Discussion and conclusions
To come to any conclusions about the adequacy of the firefighting response to the Hazelwood mine fire, the Board has necessarily taken into account the measures adopted by GDF Suez and the State to prepare for the risk of fire, as well as resourcing issues and other demands on emergency services at the time the mine fire took hold. The coordination and cooperation between the State and GDF Suez in the preparation for the mine fire is also a relevant consideration. For an understanding of those matters, see Chapter 2.2 Preparing for Fire.
phase one: Firefighting on 9 February 2014 by fire services
The Board considers that fire services responded effectively to the breakout of the Hernes Oak fire. No properties were lost in Morwell. Fire services also responded quickly to the Driffield fire, and together with the mine personnel, successfully prevented the fire from crossing the Morwell River diversion and entering the operational area of the Hazelwood mine.
Where possible, fire services sent resources to the mine to assist with the protection of assets. During the afternoon of 9 February 2014 that assistance was necessarily limited due to the other demands on the fire services’ firefighting resources.
In its submission to the Board, GDF Suez attributed part of the failure of the initial response to the Hazelwood mine fire to the limited firefighting assistance from fire services, and the demands on fire services to attend to other fires in the Latrobe Valley.123
The Board is satisfied that the way that fire services allocated their resources to suppress fire on 9 February 2014 was consistent with the State Controller’s Strategic Priorities, where the protection of life is paramount. For discussion of the State Controller’s Strategic Priorities, see Chapter 2.2 Preparing for fire.
phase ONE: firefighting on 9 february 2014 by GDF Suez
Mine personnel successfully prevented fires in the south-eastern and northern batters of the Hazelwood mine from spreading west towards the operating areas of the mine and important mine infrastructure. This was a substantial achievement given the circumstances. Mine personnel worked strategically to turn sprays on and off in the northern batters to create a fire-break between the worked out northern batters that were on fire and the western end of the northern batters near the operational areas of the mine. The Board commends those efforts.
The Board commends GDF Suez for having maintained power to the national electricity grid through the Hazelwood Power Station during the fire.
However, despite these good efforts, the Board considers that the initial response to the fire was inadequate to suppress ember attack and contain spot fires that ignited in the mine at various locations in the afternoon of 9 February 2014. Accordingly, the fire was widespread in the worked out areas of the mine by around 7 pm on 9 February 2014.
The Board notes the following specific areas of concern with respect to firefighting on 9 February 2014.
The Board was informed by mine personnel and experts that the best form of fire protection was the use of water to wet down the coal faces to reduce the likelihood that fires would take hold.
Mine personnel planned to protect the mine from the risk of fire by the application of water in the mine at all times over the course of the weekend. This was recorded in Hazelwood Mine Fire Preparedness and Mitigation Plans issued on 7 February 2014. Mine personnel did follow this plan where the reticulated fire services water system was present. The Board heard evidence that the application of water from the reticulated fire services water system did create water breaks and stopped the fire in the northern batters spreading towards the operating areas of the mine.
However, in the areas where the reticulated fire services water system did not incorporate sprays and sprinklers, firefighting efforts were severely impeded. As discussed in Chapter 2.2 Preparing for fire, there was no action taken to prepare the worked out areas of the mine for the threat of fire by wetting down those areas where the reticulated fire services water system was limited or not present. The Board heard evidence from mine personnel who were fighting the fire in the northern batters, using the mine’s water tankers, that they had no success in suppressing that fire shortly after it ignited, even when the fire tankers were coupled to the fire service network. Mr Mauger’s evidence was that the fire quickly took hold of the northern batters and that it became too dangerous to continue firefighting efforts.
The Board concludes that the suppression of fires in the mine was severely hampered by the limited reticulated water supply and in particular the lack of sprays and sprinklers in the northern, eastern and south-eastern batters. As noted in Chapter 3.3 Fire prevention and mitigation measures taken by GDF Suez, pipes had been removed from the reticulated fire services water system between 1994 and 2007 and had not been replaced, with the result that the mine’s water system could not deliver adequate quantities of water to suppress the fires in the northern batters.
