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The 2009 Victorian
By Joshua Whittaker
Research Fellow, Centre for Risk and Community Safety
RMIT University and Bushfire CRC
Figure 2: Car burnt as result of Upper Ferntree Gully
On Saturday 7 February 2009, Victoria experienced the worst
bushfires in Australia’s recorded history. One hundred and
seventy-three people lost their lives and more than 2000
homes were destroyed, in addition to substantial economic
and environmental impacts.
The devastating impacts of the fires on life and property have
raised fundamental questions about community bushfire safety
in Victoria and throughout Australia. Government, fire services
and the public have been forced to re-evaluate Australia’s
longstanding ‘Prepare, stay and defend or leave early’ policy.
Questions have also been raised about the adequacy of
warning systems, the preparedness and responses of fire and
other emergency services, the preparedness and responses
of residents, the amount and effectiveness of fuel reduction,
building standards, and the land-use planning system that
controls development in high fire-risk areas.
Figure 1: Bush fire at Steel Creek 2009.
Figure 3: A house damaged by bushfires in the Kinglake
Complex In Yarra Glen
Source: Wikipedia commons
Source: Wikipedia commons
On 16 February the Victorian Premier announced the
establishment of a Royal Commission to investigate the causes
of, preparation for and responses to the ‘Black Saturday’
bushfire disaster. The Commission submitted interim reports
in August and November 2009, with a final report due in July
2010. This article will explain what a Royal Commission
involves, the terms of reference for the ‘2009 Victorian
Bushfires Royal Commission’, the inquiry process, and
key interim findings and recommendations.
What Is A Royal Commission?
A Royal Commission is a major public inquiry established to
investigate a particular issue or problem. Royal Commissions
may be established to advise government on important
policy issues, or to investigate allegations of impropriety,
maladministration or major accidents (Prasser 2006). Unlike
other forms of public inquiry – such as taskforces, committees,
reviews, etc. – Royal Commissions are established by
legislation. The Royal Commissions Act 1902 provides for the
establishment of Royal Commissions at the Commonwealth
level, with similar legislation existing in each state. In practice,
Royal Commissions are established by letters patent issued by
the Governor-General (Commonwealth) or Governor (states)
on the advice of government.
2. The preparation and planning by governments, emergency
services, other entities, the community and households
for bushfires in Victoria, including current laws, policies,
practices, resources and strategies for prevention,
identification, evaluation, management and communication
of bushfire threats and risks.
3. All aspects of the response to the 2009 Bushfires,
particularly measures taken to control the spread of the fires
and measures taken to protect life and private and public
property, including but not limited to:
Although Royal Commissions are appointed by and report to
government, they are intended to be independent and impartial.
They employ open processes of investigation and publicly
release their reports and most of the collected evidence. The
statutory foundation of Royal Commissions means that they
have special and coercive investigative powers, including the
power to summon witnesses, take evidence, and apply for
search warrants. As such, they are often chaired by judges or
retired judges. However, Royal Commissions are not ‘judicial
inquiries’. Their proceedings are generally inquisitorial – rather
than adversarial – and are not subject to the strict rules of
evidence that apply in a court of law. Royal Commissions are
not required to reach a definitive conclusion or ruling, but are
required to produce a report that explains what the Commission
has done, the conclusions that have been drawn from its
investigations, and any advice to government based on its
deliberations (Prasser 2006; Teague et al. 2009).
a) immediate management, response and recovery
c) equipment and communication systems.
b) resourcing, overall coordination and deployment and
4. The measures taken to prevent or minimise disruption to the
supply of essential services such as power and water during
the 2009 Bushfires and
5. Any other matters you [the Commissioners] deem
appropriate in relation to the 2009 Bushfires.
The terms of reference also direct the Commission to make
recommendations to government, emergency services, other
entities and the community about measures to reduce bushfire
risk. These include: preparation and planning for future
bushfires; land use planning and management; fireproofing of
housing and other buildings; emergency response to bushfires;
public communication and community advice systems and
strategies; and training, infrastructure and resource needs
(Teague et al. 2009).
Royal Commissions have been held for a wide range of issues
and problems, including: government administration; taxation;
the efficiency and administration of hospitals; police corruption;
Aboriginal deaths in custody; the Australian meat industry; drug
trafficking; the West Gate Bridge Collapse; the Longford Gas
Plant accident; the collapse of HIH Insurance; and many more.
The Commission is examining 12 of the largest fires in which
lives were lost or significant damage occurred. These are the
Kilmore East, Murrindindi, Churchill, Delburn, Bunyip,
Narre Warren, Beechworth-Mudgegonga, Bendigo, Redesdale,
Coleraine, Horsham and Pomborneit-Weerite fires (see
Teague et al. 2009).
1. Explain the purposes of a Royal Commission.
2. How does a Royal Commission differ from a committee?
3. To what extent do you think that Royal Commissions are
independent and impartial?
4. How do you think the proceedings of a Royal Commission would
differ from a court hearing?
5. Investigate one other Royal Commission and briefly explain its
Figure 4: Black Saturday Bushfires in Victoria
The 2009 Victorian Bushfires Royal
On 9 February 2009, Victorian Premier John Brumby
announced that a Royal Commission would be established to
investigate the circumstances leading to widespread losses
of human life and property in the 7 February fires. The ‘2009
Victorian Bushfires Royal Commission’ (VBRC) was formally
established on 16 February under the chairmanship of the
Honourable Bernard Teague AO, supported by Ron McLeod
AM and Susan Pascoe AM.
The Royal Commission has used three main processes to gather
evidence: community consultations; submissions; and hearings
(VBRC 2009). The inquiry began with a series of community
consultations in 14 fire-affected locations. Twenty-six
consultations, attended by over 1200 people, were held between
18 March and 9 April 2009. These consultations enabled the
Commission ‘to hear first hand about people’s experiences
Terms Of Reference
The broad terms of reference for the Royal Commission (see
Teague et al. 2009) are, to investigate:
1. The causes and circumstances of the bushfires which burned
in various parts of Victoria in late January and in February
2009 (‘the Bushfires’).
and gain valuable insights into how individuals and groups
understood and responded to policies and programs in place
on 7 February 2009’ (VBRC 2009, p. 1).
The Commission has made a series of interim recommendations
to improve bushfire warnings and information. These include
recommendations for improving warning and information
systems, as well as the type and content of messages. Key
recommendations, for example, include:
Members of the public, experts and organisations were also
invited to write submissions for the Royal Commission’s
consideration. More than 1200 submissions were received and
analysed for the Interim Report (discussed below), with all other
submissions received by 9 April 2010 to be analysed for the
final report. These submissions are publicly available from the
Royal Commission’s website.
• Recommendation 4.2
The State ensures that the content of bushfires warnings
issued in Victoria reflects the principles set out in the
Commonwealth policy paper Emergency Warnings –
Choosing Your Words (2008). In particular, all bushfire
warnings issued in Victoria must use clear language, avoid
euphemisms, and contain explicit information in relation to:
• the severity, location, predicted direction and likely
time of impact of bushfires on specific communities and
• the predicted severity of impact of the bushfire and
whether a specific fire poses a threat to human life.
Hearings began on 20 April 2009 and concluded on 27 May
2010. The Commissioners spent a total of 155 days hearing
evidence from 434 expert and lay (non-expert) witnesses.
These witnesses include state officials and members of
emergency services agencies, individuals and organisations
with expertise in matters relating to bushfire management, and
those directly affected by the 7 February fires. Witnesses were
called and questioned by lawyers known as Counsel Assisting
the Commission, with support from the Solicitors Instructing.
Their job is to collect evidence and present it to the Commission
during the hearings. Importantly, parties deemed to have a
legitimate interest in the work of the Commission have a right to
be represented by legal counsel in the hearings and may crossexamine witnesses. Parties granted ‘leave to appear’ include: the
State of Victoria (including key departments and agencies such
as the CFA, Department of Sustainability & Environment and
Victoria Police); the Australasian Fire and Emergency Services
Authority; the Australian Broadcasting Corporation; SP Ausnet;
and many more (see Teague et al. 2009, Appendix 1).
• Recommendation 5.1
The Australasian Fire and Emergency Services Authorities
Council and the Bureau of Meteorology collaborate with
researchers to explore options for the fire danger indices
and fire danger ratings including:
• an additional fire danger rating beyond ‘Extreme’
• adjusting the existing fire danger ratings to correspond to
higher Fire Danger Index values and
• developing a revised fire severity scale for use in bushfire
warnings based on new fire danger ratings.
Although the Commission found little support for the
introduction of compulsory evacuation, it concluded that people
need more guidance on whether they should plan to relocate
because their house can not be defended, and on the ease with
which they can safely leave. The Commission also identified
deficiencies in bushfire policies for Victorian schools. It noted
that, as at 7 February, there was no state-wide policy requiring
government schools to evacuate, close or use a fire refuge in the
event of a bushfire.
6. What are terms of reference? Describe two items in the Victorian
bushfires terms of reference.
7. Explain some of the processes that were undertaken in the
investigation by the Royal Commission.
8. Do you think anyone would be able to give evidence at a Royal
Commission hearing? Explain.
• Recommendation 6.2
The CFA amend its policy Advice to the Community Before
and During Wildfire to enable trained CFA personnel
to recommend to particular households, communities
or locations that they plan to leave early, based on an
assessment of the defendability, the vulnerabilities of the
people there, and the degree of ease with which people are
able to leave the area in relative safety.
Interim Findings And
On 17 August 2009 the Royal Commission issued its first interim
report to the State Government of Victoria (Teague et al. 2009).
This report addresses a number of high priority issues related to
community bushfire safety and provides recommendations for
action in advance of the 2009/10 fire season. Key findings and
associated recommendations can be summarised as follows.
The ‘Prepare, Stay and Defend or Leave Early’ Policy
In Victoria, community response to bushfire is guided by the
‘Prepare, stay and defend or leave early’ policy (AFAC 2005).
This policy encourages people to prepare to stay and defend
their home from bushfires or leave well before a fire arrives
in their area. It is based on evidence that well-prepared people
can protect well-prepared houses, and that late evacuation is
a particularly dangerous response to bushfires (see Tibbits
et al. 2008). Given the large number of lives lost in the 7
February fires, the Commission concluded that there had been
insufficient emphasis on the risks of staying and defending and
that ‘Unquestionably, the safest course is always to leave early’
(Teague et al. 2009, p. 19).
Warnings and Information
The Commission identified a number of weaknesses and failures
of Victoria’s information and warning systems on 7 February
2009. It found that warnings were often delayed, which meant
that many people received little or no warning or received a
warning too late to respond safely. The Commission also found
that warnings did not give people a clear understanding of the
location and severity of the fire and how they should respond.
The methods and delivery of warnings were found to be
inadequate, and information sources were unable to cope with
the level of demand. For example, 80 percent of calls to
the Victorian Bushfire Information Line were unanswered.
The Commission’s recommendation concerning the policy
emphasises the need for greater emphasis on leaving early as
the safest option, the level of preparation required to stay and
defend, and the risks of staying and defending.
• Recommendation 10.1
The State amends the State Emergency Response Plan:
• so the control agency for a fire is responsible for issuing
and communicating warnings and’
• to remove from emergency response coordinators the
responsibility of ensuring the control agency gives
consideration to alerting the public to dangers and
potential dangers arising from an emergency.
• Recommendation 7.1
The CFA revise the publications and programs by which
it communicates with the community about preparing for
bushfires and what to do in the event of a bushfire to:
• reinforce existing advice that community members should
prepare, and decide, well before a fire occurs, whether to
leave early or stay and defend their homes and
• clearly convey the following principles: the safest option
is always to leave…; not all homes are defendable…; the
risks of staying include the risk of physical injury and
9. Explain the problems that were discovered in relation to warmings
and briefly explain the recommendations in relation to warnings.
