Why we weren’t warned

The morning of 7 February at Cottlesbridge, just south of the line of the most devastating bushfire in Australian history, and where our family has lived on 20 acres for the past 26 years, was baking hot but also relatively still. Before midday a ferocious northerly wind had blown up. The premier and the fire and emergency chiefs had warned that this day would be unlike any other in the history of the state. It was clear by now that they were right. The threat of bushfire was in everyone’s mind. If fire came within 25 or 30 kilometres, my wife and I intended to leave immediately with our menagerie of four cats and a dog. We are close to the Kinglake–Hurstbridge Road, five minutes from the supposed safety of the outer suburban fringe.

Shortly after midday we learned that a fire had broken out in Kilmore, some 50 kilometres to the north-west. From now on we were alert, glued to ABC local radio and the Country Fire Authority website. It soon became obvious that this was a serious fire. Wallan received threat warnings. Wandong came under attack. What this meant was that the fire had jumped the Hume Highway. My wife raised the possibility of evacuating. I was confident we would learn about the progress of the fire in good time. She was less certain. We agreed to wait. Many bushfire anecdotes have since convinced me that women are far more sensible in situations of this kind than men.

After news of Wandong, we learned that the fire had reached the dense Mount Disappointment forest, just north of Whittlesea. Shortly after, information about the progress of the fire dried up. From the small number of inscrutable threat messages posted on the CFA website there was no way of knowing where the fire was or even if it had passed beyond Mount Disappointment. At about 5 pm I heard an unearthly roar in the distance. At the time I thought it was the wind. I now think it was the fire front passing through St Andrews, six kilometres to the north. Shortly after, the wind turned from a north-westerly to a south-westerly. Although we had no idea about what had happened to the fire since it had entered Mount Disappointment, we now believed we were probably safe. The wind change would blow the fire away from us. In the early evening, although the reports were sketchy, we learned that Kinglake was under attack. Later, there were reports of deaths. We kept an all-night vigil. My wife took the early shift. At about 2 am, she heard a talkback radio caller from St Andrews appealing for help. “People have died up here.” Fires were still being fought. She was astonished. In the information age, people across the globe learn within minutes if a plane crashes or a volcano erupts. For ten hours we had learned nothing whatever about a monster fire a few kilometres away.

What had happened with what became known as the Kilmore East fire on 7 February emerged only gradually over the next few days. The fire had moved in a south-easterly direction from Wandong and Clonbinane into the forest of Mount Disappointment and then, often spotting very many kilometres ahead, to Humevale, Kinglake West, Strathewen, Arthurs Creek, St Andrews, Yarra Glen and beyond. Following the late afternoon–early evening wind change it had attacked Kinglake, Glenburn, Flowerdale and re-attacked Wandong and Clonbinane. Eventually it linked up with the so-called Murrindindi fire that had begun near Narbethong and, after the wind change, attacked Marysville, Buxton and Taggerty.

The volunteer firefighters of the Country Fire Authority brigades fought the fires gallantly and selflessly on 7 February and for very many days after. During the course of the Kilmore East fire’s passage it killed more than 100 people. The Murrindindi fire killed some 40 more. Several of those who died were known to our family. One of the dead was a teacher at our daughters’ old school; another an actor with whom I had often chatted at the Hurstbridge shops. Among the dead were the parents of one of our elder daughter’s closest school friends and an eccentric elderly couple we knew, who ran a bed and breakfast in Strathewen and whose lives had been devoted to the restoration of the natural landscape. To think about what the last minutes of these people must have been like was simply unbearable. As the Christian tradition testifies, to be consumed by fire is perhaps the most horrible kind of death humans can imagine.

Within a few days of the fire, we arrived at a state of bewilderment and delayed shock. After 4 pm on 7 February the fires had passed through our neighbourhood – Strathewen, Arthurs Creek and St Andrews – killing dozens of people. A glance at the map made it clear that a mere fluke of wind had saved us. If the wind on 7 February had been slightly more northerly and slightly less westerly we would most likely have died. And not only us. Hurstbridge is a mere five kilometres to our south. The fluke of wind saved perhaps hundreds if not thousands of lives. We had known absolutely nothing about the progress of the fire. Nor had the people in Hurstbridge. Nor had those who had died directly to our north.

