The Board accepts the opinion of Mr Lapsley regarding the cause of the mine fire given that there is strong support for it in the evidence and that there is no evidence to the contrary. Under its Terms of Reference, the Board has been directed not to prejudice any investigation by Victoria Police. Accordingly, the Board does not reach any conclusions about the causes of the Hernes Oak- McDonald’s Track, Hernes Oak and Driffield fires. The Board acknowledges that appropriate warnings were made in the lead up to 9 February 2014 about the potential risk of a catastrophic fire event occurring. However, warnings are only a short-term solution. In the long-term the emphasis needs to be on education based on past experience. Education is particularly important for those Victorians living in areas most vulnerable to bushfire.
Exhibit 92 – Expert report of Roderic Incoll, paras 236-238 Exhibit 92 – Expert report of Roderic Incoll, paras 238 & 239 5. Incoll T2156:4-28 Exhibit 92 – Expert report of Roderic Incoll, paras 239-243 Exhibit 60 – Statement of Robert Gaulton, paras 8-13 Exhibit 1 – Statement of Craig Lapsley, para. 14 Exhibit 1 – Statement of Craig Lapsley, para. 16 Adapted from Exhibit 1 – Statement of Craig Lapsley, para. 17 Exhibit 1 – Statement of Craig Lapsley, para. 15
Exhibit 1 – Statement of Craig Lapsley, para. 46 attachment, Fire Investigation Management System - Bushfire Report Fire & Incident Reporting System: 495857 (CFA.0002.001.0159) Exhibit 15 – Statement of Lawrence Jeremiah, para. 18 Exhibit 1 – Statement of Craig Lapsley, para. 71 Exhibit 15 – Statement of Lawrence Jeremiah, para. 45 Exhibit 1 – Statement of Craig Lapsley, para. 73 Exhibit 1 – Statement of Craig Lapsley, para. 75 Exhibit 6 – Statement of Jaymie Norris, Phoenix Rapidfire presentation, p. 9
Exhibit 1 – Statement of Craig Lapsley, para. 54; Exhibit 15 - Statement of Laurence Jeremiah, para. 12 (c) Exhibit 1 – Statement of Craig Lapsley, para. 48 Exhibit 6 – Statement of Jaymie Norris, Phoenix Rapidfire presentation, p. 10 Exhibit 8 – Statement of James Mauger, para. 22 Exhibit 15 – Statement of Lawrence Jeremiah, para. 70 Exhibit 74 – Bureau of Meteorology weather information Exhibit 92 – Expert report of Roderic Incoll, appendix 3 Exhibit 92 – Expert report of Roderic Incoll, appendix 3
Exhibit 6 – Statement of Jaymie Norris, Phoenix Rapidfire presentation, p. 12 Exhibit 6 – Statement of Jaymie Norris, Phoenix Rapidfire presentation, p. 10 Exhibit 7 – Statement of David Shanahan, paras 51-55 Exhibit 7 – Statement of David Shanahan, para. 55 Exhibit 7 – Statement of David Shanahan, para. 55 Exhibit 15 – Statement of Lawrence Jeremiah, para. 70 Exhibit 1 – Statement of Craig Lapsley, para. 88 Exhibit 1 – Statement of Craig Lapsley, para. 89
Exhibit 1 – Statement of Craig Lapsley, para. 46 attachment, Fire Investigation Management System - Bushfire Report Fire & Incident Reporting System: 495857 (CFA.0002.001.0159); Lapsley T36:26 – T37:2 Exhibit 1 – Statement of Craig Lapsley, para. 46; Lapsley T36:31 – T37:2; T151:26 – T152:2; Exhibit 5 – Affi of Michael Roberts, paras 4-14 Exhibit 5 – Affi of Michael Roberts, para. 11 Exhibit 1 – Statement of Craig Lapsley, para. 55 Exhibit 7 – Statement of David Shanahan, para. 49 Exhibit 15 – Statement of Lawrence Jeremiah, paras 75 & 76
Exhibit 74 – Bureau of Meteorology weather information Exhibit 10 – Statement of Steven Harkins, para. 107 Roach T654:27-30 Exhibit 5 – Affi of Michael Roberts, paras 5-8; Exhibit 17 – Supplementary affi of Michael Roberts, para. 6(a) Exhibit 1 – Statement of Craig Lapsley, para. 51; Lapsley Exhibit 5 – Affi of Michael Roberts, paras 4-14 Exhibit 5 – Affi of Michael Roberts, para. 12; Exhibit 17 – Supplementary affi of Michael Roberts, para. 6 Exhibit 29 – Second statement of Steven Harkins, para. 31 Polmear T2034:15-22
