Inquiry Into The Orroral Valley Fire
Finding date
2025-06-13
AI-generated summary
On 27 January 2020, an ADF MRH-90 Taipan helicopter ignited a fire in Namadgi National Park, ACT, during Defence Assistance to the Civil Community operations. The crew made an unplanned landing in the high-danger Orroral Valley without consulting civilian authorities. Approximately 50 seconds after landing, the activated searchlight (340–546°C) ignited grass. The aircraft departed after one minute. Critically, the crew failed to immediately report the fire's ignition and location to civilian authorities during the 17-minute flight back to Canberra. The coroner found this an error of judgment, though evidence showed it had no impact on response effectiveness. The Orroral Valley Fire burned 82,700 hectares (78% of Namadgi National Park) before spreading to NSW as the Clear Range Fire. The coroner identified systemic failures: the searchlight fire risk was not identified despite a 2013 similar Blackhawk incident; risk assessments were inadequate; and ADF-civilian communication protocols were insufficient. Recommendations addressed risk assessment, direct communication, and organisational learning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Activated searchlight reaching 340–546 degrees Celsius
- Unplanned helicopter landing in bushfire danger zone without civilian consultation
- Extreme fire danger conditions on 27 January 2020 (high temperature, wind, fuel loads, low moisture)
- Failure to immediately report fire ignition and location to civilian authorities during 17-minute flight
- Lack of risk assessment identifying searchlight fire hazard in MRH-90 flight manual
- Failure to incorporate lessons from 2013 Blackhawk landing light incident into MRH-90 protocols
- Inadequate emergency communication protocols between ADF and civilian authorities
- Unclear Standard Operating Procedures regarding landing notification obligations
- Absence of direct communication channel between aircraft captain and Emergency Services Authority
Coroner's recommendations
- ACT should provide ADF with briefings on known risks associated with planned DACC operations in accessible format, incorporated into mission-level risk assessments
- Risk assessments for unplanned landings in bushfire-prone zones should be provided and incorporated into pre-flight authorisation process, with consideration of updating frequency
- Establish procedure for reporting unplanned aircraft landings during DACC operations to ADF and relevant civilian authorities, clarifying whether prior approval is required
- Consider embedding civilian subject matter experts within ADF mission crews where resourcing, safety and space allow
- Include emergency procedure protocol in DACC operation SOPs for direct reporting of incidents creating immediate risk to public and civilian authorities
- Direct aircraft captains to provide GPS location of any fire ignited or observed, in accordance with emergency protocol, as soon as practicable
- Establish 'duty contact' arrangement with contact details specific to role rather than person, to facilitate efficient communications during DACC operations
- ADF and ACT should liaise on most effective direct line communication system between ADF aircraft and civilian authorities, whether Signal application or other arrangement
- ADF should create or ensure implementation of process whereby learnings from incidents relating to particular resources are considered service-wide for application to other resources and incorporated into training and risk assessment documentation
Further listening
Coronial podcast — Episode 85The Coronial podcast is an independent production unrelated to this website. Despite sharing the same name, the two projects operate separately and have no editorial connection. The author of coronial.com.au has no input on the content of this podcast.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —