From 9 February 2014 until 25 March 2014, the local community was overwhelmed by smoke and ash from the Hazelwood mine fire. People were affected in many ways. Smoke and ash produced by the Hazelwood mine fire resulted in a number of distressing adverse health effects for Morwell residents, some of whom may continue to be affected into the future. Many people and local businesses have also experienced financial impacts for a range of reasons.

While the CFA managed the response to the fire, the Environment Protection Authority (EPA), the Department of Health, and the Department of Human Services (DHS), together with the Latrobe City Council, responded to the fire’s health and environmental impacts and led recovery efforts.

The EPA and the Department of Health were the key agencies responsible for providing the community with information about smoke and ash produced by the mine fire and possible adverse health effects. The Department of Health (with the assistance of DHS) set up a number of initiatives to provide respite and relief for the community throughout the event.

Chapter 4.1 of the report includes detailed background information relevant to the environmental and health management of the emergency and its impact on the local community, while Chapter 4.2 provides a chronology of key events.


When coal is burnt it produces a number of different pollutants. Pollutants emitted during the Hazelwood mine fire included carbon monoxide, particulate matter, nitrogen dioxide, sulphur dioxide, polycyclic aromatic compounds, volatile organic compounds, dioxins and furans, and metals. Particulate matter is a complex mixture of very small particles and liquid droplets that can combine to make dust, soot and smoke. Exposure to both PM10 (particulate matter that is 10 micrometres or less in diameter) and PM2.5 (particulate matter that is 2.5 micrometres or less in diameter) has been linked to adverse health effects.

The Hazelwood mine fire also produced a significant amount of ash. While this ash was not ‘fly ash’ it was nonetheless an irritant, and caused significant distress to the community.

The State Environment Protection Policy on Ambient Air Quality provides standards for key pollutants, which are used to monitor ambient air quality. Most of the key pollutants produced during the Hazelwood mine fire are subject to national compliance standards, with the notable exception of PM2.5 for which there is only an advisory standard.

During the Hazelwood mine fire, Victoria’s environmental regulator, the EPA, conducted air quality monitoring in Morwell and the surrounding areas. A variety of equipment was used at different locations to obtain relevant data, which was then provided to the Department of Health. The EPA also tested soil, ash and water during the mine fire.

There were three key time periods of significantly elevated levels of pollution (primarily PM2.5 and carbon monoxide). These were 15–18 February 2014, 21–25 February 2014, and 26–28 February 2014. During these periods PM2.5 levels were well above the advisory standard. A peak reading of PM2.5 was recorded on 16 February 2014 when the daily average was approximately 28 times the advisory standard. Carbon monoxide levels were also significantly elevated during the three peak periods, for example on 16 February 2014 at almost four times the compliance standard.

Other pollutants, such as sulphur dioxide, nitrogen dioxide and ozone, were monitored during the mine fire; however they did not exceed compliance standards. The EPA also monitored volatile organic compounds. It found that benzene exceeded the standard at the Morwell Bowling Club on two occasions, and on one occasion at the Maryvale Crescent Preschool. Children were not at the facility at this time, but other residents were close by.

The Board commends the EPA for:

  • its commitment to scientific rigour and scientific competence in analysing a large amount of complex air quality data sets in a short period of time
  • working assiduously to overcome equipment deficiencies, and moving as swiftly as it could to obtain equipment from wherever it could
  • the monitoring conducted from 20 February onwards at the Morwell Bowling Club
  • seeking independent peer reviews about its response to the Hazelwood mine fire.

However, the State Control Centre’s initial request for the EPA’s support and advice in responding to the Hazelwood mine fire came too late and the EPA was ill-equipped to respond rapidly. The use of low cost, highly mobile equipment could have allowed monitoring to have commenced earlier in the critical period of the first week when the highest air polution concentrations were likely to have affected the community.

For a detailed discussion of the environmental effects and an examination of the EPA’s role as a support agency during the Hazelwood mine fire, see Chapter 4.3 of the report.


Smoke and ash produced by the Hazelwood mine fire resulted in a number of distressing adverse health effects for Morwell residents, including sore and stinging eyes, headaches and blood noses. The majority of these health effects resolved when the fire was controlled, but some have persisted. Other community members have reported the development of new health conditions as a result of exposure to smoke and ash.

