog o eo to expnd opetonl cpblty, nteopeblty nd te eslence o Vctos e

sevces. Ts would be set out n tee-ye cton pln endosed by te mnste nd would nvolve wokng

closely wt te Ce Oces, wo would led opetonl cnge n te espectve ognstons

dvsng te Govenent on te etopoltn e dstct boundy

epesentng Vcto on opetonl ttes n ntonl cottees.

Te Cosson lso looked t te undng o e sevces. Fe sevces n Vcto e cuently unded toug

x o contbutons o nsunce copnes, te Stte nd uncpl councls. insunce copnes ecoup

te cost o te sttutoy contbuton to te CFa nd te mFB by posng Fe Sevces Levy on nsunce

peus o buldng nd contents nsunce.

Te cuent odels cled benet s tt te nsunce peu s good wy o lnkng te cge o e sevces

to te e sk o ndvdul popetes. Evdence suggests, oweve, tt ts lnk s t best tenuous. Fundentlly,

te Cosson consdes tt te cuent undng odel lcks tnspency nd s nequtble snce people wo

e not nsued o e unde-nsued do not ke contbuton to te undng o e sevces.

Te Cosson tkes te vew tt te lck o equty nd tnspency n te cuent ngeents consttutes

good eson o ovng to note syste. Sevel ote austln sttes nd tetoes ledy eque ll popety

ownes to contbute to e sevces v levy on popety, s opposed to nsunce, nd te Cosson poposes

tt Vcto lso ove to eplce te Fe Sevces Levy wt popety-bsed levy.

reSearch and eValuaTIon

Govenents need to nvest oe n buse esec to enble austl to ebuld te cpcty t once d

s lede n ts eld. Te Buse Coopetve resec Cente (ntted by austln nd New Zelnd e

nd lnd ngeent gences, te esec ptnes nd te Coonwelt Govenent) contbutes to ts

eot. Ovell, te Buse CrC s de gns n e-estblsng county o eseces nd s consoldted

te esec gend, but t does not eet ll esec needs. To lge extent ts esec pog s detened

by ts stkeoldes (wc s esulted n ocus on ppled esec) nd ts undng cycle nd tus ts esec

pojects ve been eltvely sot te. Coonwelt Govenent undng o te Buse CrC s due to expe

n 2013.

a penent ntonl cente o buse esec s needed wt esonble suety o long-te undng.

in developng te odel o suc body, govenents sould consde ncopotng te ollowng etues:

pue nd ppled esec s well s long-te esec pojects

stong govennce ngeentsncludng esec ndependence

te locton o te esec cente, peebly n Vcto

blnced ocus tt ncludes pyscl, bologcl nd socl esec

lnks wt tecng nd pooton o gdute scolsps

coss-nsttutonl nd jusdctonl collboton

ntentonl collboton nd sng o knowledge

te esec potes glgted n evdence beoe te Cosson.


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Te Cossons wok eveled nube o esec gps nd potes. Soe wee sed by expet wtnesses;

otes bece ppent wen te Cosson ws conductng ts nlyss. Tese gps e good sttng ponto consdeng sot- nd long-te potes o buse esec n austl. Tey nclude te ollowng es:

te eects o pescbed bunng nd buse on bodvesty nd on educng buse sk

te estblsent o dtbses to p Vctos fo nd un, to egste Vctos e sk nd to denty

ts buse-pone es

te extent o delbetely lt buses nd te cuses o e-settng bevou

te long-te eect o tu esultng o te expeence o buse

te eects o e ctvty nd soke on do counctons

te extent o od dets n buses, ncludng use o cs s seltes n buses

ouse deendblty n extee condtons

te ccustnces o te tousnds wo suvved te Blck Study buses by levng ely o lte

o by deendng te oes o selteng

te selte optonsncludng ctos ectng te sety o deent plces o selte nd ptcully oto

vecles n te open, ds, pools, ceeks nd wte tnks.

in ddton to ts, te Cosson nvtes te Coonwelt to tke te nttve on two ttes outsde te

poposed esec ewok. Te st s to consde te developent o ntonlly cceptble buse tenology.

it bece ppent dung te Cossons engs tt nube o buse-elted tes e cubesoe,

ve obscue enngs o e potentlly conusng to te genel publc. Te second tte ses o tee beng

no geed etodology o esttng te cost o buses. Te Cosson expeenced dculty peong

ts nlyss becuse o te lck o dt nd te bsence o n geed etodology o esttng vous costs.