The lack of warning was obviously responsible for very many deaths. Take one example. In Strathewen, after 4 pm on 7 February, 27 people died. A sealed road leads from Strathewen to Cottlesbridge. It takes about 15 minutes to traverse. If the 200 people in Strathewen had been warned by mid-afternoon that a monster fire was approaching, anyone who decided to flee by car could have made it to safety with ease. So could the people in the other areas and townships attacked on that day – Kinglake, St Andrews, Marysville and Flowerdale.

This lack of warning on the radio or the CFA website became more and more perplexing. As news seeped out about the events of 7 February, it became clear that roadblocks had been quietly put in place by the Victorian Police in the region of attack, well before the fire arrived. A neighbour of ours, a fencing contractor, told us about a roadblock erected by mid-afternoon on 7 February which prevented traffic moving from Cottlesbridge to St Andrews. A friend of our younger daughter encountered a police roadblock at 3.30 pm on the approach to Strathewen. Only because he lived in the area was he allowed to pass through. Forty minutes later he was fighting alongside his father to save their home. Most tragically, by mid afternoon near Kinglake roadblocks were preventing traffic passing in either direction along the Kinglake–Whittlesea Road. Police ordered several people to return to their homes in Pine Ridge Road. All perished shortly after. Without reasonably precise official pre-knowledge of where the fires were likely to hit, how could the erection of these roadblocks be explained?

Certainty about such official pre-knowledge of the fires did not, however, rely on inference of this kind. A week or so after 7 February the three key people involved in the Victorian country fire services – Russell Rees of the CFA; Ewan Waller of the Department of Sustainability and Environment; Bruce Esplin of the State Emergency Services – spoke to journalists at the Australian of what they knew. All claimed they were aware of impending disaster once the fire had jumped the Hume Highway. According to Rees: “We realised, once it got into the forest, it was going to take off and really nothing was going to stop it until it came out at the other end at Whittlesea and the Arthurs Creek area.” According to Waller: “As soon as we saw that Kilmore fire, in a very short time we knew we had a real problem. It was running towards the populated areas. You could run a ruler along where it was going to run – you knew straight away.” And according to Esplin: “I knew it was a dangerous place for a fire. A lot of tree-changers had moved into areas around there and it is difficult firefighting country. I had a feeling of ‘Here it comes.’” If the three key officials responsible for fighting the fires had understood at once the deadly peril facing citizens when the Kilmore fire jumped the Hume Highway, why had they failed to inform those who lived in the threatened region of what they knew? Had confusion or busyness paralysed judgment? Had a decision not to issue warnings in the circumstances of 7 February been taken?

The sense of bewilderment had another dimension. The Victorian bushfire deaths constituted the greatest peacetime catastrophe in Australian history. In the case of such catastrophes I had always assumed that the media would try to understand what had occurred and why. The lack of warning had almost self-evidently led to very many deaths. In the local meetings arranged by the Victorian Bushfires Royal Commission it became clear that the people who lived in the bushfire-ravaged regions wanted an answer to one obvious but also overwhelmingly important question – why weren’t we warned? Yet with one notable exception – Gary Hughes of the Australian, who had lost his house and almost lost his own life and that of his wife when the bushfire hit St Andrews – this was the question that journalists seemed either unwilling or afraid to ask.

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On 20 April the counsel assisting the royal commission, Jack Rush, delivered his opening address. His words came to my wife and me as a very considerable relief. Rush reminded the commissioners that they were involved in an inquiry into the deaths of 173 Australians. The commission would deliver an interim report to government by August, in time for the coming bushfire season. In that report, the reason for the inadequacy of the warnings, and the relation of that inadequacy to the unique Australian bushfire policy, colloquially known as “stay or go”, would be assessed. The question that the journalists had neglected or evaded for two months would, then, be at the centre of proceedings until at least July.

The first substantial witness to appear at the commission was the chief officer of the CFA, Russell Rees. Shortly after the bushfires, Rees had claimed that the tragedy of 7 February was attributable to the self-indulgent lifestyle of the residents of the bushfire areas, the so-called tree-changers. “If we choose to live in this way, then who do we blame? My fear is that people will say the fire service failed … I will go to my grave saying we fought our guts out.” Rees was here hiding behind the near-universal admiration for the bravery and community spirit of the volunteers in the local CFA brigades in order to protect the reputation of its professional administrative cadre.