Expert advice from Mr Roderic Incoll, Bushfire Risk Consultant, and Professor David Cliff, Professor of Occupational Health and Safety in the Minerals Industry and Director of the Minerals Industry Safety and Health Centre, University of Queensland, suggests that the absence of a full reticulation system in the worked out batters was the critical weakness in the ability of GDF Suez to suppress the mine fire on 9 February 2014.124 Professor Cliff suggests that the application of water was one of the few practical measures available to suppress fire in the steep slopes of the worked out batters.125 The Board accepts the views of Mr Incoll and Professor Cliff.
The Board heard evidence that with the exception of two additional contractors rostered on for the weekend of 8 and 9 February 2014, GDF Suez did not consider additional staffing necessary, despite extreme weather conditions being predicted and experienced, and the resulting serious risk of fire.
The Board acknowledges that several members of GDF Suez management, motivated by their own concerns for the impact of any fire on the mine, came into the mine before the fires took hold and were involved in key decision-making in the early afternoon of 9 February 2014. GDF Suez also rapidly increased the number of personnel present at the mine to assist once the mine fire had ignited.
The Board heard expert evidence from Mr Incoll who stated that a key principle of success in fire suppression is a fast determined first attack. Mr Incoll reported to the Board that the resources available for first attack on a mine fire of the magnitude that was experienced on 9 February 2014 were insufficient to prevent the spread of fire inside the mine.126
The Board concludes that additional staff present at the mine prior to the outbreak of fire would have benefitted firefighting efforts.
The Board affirms GDF Suez’s commitment to ensuring that more personnel are rostered on, and additional contractors are available for dedicated fire protection duties, on extreme fire danger days (for example, instead of one 1×7 crew, the equivalent of two or more crews should be available as required in the circumstances). The amount of additional contractor support and the plant and equipment required will reflect internal staffing availability and to some extent the level of support that the CFA advises it has available.127
Emergency Response Plan
The Board heard evidence about GDF Suez’s Emergency Response Plan and procedures that should be adopted in extreme circumstances, like a mine fire.
After the first report of fire in the mine around 2 pm on 9 February 2014, neither Mr Roach in his role as ESLO, nor Mr Ian Wilkinson, GDF Suez 2×12 Shift Supervisor, the only designated GDF Suez Emergency Commander on site at that time, declared a full blown emergency to activate the Emergency Response Plan, as required by s. 2.9 of the Plan. That initial failure had several consequences.
There was no evidence that anyone within the mine notified the CFA of the fires by calling 000. Whilst calls were made to the Traralgon Incident Control Centre during the course of the afternoon, it does not appear that any request for resources was made to the Traralgon Incident Control Centre until around 4 pm. Due to the number of fires in the Latrobe Valley and the heavy workload that fell to the Regional and Incident Control Centres, early intervention and support at State level could have been beneficial to the local response. However, the Board acknowledges the evidence of Mr Lapsley and Mr Lawrence Jeremiah, Incident Controller, that firefighting resources in the area were attending to the fires threatening the townships of Yarram and Morwell before the mine fire ignited and may not have been able to assist any earlier (see Chapter 2.2 Preparing for fire).
The Board heard that the Emergency Response Plan was not implemented until approximately 3.10 pm on 9 February 2014 (more than an hour after fire was first reported), when Mr Harkins declared a ‘full blown emergency’. Once that took effect, clear command and control structures were established. However, the nominated Emergency Commander, Mr Prezioso, was not designated that role in the Emergency Response Plan. The remainder of the mine’s Emergency Commanders were out of Morwell on a weekend break or holiday, with the exception of Mr Wilkinson who was present at the mine but, as noted above, did not assume that role. This is discussed further in Chapter 2.2 Preparing for fire.
