The latest chapter in the ‘post disaster’ inquiry saga has been delivered by Queensland’s Crime and Misconduct Commission.   The Commission has recommended against any disciplinary or criminal action against three Wivenhoe Dam engineers who had been referred to the CMC over their evidence to the post 2011 flood inquiry.

The issue before the inquiry was whether or not they had operated the dam in accordance with ‘the manual’; they gave evidence as to their tasks and the movement between various flood mitigation strategies, W1, W2, W3 and W4.  Their evidence was inconsistent and they were referred to the CMC.  The CMC found that the manual itself was inconsistent and depending on what definitions of the strategies a person relied on, they would come to different conclusions as to when different strategies were in place.  This, rather than criminal intention, could explain the inconsistencies in the evidence and meant no further action was warranted.

Is that the end of the matter?  Of course not.  On ABC Radio National’s PM program, reporter Stephanie Smail interviewed Paul Tully, who lost his home in the flood.  Below is an extract from the transcript from the PM website:

STEPHANIE SMAIL: The CMC has ruled out official misconduct and criminal charges, and says no further action is required.

But the findings offer little relief for flood victims.

Ipswich city councillor Paul Tully lost his home in the suburb of Goodna when the floods hit.

He’s described the CMC investigation as a whitewash.

PAUL TULLY: People are sick and tired of the blame game or people standing back and saying it had nothing to do with us.

This wasn’t just a natural event, even though it was severe rainfall. The flooding of Brisbane and Ipswich was caused indirectly and directly by the way in which the dam gates were operated.

STEPHANIE SMAIL: Paul Tully has signed up to a possible multimillion dollar class action with thousands of other flood victims.

He’s hoping that the court process will offer some answers.

PAUL TULLY: At the end of the day, there are a lot of people in south-east Queensland still hurting, thousands and thousands of people, and they’re signing up for a class action because they’re not confident over the CMC inquiry or indeed the outcome of the floods commission, which did find that the manual, the operating manual for Wivenhoe Dam had been breached, but didn’t actually recommend that any further action be taken in respect of that.

Mr Tully says ‘People are sick and tired of the blame game or people standing back and saying it had nothing to do with us’ which sounds like he’s sick and tired of people being blamed and not accepting blame, so I’m not sure what he means by ‘the blame game’ but certainly seeking to sue someone sounds like much more of the ‘blame game’.

Mr Tully’s confidence in the legal system is reassureing but his hoep that ‘the court process will offer some answers’ seems unduly optimistic.  The Court process will focus on the legal issues that need to be proved in order to establish the cause of action, that is not a wide ranging enquiry but a focused inquiry bound by the rules of evidence.  If Mr Tully want’s answers why not look at the actual inquiry? The answer appears to be, in this case and in many others, that people don’t accept the answers if they don’t accord with their own idea of what the answers should be.  They don’t want answers per se, they want answers that they agree with.

Reading between the lines of the CMC report it appears to me that what the engineers did was focus on the objectives that were set out in the manual; these were, in order of priority:

  • Ensure the structural safety of the dams;
  • Provide optimum protection of urbanised areas from inundation;
  • Minimise disruption to rural life in the valleys of the Brisbane and Stanley Rivers;
  • Retain the storage at Full Supply Level at the conclusion of the Flood Event.
  • Minimise impacts to riparian flora and fauna during the drain down phase of the Flood Event. (CMC Report, [12])

When doing this they did not expressly record when they moved from W1 through to W4.  When preparing their evidence they went back to the records and inferred when the criteria for the different strategies were met and then said, in their evidence, that is when they moved from one to the other.  The inconsistent definitions in the manual explained why the evidence varied as to when different strategies were in place.

The CMC report said:

On Saturday 8 January to Monday 10 January 2011, the engineers concentrated on the objectives in the Manual, but not on naming a strategy, although they were all aware of the move to Strategy W4 on Tuesday 11 January 2011, the first time the dam had ever been operated under that strategy. (CMC Report, [103])

The CMC did find:

… the responsibilities of the Senior Flood Engineer are as follows:

  • Set the overall strategy for management of the Flood Event in accordance with the objectives of this Manual.”

If the Senior Flood Engineer ‘…had set the overall strategy and had announced – and recorded – that fact, a great deal of time could have been saved.’   The issue therefore was not that the engineers were not focussed on the objectives set, but that they didn’t record their strategy and objectives; in the language of the Australian Inter-Agency Incident Management System (AIIMS) they failed to manage the event by objectives.

