1. Learning from adversity – 75 years of bushfire inquiries Dr Michael Eburn ANU College of Law The Australian National University CANBERRA ACT 0200 P: + 61 2 6125 6424 E: michael.eburn@anu.edu.au

2. Since 1939 … 257 inquiries into preparation for and response to natural hazards Over 50 into bushfires alone. 2

3. Lord Taylor 'That it was allowed to happen, despite all the accumulated wisdom of so many previous reports and guidelines must indicate that the lessons of past disasters and the recommendations following them had not been taken sufficiently to heart … there is no point in holding inquiries or publishing guidance unless the recommendations are followed diligently. That must be the first lesson.' (The Hillsborough Stadium Disaster, 15 April 1989: Inquiry by the Rt. Hon. Lord Justice Taylor, Final Report (London 1990), [22] & [23]). So is there any point? 3

4. Holding an inquiry May give the impression that lessons are being identified but either: –We're failing to learn lessons from the past; or –The inquiries are failing to identify the true lessons; or –The model of inquiry is not well suited to the task. 4

5. Types of Inquiries Operational reviews (eg McLeod 2003) Parliamentary inquires (eg 'A Nation Charred', 2003) Coroner's inquiries (eg Canberra 2003, Wangarry 2008) Auditor General's reviews (eg NSW 1988) Commissioned inquiries (eg Keelty 2012, Malone 2013) Royal Commissions (eg Streeton 1939, Teague et al 2009) 51 Inquiries, 1727 recommendations. 5

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7. Canberra 2003 – a unique lab Three inquiries –McLeod Operational Review –Doogan Coronial Inquiry and Inquest and –Supreme Court litigation What do inquiries teach us? –Take a broad view over time and jurisdictions and –A narrow view, one event, one jurisdiction. 7

8. Why hold inquiries? Do they help? That's hard to know – how much worse would outcomes be if prior recommendations were not followed? BUT There are recurring themes and inconsistent recommendations. 8

9. Does this mean: The earlier recommendations were not followed diligently? The earlier recommendations were not helpful? The problem is a wicked problem? 9

10. Wicked problems A wicked problem is one for which each attempt to create a solution changes the understanding of the problem. Wicked problems cannot be solved in a traditional linear fashion, because the problem definition evolves as new possible solutions are considered and/or implemented.' (Australian Emergency Management Handbook Series, Handbook 8: Lessons Management (Commonwealth of Australia), p 3. 10

11. Inconsistent recommendations – over time 1983 Ash Wednesday Make the Minister the 'Coordinator in Chief'. 'In the event of a declared disaster … the Minister would assume his responsibilities for the implementation and control of all measures to combat the disaster…' (Report of the Bushfire Review Committee on Bushfire Disaster Preparedness and Response in Victoria Australia… (1984) p 142. 11

12. Inconsistent recommendations – over time 2009 Black Saturday The Commission agrees that the designation 'Coordinator' and the description of the role as including coordination of agency activities can lead to confusion about the Minister's role. The Commission is clear that it was not intended for the legislation to imply that the minister had any operational responsibilities' (2009 Victorian Bushfires Royal Commission, Final Report, Vol II, Part A, p 84). 12

13. Inconsistency in one event The use of the Goodradigbee river as the final line of defence in 2003 was unlikely to succeed (McLeod and Doogan) Had the IC prepared the Goodradigbee River 'the fire would, in my view, have been unlikely to have crossed' and Canberra would have been spared (Higgins CJ, West v NSW, [198]). The difference is that Higgins' view is legally binding! 13

14. So what have we learned? There are multiple recurring themes; Inquiries may be identifying problems that can't be solved; They may be making recommendations that –Change the nature of the problem; –Cannot be implemented; –Are inconsistent; or –Are ignored. Diligently applying the recommendations may not be possible and my not prevent the next disaster – is that the first lesson? 14

15. So what are we doing about it? If diligently applying the recommendations is not be possible or effective, what is the point of spending all that money? We do not have the answers (yet) but we will be looking into these issues to identify alternative processes to identify relevant lessons. 15