Under its Emergency Response Plan, GDF Suez is required to assist the CFA in its efforts to fight fires within the mine. The Board heard evidence from CFA volunteer firefighters who attended the mine on the evening of 9 February 2014, that they met with several obstacles, including difficulties accessing the mine, lack of mine staff to escort them around the mine, lack of signage within the mine and communication problems. This evidence was of concern to the Board. The Board affirms GDF Suez’s commitment to offer enhanced training specific to the Hazelwood mine to CFA brigades close to Morwell, prior to the next fire season and on an ongoing basis. This training is intended to cover:
- orientation, maps, roads within the mine and the location of firefighting infrastructure in the mine
- ongoing use of GDF Suez mine escorts to accompany emergency services vehicles on-site
- the mine’s emergency response procedures and command structure in use during the fire
- communications in the mine during emergencies, including compatible radio frequencies.128
The Board further affirms GDF Suez’s commitment to offer enhanced training to CFA personnel and other relevant emergency services agencies within a 25 kilometre radius of the mine. This 25 kilometre radius takes in town centres including Traralgon, Trafalgar, Mirboo North, Churchill, Glengarry, Yallourn and other locations. This initiative has the potential to build capacity in coal mine firefighting and GDF Suez is encouraged to extend this opportunity to a broader field of townships.129 The Board notes that several of the attending CFA volunteers on 9 February 2014 were from brigades outside a 25 kilometre radius of the mine. Accordingly, the Board encourages GDF Suez to consider the scope of the training offered to maximise the benefit of such training.
The Board affirms GDF Suez’s commitment to upgrade signage within the mine to make orientation easier for emergency services personnel.130
The mine lost power around 5 pm on 9 February 2014. The two high tension power lines owned by SP AusNet that provide power to the Hazelwood mine burnt in the mine fire. GDF Suez gave evidence that it would be unlikely that both lines would be lost at the one time, even though both power lines run in parallel in the same geographical area of the mine.
The Board heard that while there are four power substations in the mine, the two substations that were affected by the power loss were responsible for supplying power to the Emergency Command Centre and the pumps for the reticulated fire services water system. Despite the great efforts of mine electricians who were able to undertake switching works to regain power to pumphouse 53 and one of the dirty water pumps around midnight, there were several hours where the mine’s reticulated fire services water system was affected. There was no back-up power supply available to those substations in the event that mains power supply was lost during a fire. Without power, the reticulated fire services water system was ineffective and the Emergency Command Centre was disabled – staff could not use lighting or equipment such as CCTV monitors, computers and printers.
The Board accepts the evidence of GDF Suez personnel that the loss of power did not mean that there was no water available in the mine to fight the fires, although it concludes that the water flow was limited and water pressure was low. Refilling tankers was problematic as a consequence, which meant firefighting efforts were reduced.
The Board acknowledges that mine personnel and electrical contractors worked hard and in difficult conditions to re-establish power supply to the mine by the early hours of Monday 10 February 2014. They are commended for those efforts.
GDF Suez submitted that the power failure was the most significant of various factors that undermined the early containment and extinguishment of the fire.131 The Board accepts that it was a significant factor but a more significant factor was the absence of appropriate water pipes and sprinklers. By the time the power loss was sustained, there was significant fire activity in the mine in areas where there was limited or no reticulated water. There was evidence to suggest that mine personnel were unable to fight the fire on the northern batters from around 3.30 pm on 9 February 2014, as the fire was burning in areas of scrub inside the mine and the conditions were too dangerous. Firefighting efforts were therefore limited to putting out spot fires.
The Board affirms GDF Suez’s commitment to undertake a review of the redundancies in its electrical system. Further, the Board affirms (pending consultation with SP AusNet) GDF Suez’s commitment to make permanent the temporary connection that was established between MWE (Morwell East) substation (supplied at 11kV) and the clean and dirty water pumps during firefighting efforts.132 This requires SP AusNet to conduct a feasibility study to upgrade the MHO substation from temporary to permanent standard. This is a matter that will initially have to be taken up with SP AusNet.133
Phase TWO: 10–18 February 2014
Cooperation and coordination
Fire services and GDF Suez maintained two distinct command structures for the management of the Hazelwood mine fire. While this arrangement was well organised and communication and relationships were good, fire services were required to attend frequent meetings within their own structure and then additional meetings with GDF Suez fire crews.