Rees’s opening evidence, which took less than a day, amounted in essence to this. February 7 was the first day the new Integrated Emergency Coordination Centre (the IECC) had been tested, when the CFA, responsible for non-metropolitan private lands, and the Department of Sustainability and Environment (DSE), responsible for non-metropolitan crown lands, had co-operated closely. The new system had, generally speaking, worked extremely well. The fire trucks had been speedily deployed. Many fires, which might have got out of hand, were controlled. With fires like Kilmore East there was little more that could have been done.

In the course of questioning it soon became clear that on 7 February Rees had not in fact kept in close touch with the progress of the Kilmore East fire. He was unaware of the aircraft line-scan that had been taken shortly after the fire broke out. He had been unaware of the presence on that day in the IECC of the chief fire-behaviour expert, Dr Kevin Tolhurst. He had not seen the extremely accurate predictive map that Tolhurst’s team had eventually produced. At 4 pm, ten minutes before the fires razed Strathewen to the ground, Rees had accepted a state-situation report that suggested the fire was still in the Mount Disappointment forest and would not reach Whittlesea for five hours. At 4.30 pm the Kilmore East fire had attacked Kinglake West and at 6.30 pm, Kinglake. At 7.45 pm Rees appeared on ABC Radio 774. He told Jon Faine that both Kinglake West and Kinglake were being placed “under pressure” by the fires. News of deaths had reached the Kangaroo Ground CFA office at 5 pm. Rees told the commission he first learnt of deaths between 7 and 8 pm. When his obvious lack of detailed knowledge of the Kilmore East fire on 7 February was pointed out to him, Rees had several lines of defence. Intelligence on the fires remained sketchy on the day. Everyone at the IECC was incredibly busy. The fires were fought at the local level not from the centre. As on 7 February there were hundreds of fires, 47 of them serious, if he had concentrated on any one he would have lost what he called his state-wide perspective.

What then of the 7 February warnings? Rees’s evidence helped explain the warning system. Warnings were not issued from the centre but from the periphery, the local incident-control centres (ICCs). The only responsibility of the IECC was to place these warnings on the CFA website. Rees did not see the warnings. Nor did anyone at the IECC seem to take any interest in their content. Nevertheless, given the difficulties of gaining solid intelligence, in his early evidence Rees suggested that the CFA had done a reasonably good job on the warnings front.

Under questioning this claim quickly collapsed. It was pointed out to Rees that the first time the CFA website had mentioned the threat to Kinglake, where 38 had died, was at 5.55 pm, half an hour or so before the town was attacked. Rees pointed out that one of his officers had mentioned Kinglake at 4.40 pm on ABC radio. Citizens of Kinglake anyhow had access to a kind of alert message simply by looking to the sky. It was pointed out to Rees that at no time on 7 February was Strathewen, where 27 had died, even mentioned on the CFA website. Rees replied that there had been one reference on the CFA website to Arthurs Creek. Arthurs Creek was “very near” to Strathewen.

In my naivety, before listening to Russell Rees at the royal commission, I had imagined that he must have at least considered issuing a grave mid-afternoon warning from the centre about the peril which faced those living in the region under threat from the Kilmore East fire, north of Melbourne and east of the Hume Highway. In CFA jargon these are called ‘corporate warnings’. As Rees spoke, it became clear that on 7 February no consideration had ever been given to this idea.

Why? The reason gradually emerged when the next major witness –Bruce Esplin, the commissioner of Emergency Services – took the stand. Esplin was at pains to point out that he had nothing to do with operations. He was rather a policymaker, one of the intellectual architects of the Australian bushfire policy, “stay or go”. What he eventually revealed was the role this policy had played in the failure of the fire authorities to issue timely and accurate warnings to those who faced the bushfires on 7 February. For this reason, his evidence was more illuminating than Rees’s.

