The latest bushfire inquiry by Mick Keelty, former AFP Commissioner has been released and can be downloaded from the website of the Western Australia Department of Environment and Conservation.
This inquiry reviews the performance of the Department in the conduct of hazard reduction burns that escaped and destroyed many houses and valuable community assets. The report has been careful not to take a blame attitude (see ‘No one accountable, no ‘consequences’: Margaret River report‘ Sydney Morning Herald Online 24 February 2012); as Mr Keetly noted:
A sense of balance is also required to understand that everyone feels the losses, including the staff of the Department. Witness after witness from the DEC appeared before the Special Inquiry, clearly deeply affected by what had gone wrong and clearly also carrying the burden of the impact upon the very towns they were trying to protect and in which some of them live. These people are also part of the community and no evidence received by the Special Inquiry gave rise to any concern that the staff of the DEC were doing anything other than what they believed to be right. To ostracise or denigrate these people will simply amplify the losses felt by everyone and do little to make improvements for the future. (P 4, emphasis added).
The gist of the report appears to find that the fire was light a few days before extreme fire days and not enough resources were put in place to observe the fire overnight or to plan for how to deal with it should it flare up. Keetly took the view, as other inquiries have found, that fire managers tend not to think about the ‘worst case’ scenario and what will they do if their plans don’t work. He referred to the coronial inquest into the 2003 Canberra fires and said (at p 64) ‘The Coroner had been critical of the fire managers for possessing a level of optimism not based on objective facts and this, it must be said, is similar to the risk planning and understanding evident in this matter.’ Similar findings were also made in the 2009 Victorian Bushfires Royal Commission.
The recommendations from this inquiry largely deal with DEC procedures and making sure that their guidelines and procedures reflected field learning and actually set out what was intended, so that field staff didn’t either misunderstand or not apply the prescribed procedures. My concern with that is that there is an implication that you can reduce everything to writing and that what is written down should and will provide ‘guidance’ (see p 60). Written instructions are not the only method of communication, and probably not a very effective method of communication. I’m sure my employer has any number of policies and procedures recorded somewhere that I am neither aware of, nor conversant with. People don’t have time to read the manuals, don’t remember what they say and don’t carry them with them for constant reference. Manuals are translated into training and people remember their training and then think they are doing what is required even if practice actually develops that is different from or inconsistent with the manual, particularly if field operators decide that the processes in the manual don’t actually work in their context.
Putting things in writing may help with the accountabilty measure, we can then judge performance against the written policy, but it can also curtail professional judgment. If guidelines are flexible, eg managers should consider the risk to the economy’ there is room for dispute. The manager says ‘I did consider it and decided x, but with hindsight y would have been better’ but that still shows ‘compliance’ but not a result the community is happy with (assuming that they wanted ‘x’ not ‘y’). But if it’s too prescriptive judgments can’t be made. This is an issue that is likely to be explored further when we get the report into the 2011 Queensland floods. If we’re going to have a manual that says exactly what to do, we don’t need fire or flood engineers, only people who can read.
The reality is these decisions are incredibly complex and the desire to reduce everything to a decision matrix belies that, and every inquiry that reveals defects in some process that is ignored or compromised doesn’t show that the managers are not doing the right thing but that decision making takes a certain amount of intuition that can’t be reduced to writing. And sometimes the world lines up in a way that the residual risk, however small, will occur.
An interesting response to the report is that the Minister has announced that ‘DEC will suspend further prescribed burns within five kilometres of townsites and rural subdivisions’ (see Premier’s Media Statement). The problem with that is, as colleagues in the Fenner School of Environment and Society at the ANU have shown, is that it is burning close to homes that has the most significant impact on reducing the threat to homes and lives (see Black Saturday provides bushfire answers; ‘“Clearing vegetation within 40 metres of houses was twice as effective as prescribed burning,” said Dr Geoff Cary from ANU.’ The full report of the research can be found on PLoS One). Banning burning within 5kms of homes may reduce the risk from out of control hazard reduction burns, but it may mean the burns that are conducted are of little value in protecting homes and lives from wildfire! For an interesting discussion on hazard reduction burns, and the significance of this research, listen to ABC Radio National’s Background Briefing, ‘Fighting Fire with Fire’ program, (broadcast on 19 February 2012).
It is not obvious to me that the recommendations, if adopted before these fires, would have necessarily made any significant difference to the decision making or the outcome. Conducting hazard reduction burns, like everything, carries both risk and compromise. What is required is informed community debate about the level of each we are prepared to accept.