A number of vulnerable groups in the community were particularly susceptible to the adverse health effects of the smoke and ash, namely those with pre-existing cardiovascular and respiratory conditions, pregnant women and unborn children, children and the elderly. The Latrobe Valley has an ageing population with a higher incidence of cardiovascular and respiratory disease. The area also has a high percentage of low-income households and a higher percentage of residents who have a disability. As a result, the Hazelwood mine fire added further insult to an already vulnerable community. To assist the community to recover from this incident and to improve health outcomes for the future, the Latrobe Valley should be the focus of renewed efforts to improve community health.

During the Hazelwood mine fire, the Department of Health undertook monitoring of the demand on health resources to assess the potential impact of smoke and ash on the community. Through this monitoring activity, the Department of Health determined that there was an initial increase in demand for general practitioners, however there was not a significant increase in attendances at emergency departments, or other hospital admissions during the period of the fire.

Several weeks into the fire, the Department of Health commissioned the Monash University School of Public Health and Preventative Medicine to undertake a Rapid Health Risk Assessment to provide information about the short-term health effects of the Hazelwood mine fire on the local community. The study concluded that the level of exposure to smoke and ash experienced by the community in Morwell would not be expected to cause any deaths if the level of exposure remained at that level for six weeks. However, the study was based on a standard Victorian population and was not adjusted for the poorer health status prevailing in Morwell.

The Board commends the Department of Health for commissioning the Rapid Health Risk Assessment of the potential health effects of the fire. However, the utility of the Rapid Health Risk Assessment would have been enhanced had the results been available earlier to inform the Department of Health’s decision-making. It also would have been beneficial to provide the Rapid Health Risk Assessment findings to the community to address their request for more information about the potential adverse health effects of the exposure to smoke and ash.

There were serious concerns in the community about the potential long-term health impacts of exposure to smoke and ash from the Hazelwood mine fire. Understanding and managing the health and environmental impacts of the Hazelwood mine fire is challenging, as the health effects of medium-term exposure to smoke and ash from a fire in a coal mine are not known.

A primary concern, from a long-term health perspective, is the duration for which residents were living with ashy, smoky conditions. The Board heard expert evidence that people with pre-existing cardiovascular and respiratory conditions are particularly susceptible to potential adverse long-term health effects when exposed to ozone, PM2.5 and larger particulates. In particular they are susceptible to an aggravation or progression of their underlying condition, an increased risk of lung cancer and potential effects on coagulation, which could result in an increased risk of arrhythmias, morbidity, hospital admissions and death. There was also a risk that the general population could develop medium to long-term effects from the exposure to PM2.5 and ozone, including but not limited to the development of respiratory conditions, effects on cardiac conduction, increased risk of heart attack, stroke and lung cancer, long-term cognitive decline and psychosocial effects.

Chapter 4.5 of the report contains a more in-depth discussion of the health effects that the smoke and ash produced by the Hazelwood mine fire had on the community, the likely cause of these health effects, and potential long-term health impacts.


The Board of Inquiry heard a number of concerns about the health risks faced by firefighters during the Hazelwood mine fire and received submissions that the CFA, MFB and GDF Suez failed to recognise the potential health risks to those involved in the fire operations, particularly from exposure to carbon monoxide.

Over the course of the Hazelwood mine fire, numerous firefighters from emergency services and GDF Suez required medical treatment. Fourteen emergency service firefighters and 12 GDF Suez staff presented to hospital due to exposure to carbon monoxide, however none required admission. A firefighter was admitted to hospital due to a cut that subsequently became infected and another firefighter was injured activating a water spray in the mine. Several firefighters required first aid at the mine throughout the fire.

Fire services were initially inadequately prepared to respond to the hazardous conditions produced by the Hazelwood mine fire, particularly the risk of firefighters being exposed to elevated levels of carbon monoxide, which is lethal in high concentrations.

Protocols about the protection of firefighters from the risks of exposure to carbon monoxide were not implemented until late in the evening on 9 February 2014, by which time firefighters had already been exposed to increased levels of carbon monoxide.

The Draft Carbon Monoxide Regional Operating Procedure (developed in 2006 by the CFA) was then utilised, with additional measures subsequently incorporated to form a Health Management and Decontamination Plan. The Board considers that the Health Management and Decontamination Plan did not take into account that some firefighters may have had pre-existing conditions such as cardiovascular disease, which would have put them at an increased risk of adverse health effects from carbon monoxide exposure. The Board considers that it is important that all firefighters, including volunteers, are provided information about the potential risks involved in firefighting so that they can make informed choices. It is concerning that the Carbon Monoxide Regional Operating Procedure has remained in draft form since 2006.