Exhibit 7 – Statement of David Shanahan, para. 64; Exhibit 8 – Statement of James Mauger, paras 39-41 Exhibit 8 – Statement of James Mauger, para. 43 Exhibit 10 – Statement of Steven Harkins, para. 71 Exhibit 7 – Statement of David Shanahan, para. 47 Exhibit 7 – Statement of David Shanahan, para. 79 Exhibit 7 – Statement of David Shanahan, para. 81 Exhibit 7 – Statement of David Shanahan, paras 86 & 87 Exhibit 7 – Statement of David Shanahan, paras 89 & 90; Exhibit 10 – Statement of Steven Harkins, para. 86
response to a major fire. The State Controller (or the person appointed to perform that role) may exercise the power and authority granted to the Chief Officer of the CFA by the Country Fire Authority Act 1958 (Vic) (CFA Act). When the Fire Services Commissioner takes control of a major fire, the Fire Services Commissioner becomes the State Controller. Under Standard Operating Procedures Control of Major Fires SOP 05/2011, the Fire Services Commissioner automatically assumes the role of the State Controller when the following conditions are present: a Code Red Fire Danger Rating is in place in one or more forecast districts an Extreme Fire Danger Rating is in place in three or more forecast districts.22 These conditions were present on 9 February 2014.23
Phoenix Rapidfire model is shown in Figure 2.19 below. Figure 2.19 Phoenix Rapidfire modeling 40 Figure 2.19 is a Phoenix Rapidfire model that was produced during the public hearings which shows both the predicted fire behaviour (in orange, yellow and red) as well as the actual extent of the Driffield fire (in brown) on 9 February 2014. To develop the Phoenix Rapidfire models, information and assumptions about fire behaviour are entered into the software program. Relevant information and assumptions include the point of origin of the fire, the time of ignition, weather predictions (expected temperature, wind speed, wind direction, cloud cover and atmospheric conditions) and the vegetation in the landscape that may fuel the fire. The
According to the rag report prepared by Mr Dugan on 3 February 2014: The annual audit of firefighting equipment and 90 per cent of follow up action items were complete. All employees’ fire training was up to date. All firefighting equipment and infrastructure had been checked and was generally ready for use. All grass slashing was complete but a second cut may be needed in late February. Under the heading ‘fire related issues to be managed in the next week’, the weather forecast for the next seven days was noted as ‘Temperatures of 39 deg. Monday with a TFB [Total Fire Ban]. Tending to mid–20s before returning to high 30s later in the week.’
All items were assigned a green traffic light (ie ‘acceptable’), with the exception of the weather forecast, which was assigned an amber light (ie ‘item of concern’).115 Mr William Brown, former Fire Services Offi at the Hazelwood mine, stated that prior to privatisation the State Electricity Commission Victoria sent a mechanical engineering expert from Monash House to conduct an annual audit of the mine’s practices and to ensure the mine was adhering to the Mine Fire Service Policy and Code of Practice (as it then existed). According to Mr Brown, these external audits were very thorough. Following privatisation, external audits ceased and were instead conducted in-house, but Mr Brown sought to ensure that they were carried out to the same rigorous standard.116
The Victorian Government’s second submission also discusses the White Paper reforms to further improve Victoria’s emergency management arrangements. The reforms are intended to ensure that an ‘all hazards, all agencies’ approach is embedded in managing emergencies, that streamlined arrangements for emergency management governance are introduced, that shared responsibility, cooperation and clarity of roles and responsibilities is encouraged, with a stronger emphasis on emergency risk mitigation, and that the importance of improved planning processes is recognised. The Board affirms the Victorian Government’s commitments to carry out the emergency management reforms, namely:
