Coronial
NSWcommunity

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1

Demographics

unknown

Date of death

2019-12

Finding date

2024-03

Cause of death

Thermal injury and burns from bushfire exposure; smoke inhalation

AI-generated summary

The 2019/2020 NSW bushfire season was catastrophic, with 25 deaths investigated by the State Coroner through inquests and 41 fires through inquiries. Over 5.52 million hectares burned, destroying 2,476 homes and damaging 1,034 more. Deaths resulted from residents attempting to defend properties or evacuate during extreme fire conditions, and seven firefighters killed in action. Fire causes included lightning strikes and accidental welding ignition. The Coroner made 28 major recommendations targeting the NSW Rural Fire Service, NSW Police, and Essential Energy, addressing fire prediction modeling accuracy, Large Air Tanker tasking procedures, aviation communications, inter-agency coordination, vegetation management, vehicle safety for firefighting appliances, and response procedures. The inquiry examined systemic issues in emergency management during simultaneous large-scale fires, noting the unprecedented nature of fire behavior including long-distance spotting and pyrocumulonimbus events that exceeded predictive capabilities.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Rapid fire progression and long-distance spotting beyond predictive models
  • Pyrocumulonimbus events with extreme winds
  • Extreme weather conditions with high temperatures and strong winds
  • Inadequate fire prediction and communication of fire behavior
  • Underestimation of fire intensity by residents and responders
  • Limited visibility due to smoke and darkness
  • Containment line breaches
  • Resource constraints during multiple simultaneous fires

Coroner's recommendations

  1. RFS review aviation training to ensure Large/Very Large Air Tanker tasking at State Operations level, not local IMT
  2. RFS develop Flight Risk Assessment Tool for air tanker tasking decisions
  3. RFS provide enhanced guidance on adverse weather conditions requiring Air Attack Supervisors
  4. RFS amend procedures to communicate air tanker tasking rejections to other aircraft in region
  5. Develop comprehensive pre-flight information packages including weather forecasts, local rejections, ground reports, hazards, incident action plans, and asset status
  6. Provide pilots with current Incident Action Plans for assigned fires
  7. RFS consult stakeholders on improving communication systems between aircraft, ground resources, IMTs, and State Air Desk
  8. Allocate resources on high-activity days for regional State Air Desk organization
  9. RFS conduct pre-season pilot briefings on RFS communications and operational capabilities
  10. RFS conduct training simulations for officer decision-making in aerial firefighting dispatch
  11. RFS review Authorised Fire Investigator training including coordination with police and landowner consultation
  12. RFS review SOP 3.1.9 to enhance procedures when wildfires breach containment lines
  13. RFS improve training for IMT staff on intelligence verification procedures
  14. Improve integration of emergency alert system with RFS systems to reduce duplication
  15. RFS develop training for Public Liaison Officers on early warning significance for remote communities
  16. RFS ensure fire prediction completion logged in ICON system
  17. Establish automated alerts in Athena system for fire prediction completion
  18. RFS review means to improve prompt uploading of fireground reports to ICON system
  19. RFS incorporate Vesta Mk II fire prediction model within SPARK software
  20. RFS continue work with Bureau of Meteorology on fire-atmosphere coupled modeling and ensemble forecasting
  21. RFS engage Monash University to establish rollover and falling object test criteria for firefighting vehicles
  22. RFS represent to AFAC for Australian Standards development on crashworthiness testing for firefighting appliances
  23. RFS provide AFAC with expert reports and technical findings on vehicle safety
  24. NSW Police review SOPs related to fire investigation and reporting matters
  25. RFS and NSW Police consider bushfire safety reporting in MOU review
  26. RFS and NSW Police develop ICON training for merged fire navigation and naming conventions
  27. Essential Energy provided with fire prediction research and modeling findings
  28. Energy Networks Australia provided copies of technical documents for IGNIS Project
Full text

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.

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