As Esplin explained, the stay-or-go policy was unique to Australia. The policy began with one of the clichés of the era of neo-liberalism: mutual obligation. Citizens did not passively accept government services. They formed a partnership with government, in this case in the common struggle against bushfires. For the citizens who decided to stay to defend their homes, there were very specific obligations. They needed to prepare their properties carefully, in particular to remove combustible vegetation and to have protective clothing, pumps and generators ready and handy. The people who were to stay and fight were told that in case of fire, houses offer fundamental protection. When the fire front hit, they should shelter from the radiant heat. As soon as the fire front passed, they should go outside to extinguish the embers. As one of Jack Rush’s associates, Rachel Doyle, pointed out, the policy was captured in a saying which had even appeared in official literature: “Houses protect people and people protect houses.” In some of the official literature it was even claimed that people were at least temporarily safe even in houses that were actually on fire.

It was self-evident, Esplin explained, that some citizens would not be physically or psychologically capable of fighting bushfires. In this case, their responsibility was to leave their properties early, well before a bushfire strikes. Ideally, citizens should leave their properties on total fire ban days, either in the evening before or at least before 10 am in the morning.

The stay-or-go policy was founded on one fundamental empirical claim. In case of bushfire it was far safer for citizens to be in their homes, in fighting mode, than it was to be on the roads. For this claim, as Esplin made clear, the fire authorities relied essentially on one piece of research, by Dr Katharine Haynes. On the basis of coronial records over the past 100 years, Haynes had concluded that survival was more likely for those who actively fought fires than for those who evacuated late or sheltered passively. The research was not only conducted with the support of the fire authorities. It was actually published after the stay-or-go policy had been settled, providing it therefore with retrospective and also, as it turned out on 7 February, spurious empirical legitimacy. Nor did its confident conclusions fit altogether neatly with its data. Between 1956 and 2007, 25.7% of bushfire victims died during a late evacuation; 24.5% defending a property while outside.

Esplin was particularly opposed to the Californian policy of compulsory mass evacuation in the face of bushfires. Why? Californians, he claimed, did not share with Australia the tradition of volunteerism. Perhaps he had not read Tocqueville’s Democracy in America, where volunteerism is a central theme. But there was more to Esplin’s opposition than sociological surmise. Mass evacuation was beyond the capacity of even the excellent Californian freeway system. To prove his point Esplin presented photos of Californian traffic gridlock to the commission. If authorities in Victoria tried to organise mass evacuations, critical highways in bushfire-prone areas, such as the Great Ocean Road or the Dandenong Tourist Road or the Whittlesea–Kinglake Road, would be altogether unable to cope. Esplin was apparently unconvinced by a rather startling fact outlined by Jack Rush in his opening submission. Under the compulsory evacuation policy, in the Californian bushfires of October 2007, more than 3000 homes were destroyed and 10 people killed. Under the stay-or-go policy, in the Victorian bushfires of February 2009, more than 2000 houses burned down and 173 people died.

In theory, Esplin acknowledged that all matters of policy now needed to be reconsidered. In practice, he remained a true believer in the policy of stay or go. Despite what everyone now knew had happened on Black Saturday, Esplin spoke about the danger of road travel and the safety of houses in the present tense. “All the empirical evidence supports” the stay-or-go policy, he told the commission. He was not even perturbed by a reductio ad absurdum of the policy initially suggested to him by one of the commissioners, Ron McLeod. In Bendigo one death had occurred in a suburb less than two kilometres from the CBD. Was Esplin really suggesting that every citizen in Bendigo, a city of more than 100,000 people, ought to have evacuated by 10 am on 7 February if they did not plan to fight the fires? “If they’re not prepared, that’s what the policy would say.”

Esplin’s evidence had obvious implication for the question of warnings. Early “advice” or “alert” warnings about the approach of fire (to use CFA jargon) ought to have been unnecessary. By this time those planning to leave, he insisted, should already have gone. “Urgent-threat messages” were certainly valuable but they played a quite different role from what citizens generally imagined. They were to be used exclusively for those who had already decided to stay and defend their properties, as a prompt for them to put their protective clothing on or to get their pumps and generators working. It would be not merely wrong but utterly disastrous, Esplin claimed, for citizens to regard urgent-threat messages as a signal to leave. As Esplin made clear, time and again, the warnings that mattered were those that were delivered years, months or weeks not hours before bushfires. At one moment in the hearings, counsel for the government asked Esplin to “nail it”. He did. The only kind of warning that ought to be issued “on the day” was the one required to assist “the people who have planned … defending a property that is capable of being defended”. In the philosophy of Bruce Esplin, then, the kind of mid-afternoon warnings the citizens north of Melbourne desperately needed on 7 February simply had no place.