But more is demanded; the Brisbane Courier Mail says “We’re still no closer to knowing whether the southeast’s dams were properly managed during the 2011 flood and whether any of the flooding of thousands of properties in Brisbane and Ipswich was avoidable.” (Mark Solomons, ‘Murky flood waters of 2011The Courier-Mail August 22, 2012).   What ‘properly managed’ means will be a critical issue.  Does it mean that the letter of the manual was followed?  No manual is going to accurately prescribe what to do in an extreme event, and this event was the first time since the dam had been built when strategy W4 was applied, and that strategy effectively let all the water out to protect the dam. On that point, ‘The Flood Inquiry Report did not criticise the engineers for their adoption of Strategy W4, with this inevitable flooding of parts of metropolitan Brisbane …’ (CMC Report, [31] emphasis added). Once the levels were reached that trigged W4 flooding in Brisbane was inevitable but before the engineers had to consider the impact on roads and other infrastructure.   Was trying to balance all those demands, properly managing the dam?

Following the Perth Hills bushfires, Mick Keelty commented that the relevant plan required the incident controller to formally declare when an incident reached ‘level 3’.  This was not done.  (M Keelty, A Shared Responsibility: The Report of the Perth Hills Bushfire February 2011 Review,  pp 94-101).  There is no doubt that engineers and incident controllers are expected to follow the plans and procedures and having process in place to require them to consciously announce that they have changed strategy or ‘scaled up’ the incident are important and are there for good reason, but it does not follow that failure to do so makes the outcomes worse, thought it may make the response more confused.

In a discussion paper I’ve authored for the Bushfire CRC, drawing on interviews with various fire chief officers.  One chief officer said:

… lawyers are writing the plans, or helping us write the plans.  They are so prescriptive as to be almost irrelevant.  Every operation has its own unique dynamic.  Plans should be, you know, principle based and fairly broad and give a large landscape in which to operate with some principles in which to comply with.

But we’re getting so much prescription … Well, that’s great, but then you’ve got the documents and then you’ve got the environment which you’ve got to operate it within.  I’m yet to be convinced that the two will ever align.  … So I don’t think plans are a measure of success because they’re becoming very legalistic.

In that paper I go on to say:

6.10.      Defined, rigid guidelines and procedures will lead, inevitably, to a situation where managers are ‘damned if they do; and damned if they do not’ follow the procedures to the letter. If we want responders to exercise ‘imagination, flexibility, and adaptability’ then the training and doctrine of the organisation has to empower and authorise them to assess outcomes and if necessary depart from policy.  As the UK Fire Services Inspectorate said:

… given the broad and ultimately un-definable range of incidents which the Service might be called on to respond to, the best operational policies are ones which set out what can and cannot reasonably be done but which allow for intelligent and informed decision making on the incident ground.

6.11.      Emergency managers need to be allowed, and trusted, to make decisions in complex, dynamic, information poor environments. They need express permission to make decisions and to be supported when they do, even if, with the benefit of hindsight, it appears another decision may have led to a more favourable outcome.

The Wivenhoe manual set objectives and strategies.  The engineers failed to record their strategies, but according the CMC appeared to focus on the objectives.  Is that enough?  Is that ‘properly managing’ the dam?  If all we want is rigid adherence to the manual or protocol, incident managers don’t need knowledge beyond an ability to read; but don’t think for a moment the plan will always stop the undesired outcome.

As a society we need to understand that the people we put in place are human and have to exercise human judgment.  If the rain had fallen as predicted, if everything had lined up and the flood had been contained and the bridges remained open, would anyone have acknowledged that the engineers had done a great job?  Probably not, but we don’t tolerate things not going to plan.  In the days of ‘risk management’ we are lead to believe that if we simply apply the risk assessment process, then all risk and all bad outcomes can be avoided.  That is of course nonsense.   To avoid damage by flood people would simply not be allowed to build on the Brisbane River and no-one would be allowed to live in New Orelans; but we do live in those places and what the community needs to do is accept the risk, including the risk that events will overwhelm people.  At the end of the day the real risk is that your house will, for whatever reason, go underwater, or be razed to the ground, or have a truck drive into it, or fall into the ocean and the question you have to ask is ‘what are you going to do about it’.  If your answer is ‘I assume it won’t happen because someone else will have a plan in place’ then you’ve missed the point.

Moving beyond adversarial ‘fact finding’ procedures that take too long, cost too much and which are legally irrelevant (see the discussion ’More from the Black Saturday litigation’  on the fact that the Victorian Supreme Court wasn’t allowed to read the 2009 Victorian Bushfires Royal Commission Report) has to be a critical next step in disaster management if we actually want to direct resources where they are needed and actually learn lessons to save lives.   At the moment, the true lesson from the last, and previous inquiries, it is that the single most important thing an incident controller must do, is keep the paperwork up to date; keep your eye not on the event but the next post event inquiry.