Ts s decency n te ntonlly vlble buse noton nd n e n wc ute collbotve wok

s wnted.

Fnlly, e gences e to lt te cpblty nd peonce nd pove te esponse cpcty o ndvduls

nd countes, tey need to becoe tue evdence-bsed lenng ognstons. Te Cosson poposes

tt te e gences dopt nd und cultue o efectve pctce tt outnely pusues cuent esec, seces

o best pctce, nd btully evlutes polces, pogs nd pocedues wt vew to povng ntenl

pctce nd tt o te countes tey seve. Polcyespeclly n n e suc s buse setyneeds to

be evewed nd evluted peodclly, wt te esults o suc evew nd evluton beng used n te developent

o polcy nd pog poveents.

IMPleMenTaTIon

in esponse to te unpecedented events o Blck Study, te Stte, te Coonwelt nd locl govenents

de cnges to te polces nd pctces. Te govenents nd gences ntted soe o tese cngeso te own volton; ote cnges wee pleented n esponse to te ecoendtons n te Cossons

nte epots.

Snce te Cossons nte epots wee ssued te Stte s nvested consdeble ount n nstuctue,

tecnologcl poveents nd wde-ngng endents to polces nd pocedues. Fo exple, t endosed

10-ye Eegency Sevces Counctons Sttegy Fewok to pove eegency sevces

counctons nd developed te One Souce One messge tool to enble ll incdent Contolles to send buse

wnngs sultneously to nge o outlets, ncludng te CFa nd DSE webstes, Vcton Buse inoton

Lne opetos nd ed bodcstes. altoug te Stte s sown stong cotent to pleentng

te Cossons ecoendtons, te ipleentton monto neveteless noted soe concen bout te

ecoendtons eltng to te e dnge tng, negbouood se plces, nd te pepedness o soe

ncdent contol centes. Te ipleentton monto lso noted slow pogess n te locl govenent secto.


31/52

21

Summary

Te Coonwelt s lso de pogess pleentng nttves nd te Cossons nte

ecoendtons. aong te potnt developents e povson o undng to te sttes nd tetoeso te pocueent o te ntonl telepone-bsed wnng syste, ncopotng e dnge ndexes n dstct

nd townsp oecsts ssued by te Bueu o meteoology, nd ovng speedly to ntte te developent

o stndds o bunkes n buse-pone es.

as ts nl epot kes ute ecoendtons, te pleentton eot wll be ongong. Te Cosson notes

tt te ecoendtons o pevous nques ve not lwys been pleented. Fo exple, ecoendtons

ecognsng te potnce o pescbed bunng n ngng buse sk ve not led to sutble pescbed-

bunng tgets o Vcto. Te Cosson teeoe consdes tt tee s need o pocess weeby

govenents nd te county ve ccess to tnspent, ndependently veed noton on te esponse

to te Cossons ecoendtons.

Te Stte sould nonte n ndependent pleentton onto o te Vcton audto-Genel to povde to

te people o Vcto epot wtn two yes on pleentton o te Cossons ecoendtons. Te epotsould detl te pogess de towds pleentng ec ecoendton n te nl epot nd te nte

epots. recoendtons o te nte epots tt ve not been ully pleented (suc s tose concenng

euges) sould be gven specc ocus. Ote ecoendtons tt sould eceve ptcul ttenton e tose

tt govenents ve pevously sown eluctnce to pleent (suc s ncesed uel-educton tgets) nd

jo ecoendtons tt wll eque substntl pleentton eot (suc s eplcng geng electcty

dstbuton nstuctue).

Wee ppopte, te nnul epots o govenent nd e gences sould detl te outcoes nd eectveness

o te esponse to te ecoendtons. i tee s no dscenble cnge, oe extensve eo gt be needed.

ipleentton o te Cossons ecoendtons clls o eot on te pt o ll levels o govenent. Ts

gt pove ptcully cllengng o uncpl councls. Te Cosson envsges tt councls would tke

uc gete ole n locl plnnng nd pepton o buse nd n pleentng exstng plnnng nd buldnglws wtn ewok tt tkes bette ccount o buse sk, wle contnung wt te exstng ole n buse

ele nd ecovey.