The central flaws in the stay-or-go policy had by now become obvious: its utopian impracticality and its internal contradiction. Total fire ban days in Victorian summers are frequent. More than a million and a half people live in non-metropolitan Victoria. If these people evacuated every time a total fire ban was declared, as Esplin advocated, life during summer, outside Melbourne, would slowly grind to a halt. Even if it was acknowledged that, given human nature, this ideal would never be realised, under the stay-or-go policy it was certainly demanded of all citizens, who lived in bushfire-prone areas and who did not intend to defend their properties, that they at least should always evacuate many hours before fire arrived. In the absence of timely and accurate warnings on the day, to which, as we have seen, Esplin was resolutely opposed, how could this commonsensical requirement possibly be fulfilled?

The strange rigidity the stay-or-go policy had created was soon revealed in the evidence given to the commission by the most senior policeman at the IECC on 7 February, Superintendent Rod Collins. One of Jack Rush’s associates, Melinda Richards, pointed out that according to the Victorian emergency manual it was the police who had the legal obligation to arrange evacuations. Should they not have considered evacuating communities threatened by fire? According to Collins, no matter what was in the manual, this was certainly not their job. Even though he acknowledged that by mid-afternoon on 7 February the police feared that the Kilmore East fire might attack not only the heavily populated town of Whittlesea but even penetrate into metropolitan Melbourne as far as Greensborough, Collins was utterly convinced that police involvement in any bushfire evacuation was out of the question. The settled bushfire policy the police operated under was stay or go. It could not be abandoned in mid-stream. If someone from the CFA had asked the police after midday to organise an evacuation, he told the commission he would have declined. Before midday “we were telling people that ‘you should have made your decision by now … and you should have enacted your stay-and-go policy’ … If at 12 o’clock we are going to change policy I wouldn’t have considered it … If the fire services had come to me and asked for advice I probably would have said, ‘We’ve just left it too late.’” Collins recognised that under certain circumstances the choice the policy offered citizens might need to be rephrased as “leave early or stay and die”.

Shortly after Esplin had completed his evidence, Inspector O’Halloran briefly took the stand. Preliminary inquiries into the 173 Black Saturday deaths had revealed that while 113 people had died inside a house and another 27 nearby, 11 had died in a vehicle and another ten on a road or near a vehicle. The empirical foundation of the stay-or-go policy was the claim that in bushfires, for those who had not left by early morning, the safest policy was to shelter in one’s home and, then, to fight the fire; the deadliest option to evacuate late. With O’Halloran’s evidence, the empirical foundation had collapsed.

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By the time Russell Rees and Bruce Esplin had completed their initial evidence to the commission, it had become clear that on 7 February both a cumbersome bureaucratic structure and a peculiar ideological mindset had worked in combination to prevent the fire and emergency chiefs at the IECC from issuing warnings to citizens living to the north of Melbourne. If any warnings were going to be given, they could only have come from CFA staff at the local incident control centres (the ICCs), from where the fires were actually being fought. Because the commission understood this, it turned its attention from the centre to the periphery. An extraordinary story now emerged.

By far the deadliest fire on 7 February was Kilmore East. It had broken out shortly before midday. An ICC was hastily put together at Kilmore under the control of the local CFA brigade captain, Greg Murphy. Murphy was not formally qualified to manage a major fire– in CFA jargon he was level two not level three. Murphy pulled people out of fire trucks to create his team. Unfortunately there was no one capable of disseminating warnings. For this reason the warnings task was handed to a trained CFA information officer in the Seymour regional office, Alexander Caughey.