GDF Suez had a carbon monoxide procedure in place to manage the risk of exposure to carbon monoxide during a mine fire. However, the Board considers it did not provide adequate protection to the mine’s firefighters and operational staff from potential carbon monoxide exposure. If not for GDF Suez subsequently adopting the Health Management and Decontamination Plan utilised by emergency services, carbon monoxide exposure would not have been detected until firefighters began to exhibit symptoms, which may have put them at risk of significant adverse health effects.

The immediate health risks to firefighters during the Hazelwood mine fire and the methods employed to minimise these risks are described in further detail in Chapter 4.4 of the report.


The health response to the Hazelwood mine fire was led by the Department of Health with the assistance of the EPA. The Department of Education and Early Childhood Development and the Latrobe City Council managed the health response for schools and children’s services.

The Inquiry revealed that the response to poor air quality in the Latrobe Valley as a result of the Hazelwood mine fire was delayed and overly reliant on validated air data when indicative air data would have been sufficient to inform health advice. This was compounded by issues relating to the protocols relied upon by government agencies to assist their decision-making.

One such protocol was the Bushfire Smoke Protocol, jointly developed by the EPA and the Department of Health in 2006/2007. During the Hazelwood mine fire, the EPA issued 58 advisories in accordance with the Bushfire Smoke Protocol via media releases. These advisories also included general advice about actions to reduce health impacts caused by smoke. However, the advisories were generic and repetitive and did not provide actionable advice for the community to respond to varying levels of smoke. The Bushfire Smoke Protocol should be reviewed and amended to provide practical, clear and user-friendly advice.

During the mine fire two further joint protocols were developed to help inform decision-making and advice to the community about increased levels of carbon monoxide and PM2.5 in the air: the community Carbon Monoxide Response Protocol and the PM2.5 Health Protection Protocol.

The Board commends the EPA and the Department of Health for their commitment to developing and obtaining peer reviews of the community Carbon Monoxide Response Protocol and the PM2.5 Health Protection Protocol. However, because they were only developed during the mine fire, they could not be used to protect the community in the early stages of the fire.

In particular, the PM2.5 protocol was not developed until 25 February 2014, by which time the local community had already been subjected to elevated levels of PM2.5 for more than two weeks.

After 25 February 2014, levels of PM2.5 started to increase again, which prompted the Chief Health Officer to advise on 28 February 2014 that vulnerable groups (preschool aged children, pregnant women, people with pre-existing cardiovascular and respiratory conditions and people over 65 years) temporarily relocate from the area south of Commercial Road in Morwell. Based on the information provided, the Board considers that this temporary relocation advice was provided too late. Further, the basis for limiting the advice to those in vulnerable groups living south of Commercial Road was poorly explained and was perceived by the community as arbitrary and divisive.

The absence of a carbon monoxide protocol in the early stages of the fire meant the response of the EPA, CFA and Department of Health to high carbon monoxide levels lacked coordination and integration. On 15 February 2014, elevated carbon monoxide readings motivated the CFA to issue a ‘Watch and Act’ alert warning residents close to the Hazelwood mine to shelter indoors immediately and close all windows, doors and vents. The Department of Health was not involved in the decision to send the alert and did not consider it necessary or helpful. It also conflicted with health advice the Department was providing to the community at that time.

Worrying carbon monoxide levels continued to be detected on 16 February 2014. The Department of Health considered these detections to be ‘spot readings’ and not sufficiently reliable to inform public health advice. The Department of Health therefore decided not to issue any warnings or advice to the community. Yet if these readings were averaged over a four hour period they were high enough to warrant at least a ‘Watch and Act’ alert. The Board was informed that no adverse health effects from community exposure to carbon monoxide were detected on or after 16 February 2014.

The Board considers it unfortunate that the Department of Health did not have in place a pre-existing carbon monoxide protocol to provide advice to the community about elevated levels of carbon monoxide. The Board is of the view that the State should give further consideration to improving advisory mechanisms for public health emergencies.

The Board is concerned that acute exposure standards, used as a basis for the community carbon monoxide protocol, are too high according to international experts and should be reviewed. Furthermore, inconsistencies between the community carbon monoxide protocol and the firefighter carbon monoxide protocol meant that levels that were not considered safe for firefighters and required evacuation, did not require the same response if the level was measured in the community. This inconsistency in the protocols was not satisfactorily explained to the Board and remains of concern.

Following the establishment of the Inquiry, the Victorian Government signalled it intended to incorporate the Carbon Monoxide Response Protocol and the PM2.5 Health Protection Protocol documents into a single operational document. It also intends to develop a State Smoke Plan covering the management of potential public health impacts from large scale, extended smoke events such as bushfires, planned burns, brown coal mine fires or industrial (hazardous material) fires.

