Inquiry into the fire at Yankees Gap Road Bemboka

Contributing factors

• Hazard reduction burn conducted without required Hazard Reduction Certificate or burn plan
• Inadequate pre-burn inspection without risk assessment or equipment checklist
• Inadequate containment lines
• Inadequate firefighting equipment available to property owner (only 50 litres water capacity)
• Extreme fuel loads (property not burned since mid-1980s)
• Very dry conditions and drought
• RFS officers failed to consult weather forecasts
• RFS decision to depart fireground on 15 August despite adverse conditions and active fire
• Lack of clear RFS protocols and command-and-control procedures for private burns
• Inadequate training of RFS volunteers on hazard reduction burn management
• Very high fire danger rating not communicated to responding RFS brigades

Coroner's recommendations

1. RFS review Operational Protocol for Prescribed Burning to include practical guidance for pre-burn site inspections or providing advice for private burns
2. RFS develop a checklist for pre-burn inspections covering fuel loads, proximity to high-fuel-load areas, weather forecasts, Fire Danger Ratings, water sources and access, firefighting equipment, access for RFS vehicles, topography, burn area and time, containment line width, redundancy options, and whether RFS assistance is warranted
3. RFS develop education and training for officers conducting pre-burn site inspections or providing advice for private burns, with local brigades nominating representatives for specialist training
4. RFS review Standards for low intensity bush fire hazard reduction burning and 'Before you light that fire' pamphlet to enhance operational guidance on forecast risks, redundancy options, and resourcing guidance
5. RFS update procedures and policies to clarify command and control arrangements when RFS assists private landowners with hazard reduction burns without formal request, when responding to triple-0 calls during private burns, and when deciding to leave a fireground
6. RFS review procedures to include clear directions for firefighters to consider weather forecasts, drought index, and Australian Fire Danger Index when planning, responding to, managing, or deciding to leave a burn
7. RFS review training to emphasise requirement for firefighters to consider weather forecasts, drought index, and Fire Danger Index in fire management decisions
8. RFS review Hazard Reduction Certificate assessment form to incorporate qualitative operational risk assessment to identify high-risk private burns
9. RFS consider introducing procedures whereby landholder notification of planned burns triggers officer review of weather forecasts and Fire Danger Ratings to be conveyed if conditions are forecast to deteriorate
10. RFS consider developing a checklist of questions when private landholders notify of planned burns, including planned size and duration
11. RFS consider improving Hazard Reduction Certificate system to mandate Fire Permits for hazard reduction burns of specified parameters year-round
12. RFS review Guidelines for Permit Issuing Officers to update condition determination process to risk-based approach aligned with ISO 31000:2018
13. RFS develop material to educate volunteers and staff on powers to extinguish or prohibit burns, available tools for site inspections and burn management, risk assessment and management of private burns, and pre-emptive fire management, in diverse formats
14. RFS review distribution of material educating public on requirements for conducting prescribed burns outside Fire Danger Period to increase awareness
15. RFS review educational material to increase awareness and clarity regarding authorities required to conduct prescribed burns outside Fire Danger Period
16. RFS review Prescribed Burn Forecast Tool to increase clarity regarding the 'poor' category of prescribed burning conditions
17. RFS implement system where Bush Fire Management Committees are prompted annually to consider whether Fire Danger Period should be amended to reflect increased or reduced adverse fire conditions