Caughey was in charge of issuing Kilmore East fire warnings until about 4 pm. Between 1 and 3.30, he was asked by senior Seymour staff to deliver a series of awareness, alert and urgent-threat messages – to Wandong, Wallan, Hidden Valley, Upper Plenty, Heathcote Junction and, finally, to Whittlesea. Caughey told the commission that he had never issued warnings on such a “tight time frame”. “Our messages were nearly chasing the fire instead of the fire chasing our messages.” Although the invariable formula used in these warnings, about a scrub and grass fire burning near Saunders Road in Kilmore East, became progressively more and more misleading, at least in the early afternoon of 7 February it was possible for citizens to grasp that something serious was going on. While it was at Wandong, the fire was generally well covered. By mid-afternoon, an ABC journalist was even sending on-the-spot reports from there.

At 2.30 pm a second CFA information officer, Leonie Hunter, arrived at Seymour. She was sent to the Kilmore ICC to establish an information unit. When Hunter arrived, she was taken to an office without a computer or a printer. They were hastily installed. Greg Murphy asked her to prepare an urgent-threat message for the region south of Mount Disappointment, including Kinglake. The message was prepared by 4.10 pm. Murphy signed off on it. As Hunter was unable to fax the message to the IECC, she sent it to Caughey at Seymour. In turn, he sent it to the radio and the IECC for posting on the CFA website. For reasons that have never been explained, the 4.10 pm urgent-threat message was not posted on the CFA website until 5.55, half an hour before Kinglake burned down. As the information officers at Kilmore and Seymour were not checking the CFA website, no one even knew about the delay. This was the only CFA website warning to Kinglake issued before the town was destroyed.

At about 4.30 a level-three CFA officer, Stewart Kreltszheim, replaced Greg Murphy as the controller at Kilmore. Kreltszheim told the commission that he was unaware of the 4.10 urgent-threat message. On a number of occasions Jack Rush asked Kreltszheim about his responsibility for the issuing of warnings to the community. Kreltszheim made it clear that his major responsibility was to ensure that everyone was doing their job; that he could hardly be expected to be across the details of the warnings; that he worked at a “high level”; and that apart from the issuing of warnings he had very many pressing responsibilities on that day. Rush was rather incredulous. “I will just put this proposition: it seems on the day there are two matters that might be of concern to the incident control centre. One is fighting the fire and deploying resources and the other is warning the community. Do you agree with that?” “I actually don’t, Mr Rush,” Kreltszheim replied, “I think that’s a very simplistic way of putting it … There is a multitude of other things.”

Although he was in charge of the Kilmore East fire during its most lethal phase – at the time when the fire passed through Strathewen, St Andrews and Kinglake – between 4.30 in the afternoon and 7.30 in the evening, Kreltszheim authorised only two urgent-threat messages Both warnings talked of a grass-and-scrub fire burning four kilometres east of Kilmore. At 8.30, after the wind change, the fire was still described as travelling south.

On a number of occasions Rush asked Kreltszheim whether on 7 February he had experienced any communication difficulties with the Kangaroo Ground CFA. Kreltszheim claimed that he had not. The significance of these questions soon became clear.

At 8 am on 7 February, Serafina Munns had arrived at the Kangaroo Ground office of the CFA. She was briefed by Jason Lawrence, who led the CFA team there. Munns was placed in an information unit. She had kept a log during the day. After midday, a member of the Kinglake West CFA, Frank Allan, phoned Munns to tell of smoke over Mount Disappointment. Around this time, a former CFA group officer, John Cowan, arrived as a volunteer. He began to prepare what turned out to be prophetic predictive maps. During the day Colleen Keating, who was stationed in the nearby Kangaroo Ground tower, phoned Munns regularly. What Cowan’s maps predicted and what Allan and Keating observed concerned the members of the information unit. At 1.30, they suggested to Jason Lawrence issuing an awareness message to the region. According to Munns, Lawrence refused on the grounds that it was “not appropriate”.

Around 3 pm, as alarm grew, the information unit drafted an urgent-threat message for the region on either side of Mount Disappointment –Wandong and Wallan; Humevale and Whittlesea. At the same time they drafted an alert message for the area beyond. Here is the message (with the numbers who died over the next few hours in the townships mentioned inserted in brackets):

Even though the fire is not currently posing a threat, the communities of Kinglake West (4), Kinglake (38), Pheasant Creek, Strathewen (27), Arthurs Creek (2), Doreen, Yanewen [sic], Woodstock, Mernda, Nutfield, Mittons Bridge (1), Hurstbridge, St Andrews (12), Panton Hill, Smiths Gully, Christmas Hills need to be aware that the activity in the area has increased and has the potential to impact directly.