There is potential to improve the efficiency of communication and resource use between fire services and GDF Suez. A strategy to achieve this is for both organisations to work together under one integrated emergency response structure during major fires. A more integrated approach to emergency response has the advantage of achieving more effective communication, better incorporation of local knowledge from mine personnel into the development of fire suppression strategies, and the pooling of all available resources.134
In keeping with the management framework for emergencies, GDF Suez personnel who are part of the Emergency Command structure should be trained for incident management pursuant to the Australasian Inter-service Incident Management System (AIIMS). This will ensure that GDF Suez personnel providing assistance to the CFA in firefighting within the mine are working in the most collaborative and complementary way.
The Victorian Government submitted that it is considering various reforms to emergency management planning, in light of the recent Hazelwood mine fire. These reforms will aim to better facilitate a consistent response across both public and privately owned land, to better cater for complex land use, and to take account of the diverse hazards of specific industries and facilities, like the Hazelwood mine. The Board affirms the Victorian Government’s commitment to improve the State’s planning framework for emergencies.135
Further reforms that the Victorian Government has committed to, relate specifically to integration of emergency planning and management with the coal mining sector. The Board affirms the commitments of the Victorian Government to:
- improve its engagement with the coal mining sector regarding emergency management plans136
- improve integration of industry in response to an emergency.137
The Board affirms GDF Suez’s commitment to:
- establish an emergency command structure at the mine to deal with extreme fire danger days whenever they arise and nominate a pool of candidates who are able to act in these roles when required
- assign, in advance, particular roles under that emergency command structure to personnel selected from that pool of candidates to act in these roles on site
- notify the CFA of the identity and contact details of the personnel holding these roles
- provide more training to personnel who are intended to perform a role under the emergency command structure.138
The suppression of fires in the mine was severely hampered by the limited reticulated water supply in the northern, eastern and south-eastern batters. The Board heard evidence that the reticulated fire services water system was expanded significantly during firefighting efforts to enable the system to operate in the northern, eastern and south-eastern batters and the mine floor. This enhanced the firefighting efforts of the CFA and mine personnel, and played a significant role in suppressing the fire.
Phase THREE: 18 february–25 March 2014
The Board heard expert evidence from Professor Cliff. Professor Cliff acknowledged the difficulties in suppressing brown coal fires, which include the removal of the fuel, removal of the heat, isolation of the air supply and stopping chemical oxidation reactions from occurring. Professor Cliff reported to the Board that there were several methodologies that could be used to suppress fire in brown coal fires, including water, foam, helicopter water bombing and removing the coal on fire, but that there were potential weaknesses with all of these methods.139
The Board acknowledges that an effective suppression strategy was developed to extinguish a huge fire with an unlimited supply of fuel on or about 18 February 2014. This strategy addressed the knowledge gap of GDF Suez and fire services around best practice brown coal mine firefighting.
Accordingly, the Board commends those who developed and implemented the new suppression strategy so that the fire was eventually controlled when it was.
However, the Board considers that both fire services and GDF Suez have a lack of readily available equipment, such as compressed air foam systems, relevant to best practice brown coal mine firefighting. Both GDF Suez and fire services recognise that acquisition of best available technology for firefighting in coal mines is an area in need of improvement.140
The Incident Management Team’s careful planning for forecast ‘spike’ days, in particular 25 February 2014, prevented the fire spreading from the open cut into critical infrastructure of the Hazelwood mine, including the operational parts of the mine, the coal bunker and the power station. The Board commends those efforts.
|The State establish, for any future incident, integrated incident management teams with
GDF Suez and other Victorian essential industry providers, to:
|GDF Suez revise its Emergency Response Plan to:
|GDF Suez establish enhanced back-up power supply arrangements that do not depend wholly on mains power, to: