The report, commissioned by the CFS in August 2020 and released publicly on Tuesday night, also found the agency paid a “disproportionate level of attention” to protecting public rather than private assets, and was negatively affected by insubordination from crew members on the ground.
The CFS says it will accept all nine recommendations of the review, which includes establishing a project to explore “cultural issues” within the KI firefighting group, creating pre-determined plans for firefighting, and reorganising a raft of internal communication procedures.
The 2019-20 KI fires burnt 211,474 hectares of land and resulted in two deaths, 87 homes destroyed and 59,730 livestock lost. The disaster affected nearly half of the island’s land mass and accounted for around 75 per cent of all hectares burnt in South Australia during the Black Summer fire season.
CFS chief officer Mark Jones agreed with the report’s finding that his agency lacked the resources to deal with the incident, but said the disaster could have been much worse.
“The 2019-2020 season provided previously unexperienced fire conditions in South Australia and the CFS was not resourced to cope with two large campaign fires running concurrently in Kangaroo Island and Cudlee Creek,” Jones said in a statement.
“Though our teams on Kangaroo Island tried their hardest to deal with the circumstances they faced, we accept that not everything went as well as we might have hoped and this report gives us recommendations to proactively improve our preparations for future events that seem certain to threaten South Australia.
“As the report notes, despite the unprecedented challenges faced, the outcomes were mainly good and the losses, although terrible, could have been so much worse.
“I pay tribute to all involved in the fires and the recovery efforts and look forward to working with the responsible authorities to ensure that bushfire risks are never allowed to grow to such dangerous levels again on the island.”
Another key finding from the report was that 50 of the 80 lessons the CFS took from the 2007 KI bushfires – which burnt 90,982 hectares and resulted in one fatality – were not implemented, and in some cases, positive lessons from the 2007 disaster were “reversed”.
“Fires on KI are not new, nor are the challenges they bring,” the review said.
“The lessons from 2007 were repeated. The SACFS has a lessons management system, however it failed implementation for the KI fires, as the lessons have not translated into planning across coordinated fire fighting agencies.”
Lack of resources and training
The report found the “general theme” about resourcing – from survey respondents and face-to-face interviews with volunteers – was that planning was “reactive” rather than “prepared in advance”.
“The review is in agreement with the notion it was presented by many who contributed to this Review, that is; there is a significant deficiency in full-time equivalent resources for the agency,” the report said.
“The operating environment finds staff filling many roles, and the design of doctrine for staffing levels finds a high level of competition for the same resource.
“A lack of focus on resourcing, and the associated logistics which surround them, added to the resourcing issues for the KI fires.
“The regional staff were fatigued given its ongoing operational work since August. The addition of two concurrent L3 (level three) incidents subsequently overwhelmed the Regional Command Centre.”
The report pointed to a “chaotic approach” to resource management, and highlighted an example where two separate firefighting crews were sent from the mainland on January 3, with one given 24 hours to work with no rest, while the other was sent to an area which was “not under threat” and then sent home the next morning.
“Resourcing for the KI fires was underdone, with decision making impacted by a business as usual reporting relationships between Level Three Incident Controllers, the Regional Command Centre and the state, along with the general lack of resource forecasting at the Regional Command Centre (despite requesting a Resources Officer).
“The lack of trust which perhaps existed at the levels of the commands compounded this issue.
“There was no warnings officer on KI, therefore the regional warnings officer was getting multiple directions from multiple areas, which compounded workload and was not conducive to an operational rhythm being achieved within the RCC (later discussed in the report).”
The report also said aerial firefighting resources were “extremely limited” for KI while the Cudlee Creek fire was active in December, with aircraft often having to return to the mainland for accommodation and logistics reasons – despite this problem being highlighted in the 2007 review.
The review found the lack of resource capacity contributed to “untrained staff and volunteers lacking the required competencies” being asked to respond to level three fire incidents.
Insubordination and misguided priorities
Firefighting crews that did not follow orders from higher-ups also came in for criticism in the review.
“Much of the good work completed was discounted by a culture of some not following, or actively working against, the chain of command,” the report said.
“Secondly, there was a lack of accountability by some crews for the mopping up and blacking out procedures led to further fire spread.”
As a consequence, those working in the command centre were unable to get a full picture of the extent of the fire and where resources needed to be deployed, according to the review.
This problem was particularly evident regarding the protection of Flinders Chase National Park, of which 96 per cent was burnt during the fires.
The review found a “disproportionate” amount of attention was given to protecting the park’s visitor centre, despite an earlier briefing that fires were more likely to pose a threat to private houses.
“It is the opinion of the review that a disproportionate level of attention was given in both planning and operations to the protection of the Flinders Chase National Park Visitor Centre and Rocky River Precinct versus private assets to the east of the West End Highway the east of the West End Highway,” the report said.
“This was in spite of the Incident Controller outlining, at the Community Meeting at Parndana on 2 January, that the fire was likely to run through that area.”
KI Mayor Michael Pengilly, who attended a community meeting with the CFS last night for the release of the report, said he had no issues with its recommendations, but locals were “frustrated” and “disappointed” by its findings.
“It was a pretty quiet room … nobody said much,” Pengilly told ABC radio this morning.
“There was a sense of frustration outside, I walked through a few groups of people and none of them were particularly happy with the way it had gone.
“I think they felt disappointment as much as anything.”
On the issue of insubordination, Pengilly said: “It’s pretty usual to have a fair few egos at the fire.”
“That’s nothing unusual probably anywhere, and they’re volunteers … they weren’t paid staff so they’re out there doing their best for the community and trying their hardest as everybody was.
“You’d probably say if it (the review) was a school report, that all tried hard but could do a lot better.
“So I think we’ve got a long long way to go but this is a good start.”
The CFS-commissioned report follows the June 2020 release of the State Government-commissioned Keelty Review into the response of South Australia’s emergency services sector to the Black Summer bushfires.
That report made 15 recommendations, nine of which have been actioned by the Government.
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