Te Cosson kes soe suggestons tt would lso elp to cly pocesses o uncpl councls n es

suc s cleng odsde vegetton, but t s lso senstve to te blnce n te nncl cpcty o vous

uncpl councls nd te dculty tey ve obtnng tecncl expetse n elton to buse. in pevese wy,

tose councls tt ve te ost pessng need to pply substntl esouces nd eot to ke te countes

oe buse se e n ny cses tose tt e te lest well esouced. Te Stte sould exne wete

locl govenent eques gete suppot, ncludng undng, to ensue tt ndvdul councls ve te cpcty

to pleent te geed cnges.


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22

ThE COmmiSSiONS REPORTS

Te Cosson poduced two nte epots nd nl epot. Te nte epots o pt o te wok nd

delbetons o te Cosson nd, long wt te nl epot, sould be egded s one body o wok.

Ts nl epot s te culnton o te Cossons wok. it descbes nd nlyses te buses o Jnuy

Febuy 2009 nd kes ecoendtons bout cnges needed to educe te sk, nd te consequences,

o sl dsstes n te utue. it lso descbes ow te Cosson went bout ts tsk. Te nl epot conssts

o ou volues:

Volue iTe Fes nd te Fe-elted Dets

Volue iiFe Pepton, response nd recovey (Pts One nd Two)

Volue iiiEstblsent nd Opeton o te Cosson

Volue iVTe Stteents o Ly Wtnesses.

Te conclusons o Volues i nd ii e outlned n ts suy.

Volue iii descbes te wok o te Cosson, te conduct o ts nquy, nd ts dnstton o te Vcton

stocl nd publc ecod. it wll be useul o otes wo n utue e ced wt te tsk o estblsng nd

unnng oyl cosson.

in efectng on lessons lent o ts royl Cosson, te Cosson notes tt, unlke ote stte jusdctons

o te Coonwelt, Vcto does not ve specc legslton tt dels wt te ole, conduct nd powes

o cosson o nquy. Ts lck o legsltve bss cused uncetnty, wc te Cosson consdes

undesble. asng o ts, te Cosson poposes tt te Stte consde legslton o te conduct o

nquesn ptcul, te conduct o oyl cossons.

Volue iV s n electonc volue tt colltes te stteents o te 100 ly wtnesses wo sed te expeence

o te es dung te Cossons engs. Te ly wtnesses wee n potnt pt o te Cossons wok,gvng n on te gound pespectve to te expeences nd el-le exples o ow e polces nd eegency

pocedues ect ndvduls nd countes. Ts oes n potnt wy o pesevng pesonl eoes o

te es. it povdes nsgts nto peoples pepton o buse nd ow tey ected to te condtons o Blck

Study nd seves s poweul ende o te pcts o te es on ndvduls, les nd countes.

Volue iV ppes n electonc o only becuse, s well s contnng wtten stteents, t contns potogps,

vdeo ootge, ote docuenty tel povded s pt o te evdence, ps, nd stellte potogps tken

beoe nd te te es to elp llustte te pct te es d on deent pts o te stte. Te quntty nd

ntue o te tel en pnted veson s pctcl.

Te Stte s esponsble o kng copes o te Cossons epot vlble to te publc nd wll be dong so

toug inoton Vcto. Te epot s vlble n d copy nd electonclly. Te electonc veson s vlble

on DVD nd v te ntenet; t contns ypelnks tt enble te ede to lso ed te evdence eeed to n teepot. Fo te next 12 onts te electonc veson o te epot nd ote noton bout te Cosson wll

be etned on te Cossons webste, www.royalcommission.vic.gov.au. ate tt t wll be vlble toug

te webste o te Vcton Deptent o Pee nd Cbnet.


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23

Summary

in pepng ts ecoendtons te Cosson cose not to constn te Stte wt undue pescpton: t

wnted to obvte te sk o nowng polcy kes vson. To copleent te ecoendtons, te Cossonexpesses vews nd dws conclusons n te text o te epot, poposng te type o cton te Stte (nd otes)

sould tke to del wt ttes tt wnt ute ttenton. Te Cosson tusts tt tose espondng to te

epot wll ttc substntlly te se wegt to tese poposls s tey ccod te py ecoendtons.

Wen te te Stte s used n te ecoendtons t s not ntended to be ed nowly. it pples not just

to te elected govenent nd te ognstons tt o pt o te Vcton publc sevce. Dependng on te

ccustnces, t cn lso encopss publc enttes tt ke up te bode publc secto, suc s te County

Fe autoty, nd te specl bodes dened n te Public Administration Act 2004, suc s Vcto Polce.

