The risk of carbon monoxide exposure has been identified as a key risk in fires, particularly coal mine fires.12 The primary risk to firefighters during the Hazelwood mine fire was exposure to carbon monoxide.

Without monitoring equipment, firefighters can be exposed to high levels of carbon monoxide without knowing. This not only compromises their own health and effectiveness, but puts their colleagues at risk if they need to attend to and evacuate an affected firefighter.

Symptoms of carbon monoxide exposure include headache, dizziness, weakness, nausea, vomiting, chest pain and confusion.13 At extreme levels carbon monoxide exposure can lead to death.14

The presence of carbon monoxide in the air is measured in parts per million (ppm). However, the effect of carbon monoxide exposure on a person is determined by the percentage of carboxyhaemoglobin in the blood.

Carbon monoxide at high levels is acutely toxic to all; however some groups are more vulnerable to the effects. For example, older people and people with chronic cardiovascular and respiratory disease are less likely to be able to cope with the insult.15 Breathing carbon monoxide during pregnancy can cause miscarriage.16 The Country Fire Authority (CFA) does not retain comprehensive medical information about all its volunteers.17 Whether CFA volunteers have a pre-existing cardiovascular or respiratory condition, or are pregnant and therefore carry a greater risk if exposed to carbon monoxide, is unknown.


During a previous fire at the Hazelwood mine in 2006, a number of firefighters experienced symptoms consistent with carbon monoxide poisoning. The CFA report into the 2006 fire noted that ‘any similar fires in the future will require the careful management of this known risk.’18 Following this fire, and a further fire in 2008, the CFA developed a document entitled ‘Draft Regional SOP – Latrobe Valley Open Cut Coal Mines – Response to Fires (Draft Carbon Monoxide Regional Operating Procedure)’ that outlined a graded system of work arrangements to control firefighter exposure to carbon monoxide.19

The Draft Carbon Monoxide Regional Operating Procedure remained in draft form for eight years between 2006 and the commencement of the Hazelwood mine fire in February 2014.

Mr Lapsley accepted that it should have been a priority of the CFA to finalise the Draft Carbon Monoxide Regional Operating Procedure promptly, to ensure that it was available for future incidents where there was a risk of carbon monoxide exposure.20


On 9 February 2014, a number of firefighters were deployed to areas of the Hazelwood mine without breathing apparatus or personal carbon monoxide detectors.21

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 this time a number of firefighters had already been exposed to increased levels of carbon monoxide that were generated by the mine fire.

Mr Doug Steley, CFA Volunteer, attended the mine fire at approximately 10 pm on 9 February 2014. He told the Board that when he arrived at the mine he was provided with limited information about potential exposure to carbon monoxide. He was given a carbon monoxide monitor for his Unit and told that an alarm would go off continually if they needed to evacuate. However, he was not told what the alarm sounded like.22 On 11 February 2014, Mr Steley attended a local hospital emergency department with a mild headache.23 He did not require admission to hospital.

On 10 February 2014, fire services developed a carbon monoxide procedure at the mine. The Board was provided with an incident plan for the day shift, which included the following information:

  • all crews to have access to carbon monoxide monitoring
  • total withdrawal at 200 ppm.24

Following this, Mr Ross Male, CFA Division Commander at the mine, noted arrangements to rotate work shifts to reduce the time firefighters spent in the mine. He also noted arrangements to monitor carbon monoxide in the environment, and to monitor the carboxyhaemoglobin levels of individual firefighters.25

The fire services Health Support Team then implemented the Draft Carbon Monoxide Regional Operating Procedure developed after the 2006 and 2008 fires.26

The Draft Carbon Monoxide Regional Operating Procedure provided that firefighters with
a carboxyhaemoglobin level:

  • less than five per cent were able to work their full shift
  • between five per cent and seven per cent were unable to work and were excluded from
    the site for 24 hours
  • greater than eight per cent were referred to Ambulance Victoria for assessment.27

The Draft Carbon Monoxide Regional Operating Procedure also set a standard for carbon monoxide concentrations in the air and what action should be taken (see Figure 4.40).

Figure 4.40 Carbon monoxide ambient air levels – Latrobe Valley open cut coal mine28

Carbon monoxide ambient air level


Below 30 ppm
  • No restriction to personnel undertaking continuous work for a period of up
    to 8 hours
In excess of 30 ppm
  • The Incident Controller must be notified
  • Ongoing monitoring of carbon monoxide must be undertaken in the area
    and the readings must be logged with the Incident Controller
  • The Incident Controller must notify the Health Support Team Manager and/or Scientific Officer and will be advised of the maximum time that personnel can remain in the environment
  • The Health Support Team Manager will liaise with the CFA Medical Officer
  • The parent mine company must be requested to provide a Company Health Representative
In excess of 200 ppm
  • The Incident Controller must be notified immediately
  • All personnel in the area must immediately leave the area
  • Ongoing carbon monoxide concentrations must be undertaken to determine
    the extent of the area affected and concentration encountered
  • The Incident Controller will immediately notify the Health Support Team and/or Scientific Officer and will be advised of the maximum time personnel can remain
    in the environment and the duration of rest periods that must be undertaken
    prior to re-entry

