Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 2

Contributing factors

• inadequate coordination between NSW Police Force and NSW RFS in fire investigations
• communication failures due to power infrastructure damage affecting emergency alert systems
• failures in fire prediction modeling communication during extreme weather events
• vehicle design inadequacies resulting in cabin crushing injuries and deaths to firefighting personnel
• strategic backburning operations that resulted in unintended fires and rapid spotting events
• limited availability of specialist fire investigators and aerial firefighting resources
• information sharing gaps between agencies during multi-jurisdictional fire incidents
• insufficient early fire suppression capacity in remote areas

Coroner's recommendations

1. NSW RFS and NSW Police to develop additional ICON training and awareness sessions for Strike Force Tronto officers to navigate merged fires and understand RFS naming conventions (Recommendation 26)
2. During five-yearly review of the Memorandum of Understanding, incorporate State Coroner's Bulletin No 22 provisions; expressly record that bushfires suspected to have started as unintended results of strategic backburns may meet criteria requiring coroner reports; provide that NSW Police may request modelling from RFS on what would have occurred without the backburn; ensure Officer-in-Charge is notified if requested cause and origin scene examinations will not occur (Recommendation 25)
3. NSW Government to expand simulator capabilities at NSW RFS Training Academy (Recommendation 10)
4. Government to work with other Australian governments to provide long-term funding certainty to AFAC including NRSC and NAFC (Recommendation 12)
5. Government to set KPI for NPWS regarding percentage of fires started on-park and contained within 10 hectares; deploy remote area firefighting resources based on enhanced research and predictive modelling (Recommendation 45)
6. NSW RFS to trial initial aerial dispatch in high bushfire risk areas to identify appropriate and cost-effective aircraft mix (Recommendation 46)
7. Government to request Commonwealth to conduct trials on retrofitting RAAF C130 aircraft with modular airborne firefighting systems; work through NAFC to review current mix of aviation assets (Recommendation 50)
8. Government to expand FRNSW RPAS (drone) capability to major regional centres for use by NSW RFS and other NSW government agencies (Recommendation 51)
9. Government to trial aerial firefighting at night during 2020-2021 season with view to full implementation if successful (Recommendation 52)
10. Establish national register of fire and emergency services personnel, equipment and aerial assets (Royal Commission Recommendation 6.2)
11. Update and implement National Framework to Improve Government Radio Communications Interoperability (Royal Commission Recommendation 6.3)
12. Develop Australian-based and registered national aerial firefighting capability including large air tankers and Type-1 helicopter capability (Royal Commission Recommendation 8.1)
13. Support ongoing research and evaluation into aerial firefighting capabilities and effective strategies (Royal Commission Recommendation 8.2)
14. Adopt procurement and contracting strategies to support development of broader Australian-based sovereign aerial firefighting industry (Royal Commission Recommendation 8.3)
15. Commonwealth Government to develop business case for establishment of permanent, sovereign aerial firefighting fleet including LATs and VLATs (Senate Inquiry Recommendations 8 and 1)
16. NSW RFS to develop performance measures for fire response times and outcomes, and fire hazard reduction completion (NSW Auditor-General Recommendation 2)