ViCTORiAS buShFiRE SAFETy POliCy

RECOmmENdATiON 1

The State revise its bushre saety policy. While adopting the national Prepare. Act. Survive. ramework

in Victoria, the policy should do the ollowing:

enhance the role o warningsincluding providing or timely and inormative advice about the predicted

passage o a re and the actions to be taken by people in areas potentially in its path

emphasise that all res are dierent in ways that require an awareness o re conditions, local

circumstances and personal capacity

recognise that the heightened risk on the worst days demands a dierent response

retain those elements o the existing bushre policy that have proved eective

strengthen the range o options available in the ace o re, including community reuges, bushre

shelters and evacuation

ensure that local solutions are tailored and known to communities through local bushre planning

improve advice on the nature o re and house deendability, taking account o broader landscape risks.

RECOmmENdATiON 2

The State revise the approach to community bushre saety education in order to:

ensure that its publications and educational materials refect the revised bushre saety policy

equip all re agency personnel with the inormation needed to eectively communicate the policy

to the public as required

ensure that in content and delivery the program is fexible enough to engage individuals, households

and communities and to accommodate their needs and circumstances

regularly evaluate the eectiveness o community education programs and amend them as necessary.

RECOmmENdATiONS


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RECOmmENdATiON 3

The State establish mechanisms or helping municipal councils to undertake local planning that tailors

bushre saety options to the needs o individual communities. In doing this planning, councils should:

urgently develop or communities at risk o bushre local plans that contain contingency options such

as evacuation and shelter

document in municipal emergency management plans and other relevant plans acilities where vulnerable

people are likely to be situatedor example, aged care acilities, hospitals, schools and child care centres

compile and maintain a list o vulnerable residents who need tailored advice o a recommendation to

evacuate and provide this list to local police and anyone else with pre-arranged responsibility or helping

vulnerable residents evacuate.

RECOmmENdATiON 4

The State introduce a comprehensive approach to shelter options that includes the ollowing:

developing standards or community reuges as a matter o priority and replacing the 2005 Fire Reuges

in Victoria: Policy and Practice

designating community reugesparticularly in areas o very high riskwhere other bushre saety

options are limited

working with municipal councils to ensure that appropriate criteria are used or bushre shelters, so that

people are not discouraged rom using a bushre shelter i there is no better option available

acknowledging personal shelters around their homes as a allback option or individuals.

RECOmmENdATiON 5

The State introduce a comprehensive approach to evacuation, so that this option is planned, considered

and implemented when it is likely to oer a higher level o protection than other contingency options. The

approach should:

encourage individualsespecially vulnerable peopleto relocate early

include consideration o plans or assisted evacuation o vulnerable people

recommend emergency evacuation.

RECOmmENdATiON 6

Victoria lead an initiative o the Ministerial Council or Education, Early Childhood Development and

Youth Aairs to ensure that the national curriculum incorporates the history o bushre in Australia and that

existing curriculum areas such as geography, science and environmental studies include elements o

bushre education.


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Summary

RECOmmENdATiON 7

The Commonwealth lead an initiative through the Ministerial Council or Police and Emergency Management,

acilitated by Emergency Management Australia, to develop a national bushre awareness campaign.

EmERgENCy ANd iNCidENT mANAgEmENT

RECOmmENdATiON 8

The Country Fire Authority and the Department o Sustainability and Environment amend their procedures

to require the ollowing:

that at locations that attract preparedness levels A or B there be a ull incident management team underthe leadership o an accredited level 3 Incident Controller in position by 10.00 am on days o code red

re danger and a core incident management team (eight personnel) under the leadership o an accredited

level 3 Incident Controller in position by 10.00 am on days o extreme re danger

that a ull level 3 IMT be led by a level 3 Incident Controller unless the State Controller determines

otherwise.

RECOmmENdATiON 9

The Country Fire Authority and the Department o Sustainability and Environment prescribe and audit

the minimum number and nature o level 3 joint training exercises in which incident management team

sta (including volunteers) are required to participate.

RECOmmENdATiON 10

The State clariy whether, during major res, Victoria Police should discharge its coordination unctions

rom the State Emergency Response Coordination Centre or rom the State Control Centre.

RECOmmENdATiON 11

The State consider amending the Emergency Management Act 1986 and the Emergency Management

Manual Victoria in order to achieve the ollowing:

remove the title o Coordinator in Chie o Emergency Management rom the Minister or Police

and Emergency Services

clariy the unction and powers o the Minister

designate the Chie Commissioner o Police as Coordinator in Chie o Emergency Management,

who would have primary responsibility or keeping the Minister inormed during an emergency.