On the evening of 11 February 2014, following a report that several firefighters had presented to the Sale Hospital for possible carbon monoxide exposure, the Incident Controller suspended firefighting in the mine pending review of the safe work arrangements.29 Mr Lapsley told the Board that from this moment on his personal attention was focused on ensuring that the management of carbon monoxide exposure in the mine was correct.30

On 12 February 2014, the CFA received advice from an occupational hygienist, Mr Robert Golec from AMCOSH Pty Ltd, Mr Mike Smith, Deputy Chief Officer of the South Australian Metropolitan Fire Service, and Dr Michael Sargeant, the CFA Medical Officer, about the risk of carbon monoxide exposure. Around this time, Mr Lapsley advised that pregnant women, and those with pre-existing heart and lung disorders, should not be deployed to the mine.31

On the evening of 12 February 2014, the Incident Controller implemented an upgraded carbon monoxide system of work based on the advice of the occupational hygienist and interstate experts. The new system of work required:

  • each crew leader to monitor carbon monoxide levels with a personal carbon monoxide monitor
  • that carbon monoxide levels be reported to the Division Commander every 15 minutes
  • if the ambient carbon monoxide levels exceed 50 ppm firefighters are required to wear breathing apparatus
  • if the ambient carbon monoxide levels exceed 75 ppm firefighters are to immediately put on breathing apparatus and leave the area.32

On 13 February 2014, Mr Lapsley declared that the Hazelwood mine fire was a HazMat fire.33

On 14 February 2014, the carbon monoxide procedures at the mine were formalised into the Health Management and Decontamination Plan. The Health Management and Decontamination Plan was based on the Draft Carbon Monoxide Regional Operating Procedure, and included the upgraded carbon monoxide system of work implemented from the evening of 12 February 2014.

The Health Management and Decontamination Plan was developed specifically for the Hazelwood mine fire and was endorsed by Mr Lapsley, the Chief Officers of the CFA and Metropolitan Fire Brigade (MFB), and the State Emergency Service (SES). The Plan was based on the SafeWork Australia National Occupational Exposure Standard, which allows a worker to be exposed to a maximum average of 30 ppm carbon monoxide for an eight-hour period in order to prevent the worker’s carboxyhaemoglobin level exceeding five per cent.34

Mr Peter Rau, MFB Acting Chief Officer, described in an email update to firefighters the review process that generated the Health Management and Decontamination Plan as ‘a turning point where fire services began to treat Hazelwood not only as a fire, but as a hazardous materials incident, with the associated protocols’.35

Figure 4.41 Firefighters at the mine wearing protective face masks


Image source AAP NewsWire

The United Firefighters Union (UFU) and Volunteer Fire Brigades Victoria (VFBV) submitted to the Board that many firefighters were unable to comply with the Health Management and Decontamination Plan as the requirements were impractical, or because they did not have the available equipment (specifically, carbon monoxide monitors). There was also confusion about the standards and the accuracy of the carbon monoxide measurements.36

Mr Lapsley accepted that there was a delay in implementing the Health Management and Decontamination Plan and that the changes in the way the carbon monoxide exposure was managed during the initial stages of the fire had the potential to make it confusing for firefighters.37

A further concern was raised about the threshold level of five per cent carboxyhaemoglobin used in the Health Management and Decontamination Plan.38 The World Health Organisation (WHO) recommends a threshold of 2.5–3 per cent carboxyhaemoglobin.39 However, the WHO standard applies to the community, not a workplace (where exposure is limited to the period of time at work and it is assumed that the employees are healthy).


GDF Suez also had firefighters, other employees and contractors at the mine who were exposed to the same risks during the fire, in particular elevated carbon monoxide levels.

Following the 2006 mine fire, GDF Suez conducted an investigation, which concluded that a procedure should be developed for dealing with carbon monoxide during firefighting.40 A carbon monoxide procedure was developed and included in the Hazelwood Mine Fire Instructions (issued 27 July 2011), and was in place at the time of the Hazelwood mine fire.41 The carbon monoxide procedure stated that the maximum exposure for an individual to carbon monoxide was 200 ppm over two to three hours, and 30 ppm over eight hours. The carbon monoxide procedure contained no guidance about safe levels of carboxyhaemoglobin generally or for susceptible individuals (those with pre-existing cardiovascular and respiratory disease or pregnancy).

Mr Harkins told the Board that GDF Suez had developed a further informal protocol which required all staff to have a carbon monoxide monitor, known as a ‘canary’, when entering the mine during a fire. The canary monitors carbon monoxide levels in accordance with the carbon monoxide procedure.42

During the Hazelwood mine fire GDF Suez firefighters were also required to comply with the emergency services Draft Carbon Monoxide Regional Operating Procedure and subsequently the Health Management and Decontamination Plan.

GDF Suez firefighters had their carboxyhaemoglobin levels tested before entering and when leaving the mine. A number of GDF Suez firefighters received first aid (including oxygen therapy) and 12 GDF Suez staff were sent to hospital as a result of high carboxyhaemoglobin levels, however none were admitted.43