Exhibit 59 – Statement of Kylie White, para. 56 attachment, Part 7: Emergency Management Manual Victoria (DSDBI.0006.004.0001), pp. 7–1 & 7–4 Exhibit 59 – Statement of Kylie White, para. 56 attachment, Part 7: Emergency Management Manual Victoria (DSDBI.0006.004.0001), p. 7–27 Exhibit 59 – Statement of Kylie White, para. 56 attachment, Part 7: Emergency Management Manual Victoria (DSDBI.0006.004.0001), p. 7–30 Exhibit 59 – Statement of Kylie White, para. 56 attachment, Part 7: Emergency Management Manual Victoria (DSDBI.0006.004.0001), p. 7–54 Exhibit 59 – Statement of Kylie White, para. 56 attachment, Part 7:
Emergency Management Manual Victoria (DSDBI.0006.004.0001), p. 7–3 Exhibit 56 – Statement of Alan Hall, attachment 3, Emergency Management Manual Victoria (DOJ.0001.001.0172), p. 3–8 Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, pp. 1 & 5 Adapted from Exhibit 15 – Statement of Lawrence Jeremiah, attachment 11, p. 2 Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, p. 2 Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, pp. 1 & 5 Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, pp. 2 & 5 Exhibit 56 – Statement of Alan Hall, attachment 3, Emergency
Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, pp. 5 & 18 Exhibit 56 – Statement of Alan Hall, attachment 3, Emergency Management Manual Victoria (DOJ.0001.001.0172), pp. 3–5 & Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, p. 20 Exhibit 15 – Statement of Lawrence Jeremiah, attachment 6, pp. 5, 20 See for example, Exhibit 1 – Statement of Craig Lapsley, para. 105 attachment, Incident Shift Plan Day (10/2/14) (FSC.0006.001.0001) (FSC.0006.007.0103) Exhibit 15 – Statement of Lawrence Jeremiah, attachment 2, p. 1
Exhibit 15 – Statement of Lawrence Jeremiah, para. 91 Exhibit 10 – Statement of Steven Harkins, para. 21 Central Gippsland Essential Industries Group 2011, Welcome, CGEIG, viewed 28 July 2014, Exhibit 10 – Statement of Steven Harkins, para. 21 Jeremiah T475:26-28 Occupational Health and Safety Act 2004 (Vic), s. 21 Occupational Health and Safety Act 2004 (Vic), s. 23 Occupational Health and Safety Regulations 2007 (Vic), r. 5.3.9 Exhibit 10 – Statement of Steven Harkins, para. 11; Exhibit 13 –
Prezioso T372:10-11 Exhibit 13 – Statement of Robert Dugan, annexure 2, p. 12 Exhibit 13 – Statement of Robert Dugan, annexure 2, p. 21 Exhibit 13 – Statement of Robert Dugan, annexure 4, p. 14 Exhibit 13 – Statement of Robert Dugan, annexure 5, p. 2 Exhibit 93 – Statement of Romeo Prezioso, para. 57; Exhibit 93 – Statement of Romeo Prezioso, annexure 2 Exhibit 4 – Statement of William Brown, annexure WB–3, p. 36 Exhibit 12 – Mine Fire Instructions, p. 12 Exhibit 12 – Mine Fire Instructions, p. 12
Exhibit 12 – Mine Fire Instructions, p. 14 Exhibit 11 – Emergency Response Plan, pp. 10-14 Exhibit 13 – Statement of Robert Dugan, para. 33 Exhibit 11 – Emergency Response Plan, pp. 12-14 Exhibit 13 – Statement of Robert Dugan, para. 11 Harkins T753:11-13; Exhibit 58 – Statement of Steven Harkins, para. 4 Harkins T753:11-13; Exhibit 58 – Statement of Steven Harkins, para. 4 Harkins T753:13-18 Exhibit 25 – Statement of Robert Dugan, para. 22
GDF Suez Documents, 5 May 2014, Check List for Fire Fighting Equipment Annual Inspection (issued 18 January 2013) Exhibit 13 – Statement of Robert Dugan, para. 34 Exhibit 10 – Statement of Steven Harkins, para. 19 Exhibit 10 – Statement of Steven Harkins, annexure 3 Exhibit 4 – Statement of William Brown, paras 21, 22 & 27; Brown T157:27 – T159:8 GDF Suez Documents, 5 May 2014, Hazelwood Mine Guidelines for Season and Period Specifi Fire Preparedness and Mitigation Planning (issued 13 September 2007), p. 7
