Inquest into Fire at Flagview South, Sir Ivan Dougherty Drive Leadville
Finding date
2019-10-30
Cause of death
Not applicable—this is a fire investigation, not a death investigation. The finding concerns the cause and origin of the fire, not any person's death.
AI-generated summary
This coronial inquiry examined the Sir Ivan fire, which burned 55,372 hectares across rural NSW in February 2017 during catastrophic fire conditions, destroying 35 homes without loss of life. The coroner found the fire originated from a lightning strike on a wooden fence post that smouldered internally for days before igniting. Key issues included communication breakdowns between the NSW Rural Fire Service and local landholders, disputes over back-burning tactics and authorization timing, and RFS decisions to prioritize protecting Cassilis village over individual rural properties. An apparent unauthorized back burn near Moreton Bay forced the RFS to change strategy mid-operation. While finding RFS management appropriate given the unprecedented weather conditions and extreme fire behaviour, the coroner made nine recommendations focused on improving community engagement, information sharing between RFS and farming communities outside fire season, clearer fire-ground coordination protocols, promotion of the Rural Liaison Officer role, and better identification of asbestos hazards in fire-damaged buildings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Lightning strike on wooden fence post
- Extensive fuel loads from spring rains and hot dry summer
- Catastrophic fire weather conditions
- Rugged terrain with dense vegetation limiting fire suppression access
- Communication difficulties between RFS and local landholders
- Limited mobile phone coverage in rural areas
- Possible unauthorized back burning
Coroner's recommendations
- RFS to offer information and engagement briefing with affected residents in Dunedoo and Cassilis areas discussing findings and agreed chronology, anticipated changes in bushfire frequency and behaviour, access to RFS information about predicted conditions, and adaptive firefighting strategies
- RFS to consider providing farming communities with access to topographical maps and information held by RFS to assist fire preparedness
- RFS to review Community Field Liaison Team Program to incorporate rural initiatives, information sharing and joint training opportunities targeted to particular RFS districts
- RFS to undertake community engagement campaign reflecting any revision of Fire Danger Ratings system, including notice that RFS cannot guarantee assistance to every landholder in large fire events
- RFS to review Building Impact and Damage Assessment Team process to increase early detection of asbestos risk in fire-damaged buildings and associated protocols
- RFS and NSW Farmers to consider joint approach to research into developing shared responsibility for hazard reduction, community engagement outside bushfire season, information sharing about extreme fire behaviour, and delineation of decision-making responsibilities when RFS and private vehicles respond to fires
- RFS in consultation with NSW Farmers to extend and expand primary producer engagement strategies including information sharing outside bushfire season, fire-ground communication, management structure and firefighter safety
- RFS in consultation with NSW Farmers to promote use of Rural Liaison Officer within Incident Management Team including information about the role, when likely to be appointed, and locating RLO on fire-ground
- RFS and NSW Farmers to collaborate to develop engagement program for NSW Farmers representatives serving on fire risk management committees
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