Discussion and conclusions
The Board has considered the adequacy and effectiveness of the preparation and planning measures of both the State and GDF Suez in preparing for fire. In doing so, the Board has taken into account the predicted weather conditions for the weekend of 8 and 9 February 2014 and the fire activity in Victoria and the Latrobe Valley at that time (see the discussion in Chapter 2.1 Origin and circumstances of the Hazelwood mine fire).
The discussion and conclusions recorded in this Chapter relate only to the application of the preparation measures prior to the mine fire. The adequacy and effectiveness of the preparation measures as they were implemented during firefighting (for example, power supply) are discussed in Chapter 2.3 Fighting the Hazelwood mine fire.
The Board has identified several areas where preparation and planning were appropriate and in line with policies and regulations. Equally, the Board has identified areas where preparation and planning were deficient.
PREPARATION BY THE STATE
The State was generally well prepared for the extreme fire weather conditions on 9 February 2014.
The Traralgon Incident Control Centre was established with the appropriate team structure and experienced staff. However, due to the extensive fires burning across Victoria, no base Incident Control Centres were set up in Ellinbank, Yarram, Noojee or Erica. Only Leongatha had a base Incident Management Team in place that weekend. The outbreak of the Jack River fire was assigned to the Traralgon Incident Control Centre when it would ordinarily have been managed by the Yarram Incident Control Centre. This put additional pressure on Mr Jeremiah and his team to manage fires outside the Traralgon footprint. The Board notes that the decision that the Yarram Incident Management Team would not be established was approved at State level in accordance with Standard Operating Procedure J2.03.
In addition to the inability to set up the south and west Gippsland cluster with the required readiness levels, the Traralgon Incident Control Centre was further disadvantaged by the slow allocation of the additional aircraft requested by Mr Jeremiah in anticipation of the extreme fire weather conditions on 9 February 2014. The additional aircraft requested on the afternoon of 8 February 2014 did not arrive in the Latrobe Valley until around noon on 9 February 2014 and were not available to suppress the Hernes Oak–McDonald’s Track fire during the evening of 8 February 2014 and the morning of 9 February 2014.
The Board accepts the evidence of Mr Lapsley that resources were stretched state-wide. The Board was not sufficiently informed as to whether the additional resources requested by the Traralgon Incident Control Centre could have been allocated any earlier.
PREPARATION BY GDF SUEZ
GDF Suez recognised the need for fire preparedness planning on 7 February 2014 upon the declaration of a Total Fire Ban for the area. However, the Board considers that those preparation measures were inadequate. Instead of planning for the worst, mine management hoped for the best. GDF Suez should have adopted greater preparation measures.
Because GDF Suez is the operator of a brown coal mine in a bushfire prone area, it should have understood the specific vulnerability of the mine site and that the likely consequences of a fire entering the mine would be catastrophic. Accordingly, it should have taken as much action as possible to prepare for, and minimise the risk of, a fire taking hold in the mine. Best practice, not minimum practice was needed. The Board considers that it was not enough for the mine to prepare well—the mine should have prepared extremely well.
The strongest criticism the Board makes of GDF Suez is its failure to undertake a fire risk assessment of the worked out areas of the mine, including a cost/benefit analysis. Not undertaking this risk assessment was contrary to a recommendation made after the fire in the mine in September 2008, which is discussed in Chapter 3.3 Fire prevention and mitigation measures taken by GDF Suez.
The Board concludes that there are several other areas where preparation by GDF Suez was inadequate, as described below.
Access to water in the worked out batters
GDF Suez recognised the need for fire preparedness planning on 7 February 2014 upon the declaration of a Total Fire Ban for the area.
The Fire Preparedness and Mitigation Plans issued by GDF Suez addressed the relevant features required by Hazelwood Mine Guidelines for Season and Period Specific Fire Preparedness and Mitigation Planning, except that they failed to address the protection of the areas where the reticulated fire services water system was limited (no sprays or sprinklers) or non-existent. The protective measures addressed the critical assets of the mine and not the worked out areas. There were no actions recorded to direct mine personnel to address the flammability risks of the batters. This was a fundamental gap in the preventative measures undertaken by GDF Suez. Further discussion about the effect of limited water in the worked out areas is discussed in Chapter 2.3 Fighting the Hazelwood mine fire.
The Board is critical of GDF Suez for not having back-up generators available to supplement the mains power supplying the mine, and in particular, the Emergency Command Centre. Further discussion of the impact of this failure is contained in Chapter 2.3 Fighting the Hazelwood mine fire.
Resourcing for the fire risk
While Fire Preparedness and Mitigation Plans were prepared, the Board is critical of the fact that the Fire Preparedness and Mitigation Plans were not updated once the Hernes Oak–McDonald’s Track fire ignited on Friday afternoon 7 February 2014 and became a serious threat to the mine. The Plans should have been reviewed and modified to reflect the changing and serious situation taking place.
The Fire Preparedness and Mitigation Plans relied on the CFA being able to promptly respond to a fire in the mine. GDF Suez should have made a more considered assessment of the likely pressures that the CFA would be under in the circumstances, given that the Hernes Oak–McDonald’s Track fire was going on 7 February 2014 and conditions over the weekend were predicted to be the worst since Black Saturday. GDF Suez should have appreciated that it was likely that the CFA would be responding to fires over the weekend, leaving fewer resources to assist the mine in the event that assistance was necessary. GDF Suez should have more closely liaised with the CFA to understand the CFA’s position with respect to resourcing and its consideration about the likely threat to the mine.
Accordingly, GDF Suez should have revised its assessment of staffing levels and the other protective measures it planned to implement over the weekend. Save for two additional contractors supplementing the usual weekend staff, no additional staff were rostered on. Senior managers should have been on site to take control of any fire threats within the mine to enable the 1×7 and 2×12 crews to fulfil fire spotting and suppression roles.
Attention should have been directed to the Mine Shift Supervisor and the ESLO on Friday 7 February 2014 to ensure both were ready and prepared to action the Fire Preparedness and Mitigation Plans and to activate the Emergency Command Centre in the event it was required.
Failure to liaise with emergency services
The Board heard evidence from the Incident Controller that over the course of the weekend, several Phoenix Rapidfire models were produced, showing the significant threat to the Hazelwood mine in the event that the Hernes Oak–McDonald’s Track fire broke its containment lines.
The Incident Controller held briefings with the CGEIG Chair to inform him of the latest information relevant to the fire activity in the Latrobe Valley, together with the Incident Controller’s assessment of the risks faced by members of the CGEIG. The Incident Controller relied on the CGEIG to provide that relevant information to CGEIG’s members. The Board accepts the evidence of Mr Jeremiah and Mr Lapsley that communications of emergency risks through CGEIG had occurred successfully in the past and that there was the same expectation in relation to the risks present on the weekend of 8 and 9 February 2014.
The Board heard evidence from Mr Roach that information was provided by the Chair of CGEIG to him in relation to the fire activity and predicted weather. Mr Roach confirmed receiving one Phoenix Rapidfire model from the Chair of CGEIG.
The significance of the threat to the mine, appreciated by Mr Jeremiah by reference to the Phoenix Rapidfire modelling, was not so appreciated by GDF Suez personnel.
The evidence of Mr Roach was that he did not understand the Phoenix Rapidfire model provided to him, despite discussions with the Chair of CGEIG on 8 February 2014. The evidence suggests that Mr Roach did not discuss the model again on Sunday 9 February 2014 despite indications to Mr Harkins that he would gain a better understanding by doing so. Accordingly, it seemed that Mr Roach disregarded the model and its utility in appreciating the possible risks that would flow from a break-out of the contained Hernes Oak–McDonald’s Track fire.
GDF Suez submitted that it was unsafe for the Incident Controller to rely upon or expect a third party, such as the CGEIG Chair, to pass on and explain significant information regarding a critical risk to the Hazelwood mine. GDF Suez further submitted that the provision of only one Phoenix Rapidfire model in circumstances where several predictive models had been prepared was not sufficient information. GDF Suez also criticised the Incident Controller for simply forwarding the model to the CGEIG Chair without any accompanying detailed explanation about the meaning of the simulation.216
The Board agrees that there is a risk that all relevant information about the risks of the spread of fire will not be passed on, or certain information may be lost in translation, if reliance is placed on third parties. The Board notes that the Phoenix Rapidfire model provided by the Traralgon Incident Control Centre to CGEIG by email had no explanation about the significance of the model. Further, the evidence suggests that this was the only model sent to GDF Suez by CGEIG. From the three models produced to the Board in evidence, this model appears to have been the least relevant of the prediction models that the Traralgon Incident Control Centre had available to it on Saturday 8 February 2014.
OpPortunIties for enhancing GDF Suez preparation
GDF Suez has recognised further preparation for the risk of fire could have been done and has committed to undertaking the following actions:217
- nominating a group of staff to be trained in the Phoenix Rapidfire modelling tool before the next fire season
- establishing 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
- assigning, in advance, particular roles under that emergency command structure to personnel selected from that pool of candidates to act in these roles on site
- notifying the CFA of the identity and contact details of the personnel holding these roles
- providing more training to personnel who are intended to perform a role under the emergency command structure
- ensuring more personnel are rostered on and that additional contractors are available for dedicated fire protection duties
- reducing vegetation in the worked out areas of the northern batters of the mine to reduce fire risk
- reviewing the current pipework and condition and maintaining and using the additional pipe system located in the northern batters installed in 2014
- on extreme fire days, instigating wetting down of non-operational areas.
The Board affirms these actions.
OPPORTUNITIES FOR ENHANCing EMERGENCY PREPARATION
The Victorian Government’s second submission to the Inquiry, dated 18 June 2014, notes that it is considering reforms to emergency management planning. These reforms would ensure consistency across both public and privately owned land, better cater for complex land use, and take account of the diverse hazards of specific industries and facilities (like the Hazelwood mine) to mitigate risks in a coordinated way. The Board affirms the Victorian Government’s commitment to improve the State’s planning framework for emergencies.218 Further, the Board affirms the commitment of the Victorian Government to improve its engagement with the coal mining sector regarding emergency management plans.219
The Victorian Government’s second submission also discusses the White Paper reforms to further improve Victoria’s emergency management arrangements. The reforms are intended to ensure that an ‘all hazards, all agencies’ approach is embedded in managing emergencies, that streamlined arrangements for emergency management governance are introduced, that shared responsibility, cooperation and clarity of roles and responsibilities is encouraged, with a stronger emphasis on emergency risk mitigation, and that the importance of improved planning processes is recognised.
The Board affirms the Victorian Government’s commitments to carry out the emergency management reforms, namely:
- developing a Strategic Action Plan to improve and strengthen Victoria’s emergency management capability
- establishing Emergency Management Victoria as the new overarching body for emergency management in Victoria
- establishing an Emergency Management Commissioner to ensure that all control arrangements are in place, and to coordinate the response roles of relevant agencies’ resources
- establishing Inspector General Emergency Management as the assurance authority for Victoria’s emergency management arrangements.220