GDF Suez Documents, 5 May 2014, Hazelwood Mine Guidelines for Season and Period Specifi Fire Preparedness and Mitigation Planning (issued 13 September 2007), pp. 11-12 Exhibit 13 – Statement of Robert Dugan, para. 32 Exhibit 11 – Emergency Response Plan, p. 16 Exhibit 11 – Emergency Response Plan, p. 27 Exhibit 11 – Emergency Response Plan, pp. 7-8 Exhibit 11 – Emergency Response Plan, p. 9 Exhibit 11 – Emergency Response Plan, pp. 19-26 Exhibit 10 – Statement of Steven Harkins, para. 20
Statement of Lawrence Jeremiah, attachment 5, p. 7 Exhibit 15 – Statement of Lawrence Jeremiah, para. 16 Exhibit 15 – Statement of Lawrence Jeremiah, para. 5 Exhibit 15 – Statement of Lawrence Jeremiah, paras 23-28 Exhibit 15 – Statement of Lawrence Jeremiah, paras 19-23 Lapsley T712:14 – T713:6 Exhibit 15 – Statement of Lawrence Jeremiah, paras 89-91 Exhibit 1 – Statement of Craig Lapsley, para. 36 Exhibit 1 – Statement of Craig Lapsley, para. 35
Exhibit 1 – Statement of Craig Lapsley, paras 67 & 68 Exhibit 15 – Statement of Lawrence Jeremiah, paras 45 & 46 Exhibit 15 – Statement of Lawrence Jeremiah, paras. 47 & 49; Exhibit 1 – Statement of Craig Lapsley, paras 69 & 71-73 Exhibit 15 – Statement of Lawrence Jeremiah, paras 51 & 52 Exhibit 15 – Statement of Lawrence Jeremiah, para. 106; Jeremiah T474:24-31 Exhibit 10 – Statement of Steven Harkins, annexure 7 Jeremiah T475:14-22 Exhibit 15 – Statement of Lawrence Jeremiah, para. 29
Prezioso T358:9 Prezioso T358:10-11 180. Harkins T319:19 – T321:1 Exhibit 7 – Statement of David Shanahan, para. 17; Shanahan T215:8-12; Exhibit 10 – Statement of Steven Harkins, paras 30 & 31 Shanahan T216:13-17 Exhibit 10 – Statement of Steven Harkins, para. 30 Exhibit 10 – Statement of Steven Harkins, annexure 7 Roach T635:18-20 Roach T635:28 – T636:24 Exhibit 10 – Statement of Steven Harkins, annexure 7 Roach T637:14-28
Harkins T322:29 – T324:2; T340:27 – T341:4; T349:23 – T350:27 Harkins T324:2-5 Roach T639:31 – T642:9 Roach T635:15 – T636:24; T637:10-13 Exhibit 15 – Statement of Lawrence Jeremiah, para 106 Harkins T350:17 – T351:5; Exhibit 10 – Statement of Steven Harkins, para. 31 Exhibit 13 – Statement of Robert Dugan, para. 37 Exhibit 7 – Statement of David Shanahan, annexure 4; annexure 6 Exhibit 7 – Statement of David Shanahan, para. 31
Exhibit 7 – Statement of David Shanahan para. 16 Exhibit 58 – Third statement of Steven Harkins, para. 4 Exhibit 8 – Statement of James Mauger, para. 17 Exhibit 25 – Police statement of Alan Roach, p. 3 Exhibit 25 – Log of events produced by Mr Roach, p. 1 Exhibit 8 – Statement of James Mauger, para. 18 Exhibit 8 – Statement of James Mauger, para. 19; Exhibit – Statement of David Shanahan, para. 41 Exhibit 8 – Statement of James Mauger, para. 19
Exhibit 8 – Statement of James Mauger, para. 20 Exhibit 8 – Statement of James Mauger, para. 21 Exhibit 10 – Statement of Steven Harkins, annexure 9 Exhibit 73 – ESTA logs from 7 February to 24 February 2014 provided by VGSO Roach T649:11-13; Prezioso T368:3-9; Harkins T328:2-4, T332:23-25 Prezioso T358:31 – T359:8; T361:4-8; Exhibit 7 – Statement of David Shanahan, paras 43 & 45 Exhibit 25 – Log of events produced by Mr Roach, p. 1 Exhibit 7 – Statement of David Shanahan, paras 46 & 47
Exhibit 7 – Statement of David Shanahan, para. 49 Written submission of GDF Suez, 18 June 2014, para. 64 Graham T2236:29 – T2238:11 Second written submission of the Victorian Government, 18 June 2014, paras 4.10 & 4.11 Second written submission of the Victorian Government, 18 June 2014, paras 4.14 & 4.16 Second written submission of the Victorian Government, 18 June 2014, paras 3.4 & 3.8