According to Munns, Lawrence once again refused to authorise either warning, for the same reason as before. Munns was asked by Rush why all these messages had been prepared. “I didn’t believe our communities at the southern end of the fire were being warned while we knew the fire was coming into the area.”

Around 4.30 pm Kangaroo Ground was upgraded to a divisional command centre, meaning it had responsibility for a section of the Kilmore East fire. According to Munns, Lawrence was approached once more by the information unit. Was he willing now to issue a warning? Lawrence made it clear that he was not; he did not yet have what he called “a handle on resources”. Shortly after 4.30, there was a planning meeting at Kangaroo Ground. Munns learned around this time about deaths in Strathewen from the Arthurs Creek CFA brigade captain, Dave McGahy, who was appealing for help. “Put it this way,” she remembered him saying, “I can see bodies where I’m standing.” She was too distressed to record this information in her log. At 5.20, the information unit prepared another urgent-threat message. After Munns discovered that Kilmore was having trouble with its email and fax machine, Lawrence finally agreed that Kangaroo Ground might itself issue it. The message was sent to the Lilydale regional centre and from there to the IECC. People living in the entire region between Wandong, Whittlesea, Hurstbridge, Kinglake and Flowerdale were warned. The message was posted on the CFA website at about 6.30. For very many, the warning had come far too late.

Following Serafina Munns, Jason Lawrence took the stand. Lawrence did not challenge Munns’ account of the several warnings he had refused to authorise. He also did not challenge her explanation of his reasoning. While the Kilmore ICC remained in charge of the Kilmore East fire, warnings were their responsibility not his. These were the rules. Lawrence claimed that throughout the afternoon of 7 February he had sought to establish communication with the Kilmore ICC. It had been in vain. In their earlier evidence neither Kreltszheim nor Hunter recalled that communication with Kangaroo Ground had been a problem. Throughout the afternoon of 7 February, Lawrence’s log made clear that he had fought what Rush called a jurisdictional battle with Kilmore to become the designated ICC for the Kilmore East fire once it had penetrated south of Mount Disappointment. He had lost the battle on that day. Lawrence believed that while Kilmore remained the designated ICC it had the job of issuing warnings.

In reality, Lawrence seemed no more exercised by the question of community warnings than many other officers from the top to the bottom of the CFA. Even though he regarded the issuing of warnings as Kilmore’s responsibility; even though he claimed that throughout the afternoon he had tried to pass on to Kilmore the warnings drafted by his information unit; even though he fully accepted the accuracy of the early-afternoon prediction maps John Cowan had produced, that showed the entire Kangaroo Ground region down to Warrandyte was under threat – Lawrence conceded that at no time on 7 February had he monitored the CFA website to see what warnings Kilmore had actually released. At 3.30 pm Lawrence had been asked by the Lilydale regional office whether he had the resources to defend the Kinglake powerlines. He therefore must have known the peril the township of Kinglake faced. Yet he conceded at the commission that he had done nothing to try to warn either the townspeople of Kinglake or even its CFA brigade captain. Half an hour later, Lawrence had another discussion with Lilydale about the threat to life and property in Arthurs Creek, Strathewen, St Andrews, Kinglake and Kinglake West. Once again he conceded that he had done nothing to try to warn these communities or their brigade captains. As Munns’ evidence had already made clear, after 5.20 Lawrence finally decided to issue an urgent-threat message from Kangaroo Ground. He argued that he had made this decision because communications with Kilmore were down. “But just to put that in context, Mr Lawrence,” Rush interjected, “that had been the situation throughout the afternoon.” Lawrence could not disagree.

A few days after Lawrence’s testimony, the Arthurs Creek–Strathewen CFA brigade captain, Dave McGahy, appeared at the commission. McGahy was a local farmer who had been in the CFA for 40 years. He told a hair-raising tale.