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RECOmmENdATiON 12

The State consider either amending the Emergency Management Act 1986 or adopting a standing practice

to require the Minister or Police and Emergency Services or the Chie Commissioner o Police to consult

the Premier about the possibility o declaring a state o disaster or all o or any part o Victoria whenever

the Minister or the Chie Commissioner o Police becomes aware o circumstances that make it a reasonable

possibility that the criteria or making such a declaration will be satised.

RECOmmENdATiON 13

The State consider amending the Emergency Management Act 1986 to introduce a graded scale

o emergency declarations short o a state o disaster.

RECOmmENdATiON 14

The Victorian re agencies amend the AIIMS ramework beore the 201011 re season in order to do

the ollowing:

designate the Inormation Unit as a separate section reporting directly to the Incident Controller and

require that the Inormation Unit contain a dedicated Public Inormation Ocer whenever a ull incident

management team is required

speciy a set o unctions in relation to which the Deputy Incident Controller or a level 3 incident will have

oversight, which may be adjustable or a particular incident by agreement between the Incident Controller

and the Deputy Incident Controllerensure that an individual with local knowledge is incorporated in an incident management team.

RECOmmENdATiON 15

The Country Fire Authority and the Department o Sustainability and Environment:

amend their procedures to require that an incident action plan summary be completed within the rst

our hours o an incident being reported and be provided to the State Control Centre and, where

established, to the relevant Area o Operations Control Centre

adopt DSEs incident action plan summary as the template to be used by all incident management teams

and ensure that the template is included in the online IMT Tool Box

provide regular training to IMT sta, highlighting the importance o inormation and reinorcing the support

available rom specialists within the State Control Centre.


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Summary

RECOmmENdATiON 16

The Country Fire Authority and the Department o Sustainability and Environment improve mapping support

in the ollowing ways:

DSE providing mapping data ree o charge to emergency response agencies

greatly increasing the CFAs write access to FireMap or incident management team sta

establishing a joint DSECFA training program to ensure that mapping ocers in level 2 and 3 incident

management teams are ully trained in using FireMap, including in producing re prediction maps

requiring beore the 201011 re season that FireMap be used or joint incidents.

RECOmmENdATiON 17

The Country Fire Authority and the Department o Sustainability and Environment establish beore the

201011 re season:

a uniorm, objective and transparent process based on the current DSE approach or the accreditation

o level 3 Incident Controllers

a perormance review system or level 3 Incident Controllers

a traineeship program or progression rom level 2 to level 3 incident management team positions.

RECOmmENdATiON 18

The Country Fire Authority and the Department o Sustainability and Environment amend their procedures

to require that a suitably experienced, qualied and competent person be appointed as Incident Controller,

regardless o the control agency or the re.

RECOmmENdATiON 19

The Country Fire Authority provide to all CFA volunteers an identication card or similar to acilitate their

passage through roadblocks established in accordance with the 2009 Guidelines or the Operation o

Trac Management Points during Wildres.


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FiREgROuNd RESPONSE

RECOmmENdATiON 20

The Country Fire Authority and the Department o Sustainability and Environment amend their policies

on aerial preparedness and standby arrangements, their dispatch protocols and the management o aircrat

in order to do the ollowing:

require that at locations that attract the risk assessment or preparedness level A on code red days all

personnel needed or air operations must be on standby by 10.00 am

establish a system that enables the dispatch o aircrat to res in high-risk areas without requiring

a request rom an Incident Controller or the State Duty Ocer.

RECOmmENdATiON 21

The State, in conjunction with Emergency Management Australia and the Department o Deence, develop

an agreement that allows Commonwealth aerial resources that are suitable or reghting and support

activities to be incorporated in preparedness plans and used on days o high re risk.

RECOmmENdATiON 22

The Country Fire Authority and the Department o Sustainability and Environment standardise their operating

systems and inormation and communications technologies with the aim o achieving greater eciency andinteroperability between agencies.

RECOmmENdATiON 23

The Country Fire Authority review and improve its communications strategy as a matter o priority and

develop a program or identiying and responding to black spots in radio coverage.

RECOmmENdATiON 24

The Country Fire Authority and the Department o Sustainability and Environment amend their procedures or

investigating saety incidents and near-misses to ensure that all dangerous incidents, including back-burns,

are ully investigated and that all relevant people are consulted and inormed o the results.