system was not installed, or was only installed to a limited extent, in areas where the fire took hold. This meant that there were significant areas of the mine that were unable to be prepared or ‘wet down’ prior to the fire entering the mine and suppressed by water sprays. By late afternoon, firefighting efforts were further impeded by the loss of power, which affected the GDF Suez reticulated fire services water system and the Emergency Command Centre. The fires were so widespread by early evening that firefighting in the worked out areas of the mine was considered too dangerous, and firefighting was limited to suppressing the fires at grass level. Fire services took command of the firefighting that evening. The second phase of firefighting was led by fire services. Planning of a suppression strategy was undertaken across incident, regional and state
Roach T646:4-17 Roach T646:26-31; T647:1-10 Exhibit 25 – Log of events produced by Mr Roach, p. 1 Exhibit 25 – Police statement of Alan Roach, p. 5; Roach Exhibit 7 – Statement of David Shanahan, paras 59 & 60 Exhibit 7 – Statement of David Shanahan, paras 60-62 Shanahan T268:2-16 Exhibit 7 – Statement of David Shanahan, paras 62, 66 & 68 Shanahan T268:20-25 Prezioso T365:11-28 Exhibit 13 – Statement of Robert Dugan, annexure 11
Exhibit 13 – Statement of Robert Dugan, paras 1718 Roach T649:21 – T650:15 Exhibit 8 – Statement of James Mauger, para. 36 Exhibit 8 – Statement of James Mauger, para. 37 Exhibit 29 – Second statement of Steven Harkins, para. 57 Exhibit 10 – Statement of Steven Harkins, para. 64 Exhibit 10 – Statement of Steven Harkins, para. 65 Exhibit 7 – Statement of David Shanahan, para. 67; Exhibit 8 – Statement of James Mauger, paras 39 & 41
Exhibit 7 – Statement of David Shanahan, para. 85 Exhibit 10 – Statement of Steven Harkins, para. 90; Exhibit 25 – Police statement of Alan Roach, p. 8 Exhibit 10 – Statement of Steven Harkins, paras 90 & 91 Exhibit 8 – Statement of James Mauger, para. 44 Prezioso T372:10-11 Faithful T389:2 – T390:1 Exhibit 7 – Statement of David Shanahan, para. 86 Prezioso T374:18-31 Exhibit 7 – Statement of David Shanahan, paras 87-89
Exhibit 14 – Statement of Anthony Lalor, paras 11 & 12; Exhibit 10 – Statement of Steven Harkins, para. 87 Exhibit 14 – Statement of Anthony Lalor, paras 14-17 Exhibit 14 – Statement of Anthony Lalor, paras 13, 18 & 19 Exhibit 58 – Third statement of Steven Harkins, para. 4; Exhibit 10 – Statement of Steven Harkins, para. 97 Exhibit 7 – Statement of David Shanahan, para. 94 Exhibit 10 – Statement of Steven Harkins, para. 92 Exhibit 10 – Statement of Steven Harkins, para. 83
Exhibit 10 – Statement of Steven Harkins, paras 95, 100-102 Exhibit 1 – Statement of Craig Lapsley, para. 98 attachment, Incident Action Plan for 9 February 2014 (CFA.0007.001.0001) Exhibit 10 – Statement of Steven Harkins, annexure 14 Exhibit 10 – Statement of Steven Harkins, para. 11(g) Exhibit 24 – Statement of Doug Steley, para. 22 Exhibit 1 – Statement of Craig Lapsley, para.104 Exhibit 16 – Incident Shift Plan for 10 February 2014 Exhibit 1 – Statement of Craig Lapsley, para. 99
Exhibit 16 – Incident Shift Plan for 10 February 2014, pp. 4 & 11 Exhibit 1 – Statement of Craig Lapsley, para. 104; Exhibit 84 – Statement of Steven Warrington, para 19 Exhibit 84 – Statement of Steven Warrington, paras 27 & 28 Exhibit 84 – Statement of Steven Warrington, paras 2224 & 30 Exhibit 1 – Statement of Craig Lapsley, para. 107 Exhibit 1 – Statement of Craig Lapsley, para. 111 Adapted from Exhibit 1 – Statement of Craig Lapsley, para. 111 attachment, State Strategic Support Team Brief – Latrobe Valley Coal Mine (FSC.0006.005.0067)
for improvements; Graham T2245:12 – T2247:3 Exhibit 1 – Statement of Craig Lapsley, paras 207 & 228 Second written submission of the Victorian Government, 18 June 2014, paras 4.10 & 4.11 Second written submission of the Victorian Government, 18 June 2014, paras 4.14 & 4.16 Second written submission of the Victorian Government, 18 June 2014, paras 4.19 & 4.20 Exhibit 94 – Bundle of three documents created by George Graham, mine fire inquiry proposals for improvements Exhibit 91 – Expert report of David Cliff, pp. 6 & 7