McGahy had learned nothing whatever about the fires in the early afternoon from his CFA superiors. The only intelligence he received was from the Whittlesea captain, who had driven to the Hume Highway. The lack of official information, McGahy pointed out, did not really matter much. Once the fire had jumped the Hume, “it didn’t exactly take Einstein” to understand the threat. Around 4 pm, the fire spotted into Strathewen. McGahy had never seen anything like it in his life. It was a monster with a will of its own. The devastation it brought to Strathewen was “indescribable”. Until the fire front passed, there was little his brigade could do. They then went into action. McGahy could not praise highly enough the work of his men. For others he still felt undisguised rage. Roads were blocked by fallen trees; dying people were still trapped in their houses. A group of local-council men had arrived on Saturday evening around 8 pm, with chainsaws and bobcats. Shortly afterwards they left. “We’re off, mate. It’s too dangerous for us.” Later in the evening he begged a police commander at St Andrews for help. He was refused. “You take care of the fire brigade business and I’ll take care of mine.” On 7 February and for three days after, McGahy received not even one phone call from the CFA office in Kangaroo Ground. He remembered saying to a friend: “It is like as if Strathewen has dropped into a black hole and doesn’t exist.”

On Saturday night, McGahy and two CFA volunteers walked through the moonlit bush, silent apart from the sound of falling trees, to reach a house where 19 had taken shelter. Wasn’t this against the CFA rules, he was asked? “The rulebook went out the window a bit.” They stumbled upon a couple who had hidden for hours in a concrete pipe, sharing their refuge with a kangaroo. When they reached the house, all were safe. “It was so good to see the kids asleep and smiling faces.” Next morning he urged a detective investigating Strathewen deaths to place a cloth over the body of a man he had known for 40 years, who had been lying on the oval since the afternoon before. “No mate, not my job.” “So my son and myself, we went up to the middle of the oval and we cut the end off the cricket matting and we dragged it behind the command car and covered his body because it was just the respectful thing to do, I thought at any rate.”

To judge by the evidence they had given at the commission, at every level the professional members of the CFA spoke and thought like bureaucrats. The volunteer brigade captain McGahy had the eloquence of a poet.

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The answer to the question that has obsessed very many people in our region since 7 February – why were the people north of Melbourne and east of the Hume Highway not warned of the deadly peril they faced – turns out to be far more complicated than I had originally imagined.

In part the answer is straightforward. No one at the command centre seems to have grasped what Serafina Munns and John Cowan at Kangaroo Ground instantly understood, namely that in the face of the uncontrollable fires of 7 February, there was nothing more important than to warn citizens about the looming danger. Yet even if someone at the centre had grasped this, it is not clear that they would have acted. From the evidence collected at the royal commission, the cumbersome new bureaucratic machine, the IECC, seems to have operated like an army without a general, where no one thought it their responsibility to take the lead.

As evidence before the royal commission has already revealed, there was, however, more to the inaction at both the centre and the periphery than this. Because of the false empirical assumptions of the stay-or-go policy, many of those at the IECC seem to have convinced themselves that if last-minute warnings triggered flight, this would pose a deadlier threat than staying put. Because of the ambiguity which surrounded the issuing of warnings as a result of the stay-or-go philosophy, many of those who worked at the local ICCs, which were responsible for issuing the warnings, had clearly come to think that warning communities was at most a second-order responsibility. In turn, no one who worked on the CFA and DSE websites at the command centre seems to have thought that either the quality of the information in the warnings coming from the ICCs, or the speed at which they were posted, was of any great importance.

There were, however, deeper and more troubling reasons for the failure of the fire authorities to issue the desperately needed warnings. Far too few inside the firefighting bureaucracies were willing on 7 February to break the rules, to disobey authority or to act spontaneously at time of crisis. By common consent the hero of the 2009 Victorian bushfires was the Morwell CFA group officer, Lou Sigmund. In late January he saved many lives when he decided, against higher authority and settled policy, to sound a siren to evacuate his town. At every level, the professionals inside the CFA, and no doubt the DSE, were imprisoned by their organisations’ mind-numbing bureaucratic rules. Conformity to rules was, in turn, the enemy of judgment, commonsense and moral responsibility. Like the detective Dave McGahy encountered on the oval at Strathewen, far too many seem to have believed that anything more than fulfilment, to the letter, of what their organisational roles required, was simply not their job. The answer to the question of why we weren’t warned on 7 February requires not only the forensic capacity of a royal commission but also a sociologist with the capacity to illuminate the strange character of our postmodern world.