RECOmmENdATiON 25

The Country Fire Authority and the Department o Sustainability and Environment require without

exception that all relevant sta be trained in the need or Incident Controller approval to be obtained beore

a back-burn is lit.


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Summary

RECOmmENdATiON 26

The Country Fire Authority and the Department o Sustainability and Environment adopt the title saety

ocer (as opposed to saety adviser) and require without exception that a saety ocer be appointed

to every level 3 incident management team.

ElECTRiCiTy-CAuSEd FiRE

RECOmmENdATiON 27

The State amend the Regulations under Victorias Electricity Safety Act 1998 and otherwise take such steps

as may be required to give eect to the ollowing:the progressive replacement o all SWER (single-wire earth return) power lines in Victoria with aerial

bundled cable, underground cabling or other technology that delivers greatly reduced bushre risk.

The replacement program should be completed in the areas o highest bushre risk within 10 years and

should continue in areas o lower bushre risk as the lines reach the end o their engineering lives

the progressive replacement o all 22-kilovolt distribution eeders with aerial bundled cable, underground

cabling or other technology that delivers greatly reduced bushre risk as the eeders reach the end o their

engineering lives. Priority should be given to distribution eeders in the areas o highest bushre risk.

RECOmmENdATiON 28

The State (through Energy Sae Victoria) require distribution businesses to change their asset inspection

standards and procedures to require that all SWER lines and all 22-kilovolt eeders in areas o high bushre

risk are inspected at least every three years.

RECOmmENdATiON 29

The State (through Energy Sae Victoria) require distribution businesses to review and modiy their current

practices, standards and procedures or the training and auditing o asset inspectors to ensure that

registered training organisations provide adequate theoretical and practical training or asset inspectors.

RECOmmENdATiON 30

The State amend the regulatory ramework or electricity saety to require that distribution businesses adopt,

as part o their management plans, measures to reduce the risks posed by hazard treesthat is, trees that

are outside the clearance zone but that could come into contact with an electric power line having regard to

oreseeable local conditions.


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RECOmmENdATiON 31

Municipal councils include in their municipal re prevention plans or areas o high bushre risk provision

or the identication o hazard trees and or notiying the responsible entities with a view to having the

situation redressed.

RECOmmENdATiON 32

The State (through Energy Sae Victoria) require distribution businesses to do the ollowing:

disable the reclose unction on the automatic circuit reclosers on all SWER lines or the six weeks

o greatest risk in every re season

adjust the reclose unction on the automatic circuit reclosers on all 22-kilovolt eeders on all total

re ban days to permit only one reclose attempt beore lockout.

RECOmmENdATiON 33

The State (through Energy Sae Victoria) require distribution businesses to do the ollowing:

t spreaders to any lines with a history o clashing or the potential to do so

t or retrot all spans that are more than 300 metres long with vibration dampers as soon as

is reasonably practicable.

RECOmmENdATiON 34

The State amend the regulatory ramework or electricity saetyto strengthen Energy Sae Victorias

mandate in relation to the prevention and mitigation o electricity-caused bushres and to require it to ull

that mandate.

dElibERATEly liT FiRES

RECOmmENdATiON 35

Victoria Police continue to pursue a coordinated statewide approach to arson prevention and regularly

review its approach to ensure that it contains the ollowing elements:

high-level commitment rom senior police

a research program aimed at rening arson prevention and detection strategies

centralised coordination that includes comprehensive training, periodic evaluation o arson prevention

strategies and programs, and promotion o best-practice prevention approaches

a requirement that all re-prone police service areas have arson prevention plans and programs,

according to their level o risk.


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Summary

RECOmmENdATiON 36

The Commonwealth, states and territories continue to pursue the National Action Plan to Reduce Bushre

Arson in Australia, giving priority to producing a nationally consistent ramework or data collection and

evaluating current and proposed programs in order to identiy and share best-practice approaches.

PlANNiNg ANd buildiNg

RECOmmENdATiON 37

The State identiy a central point o responsibility or and expertise in mapping bushre risk to:

review urgently the mapping criteria at present used by the Country Fire Authority to map the WildreManagement Overlay, to ensure that the mapping used to determine building and planning controls

is based on the best available science and takes account o all relevant aspects o bushre risk

map and designate Bushre-prone Areas or the purposes o planning and building controls,

in consultation with municipal councils and re agencies

nalise the alignment o site-asses

Documents

Vbrc Summary Pf[1]