The Board affirms this proposal, and recommends that the State Smoke Plan be incorporated into a State Smoke Guide, which would consist of a comprehensive suite of documents and support materials that could be used to minimise the harmful effects of smoke in the community.

A number of additional measures were put in place to provide health information and support to the community during the Hazelwood mine fire. These include the establishment of a community respite centre and a health assessment centre.

The Board commends the Department of Health for the development of a health assessment centre. The centre provided the community with an additional resource to provide health information, guidance and reassurance. Although, the effectiveness of the centre would have been enhanced if local general practitioners had visited the centre to demonstrate their support and to reassure the community that appropriate measures were in hand.

In terms of the longer-term health response, the toxic nature of smoke from the Hazelwood mine fire has raised community and medical concerns that there will be ongoing physical and mental health implications. The Department of Health has agreed to fund a long-term and wide ranging health study. This is not a decision that would have been taken lightly—there are few examples in Australia of long-term studies linked to an environmental disaster.

The Board agrees a long-term study would be an extremely useful predictive tool to assist with understanding future risks, and to prevent or reduce the chances of adverse health effects arising from similar situations in the future. However, all efforts ought to be made to extend the duration of the study to at least 20 years given the long lead times of some potential pollutants and the fact that young children were susceptible to the impacts.

Although there are many excellent health services in the Latrobe Valley and visits to those services increased during the mine fire, there was not a coordinated whole of health sector approach. There is a strong case for the health of the population of the Latrobe Valley to be substantially improved. Based on current health status information, this was justified before the Hazelwood mine fire and is even more necessary now. In the view of the Board, consideration ought to be given to potential avenues to achieve better outcomes for the region, such as the creation of a health conservation zone and the appointment of an independent health advocate.

The adequacy and effectiveness of the health response to the Hazelwood mine fire is considered more comprehensively in Chapter 4.6 of the report.


During the Hazelwood mine fire, the Latrobe City Council, government agencies and GDF Suez delivered a range of relief and recovery initiatives. These included respite and relocation payments to eligible Morwell residents, clean up kits and financial assistance for professional cleaning services, and financial assistance for businesses.

At community consultations and in written submissions, there was widespread criticism of the timing, adequacy and eligibility criteria for these initiatives.

In accordance with the emergency management arrangements in effect at the time of the Hazelwood mine fire, both DHS and Latrobe City Council had a role in planning and coordination of relief and recovery, with the Council largely responsible for local operational delivery. This led to community confusion regarding their roles and responsibilities.

For example, it is apparent from community consultations that the community was not clear about the decision-making and funding process for the clean up. The Board agrees with Latrobe City Council that improved systems of coordination and communication are required in emergencies of this type. The Board recognises that emergency management reforms underway in Victoria are likely to assist with achieving this objective.

Based on information before the Board, it is apparent that the Latrobe City Council worked hard to implement relief and recovery measures, and to advocate on behalf of the community for adequate clean up packages.

While acknowledging that clean up assistance has not previously been provided by the Victorian Government to households after floods and bushfires, the Board considers the self-clean package was inadequate to the scale of the cleaning task faced by community members. The clean up assistance package for Morwell was not announced until 18 March 2014 and there were further delays in implementing the assisted clean up package. This diminished the usefulness of the package as many people had already made their own cleaning arrangements.

DHS developed tailored relief payments to meet the needs of the residents of Morwell, in particular residents who were advised to temporarily relocate. However, there was confusion about eligibility requirements regarding the respite and relocation payments and flaws in communication, which caused distress in the community. The relief payments created divisions in the local community that have impeded recovery. The Board recognises and supports the decision by DHS to review its programs and guidelines for consistency and clarity of purpose. The Board also supports the Victorian Government’s proposal to implement new technology for recording emergency assistance payments.

The Victorian Government, through the Department of State Development, Business and Innovation, has provided considerable support and assistance for small businesses in Morwell affected by the mine fire. Financial assistance was made available through the Morwell Business Relief Fund and a range of other practical support was also available. GDF Suez has provided additional stimulus to Morwell retailers through its ‘Revive Morwell’ initiative and Community Social Capital grants.

The Board affirms the Victorian Government’s commitment to support local councils through Local Government Victoria. In particular, the Board supports developing formal and informal networks between emergency management officers and a resource base that Local Government Victoria can work closely with during the response and recovery phases. The proposal for Local Government Victoria to coordinate emergency management officers across local councils is an appropriate approach.

For further exploration into the relief and recovery measures taken to support the Latrobe Valley community during and after the Hazelwood mine fire, see Chapter 4.7 of the report.