10. What is the ‘Prepare, stay and defend or leave early’ policy?
Does the Royal Commission believe that this policy should be
11. Explain suggested changes to the State Emergency
The Commission identified a lack of fire refuges throughout
Victoria as a significant issue affecting public safety on 7 February
2009. It notes that refuges are important for people who find
themselves in danger when their plans fail, circumstances change,
or when they have no plan. Such refuges are also important for
people in areas threatened by fire who are away from their homes,
such as employees, visitors, tourists, campers, etc.
The final report of the Royal Commission is due to be delivered
to the Victorian Government by 31 July 2010. The Governor
of Victoria will present the report to the Premier, who will
table it in the Victorian Parliament. The report will present
the Commission’s findings and recommendations on the full
range of issues set out in its terms of reference. Of particular
importance for future fire and emergency management will
be findings and recommendations relating to the Commission’s
inquiry into fire-related deaths.
• Recommendation 8.3
The CFA give priority where possible to provide resources
to assist in the defence of designated community fire refuges
and neighbourhood safer places at times when they are likely
to be in use.
• Recommendation 8.5
The State promulgates criteria for the identification and
operation of neighbourhood safer places, and involve
councils and local communities in their development and
implementation as appropriate.
It is important to note that the Commission’s interim findings
and recommendations have already influenced fire and
emergency management. Significant changes include a new
National Framework for Scaled Advice and Warnings, which
saw the introduction of a catastrophic fire danger rating, an
increased emphasis on leaving early on days of catastrophic fire
danger, and greater communication of the preparation required,
and risks associated with staying to defend homes and property
The lack of statutory responsibility in the Country Fire Authority
Act 1958 for issuing community warnings was brought to
the Commission’s attention during the public hearings. The
Commission declared that this responsibility should have been
understood and accepted by the CFA as a normal part of its
functions. Nevertheless, to remove any ambiguity between the
roles of the CFA and Victoria Police, it recommended that the
legislation be amended and that unambiguous arrangements be
in place prior to the 2009/10 bushfire season.
12. Investigate the Royal Commission into the Victorian bushfires
on the internet and explain:
a) the extent of community consultations
b) the types of submissions made.
13. Investigate the media reports and ascertain the final findings of
the Royal Commission. Write a brief report.
• Recommendation 9.4
The State amends the Country Fire Authority Act 1958 to
provide that the Chief Officer has responsibility to issue
warnings and provide information to the community
concerning the risk of bushfires.
References And Further Reading
Australasian Fire Authorities Council (AFAC). 2005. Position paper on
bushfires and community safety. AFAC Limited: East Melbourne.
Prasser, S. 2006. ‘Royal Commissions in Australia: when should governments
appoint them?’, Australian Journal of Public Administration, vol. 65,
no. 3, pp. 28–47.
Teague, B., McLeod, R., and Pascoe, S. 2009. 2009 Victorian Bushfires Royal
Commission: interim report. State Government of Victoria: Melbourne.
Tibbits, A., Handmer, J., Haynes, K., Lowe, T., and Whittaker, J. 2008. ‘Prepare,
stay and defend or leave early: evidence for the Australian approach’. In:
Handmer, J. and Haynes, K. 2008. Community bushfire safety. CSIRO
Publishing: Collingwood. pp. 59–71.
Victorian Bushfires Royal Commission (VBRC). 2009. ‘How we work’.
<http://www.royalcommission.vic.gov.au/getdoc/be61ff85-8094-41a7-9a54a4578db1b77b/How-We-Work> [Accessed June 8th 2010]
The Commission noted that immediate changes are required to
the State Emergency Response Plan (SERP). It found that the
SERP does not clearly designate the agency responsible
for issuing warnings and recommending relocation. It also
found that the warnings and information issued on 7 February
bore little resemblance to the arrangements set out in the SERP.
The Commission has indicated its intention to further examine
emergency management arrangements for bushfires in the
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