Finding into death of Steven Kadar
Deceased
Steven Kadar
Demographics
34y, male
Date of death
2013-02-13
Finding date
2015-12-17
Cause of death
Consistent with injuries sustained by falling tree impacting cabin of truck
AI-generated summary
Steven Kadar, 34, died when a 30-metre alpine ash tree fell onto his vehicle during firefighting operations at Pheasant Creek Track on 13 February 2013. The coroner found no fault with the strategic decision to use this location or with hazardous tree identification procedures. However, systemic communication failures prevented decision-makers from receiving complete weather information. Critical data about approaching storms—held by different personnel (Fire Behaviour Analysts, lookouts, radio operators, Bureau of Meteorology)—were not consolidated and communicated along the full chain of command to operations managers and incident controllers. No individual had all relevant information when deciding whether to order earlier withdrawal. The coroner found no person unreasonable in their decisions with information available to them at the time, but emphasised that ensuring complete information flow to decision-makers is essential for firefighter safety in future operations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Systemic failure to ensure all available weather information was collated and communicated to decision-makers
- Fragmented communication between Fire Behaviour Analysts, incident control centre, and ground commanders
- Fire Behaviour Analyst and meteorological information not reaching key decision-makers
- Lookout observations of approaching storm not communicated to senior ground commanders
- Information conveyed to air attack supervisor at 2.25pm not reaching divisional or sector commanders
- Divisional commander received incorrect information that storm activity was remote and insignificant
- Weather forecasting information held by Bureau of Meteorology not fully integrated into operational decisions
- Alpine ash forest environment with dead trees creating high tree-fall risk during storm activity
- Sudden wind direction change associated with storm cell
- Subject tree fell uphill against slope due to significant uphill wind in storm, unusual for steep slopes
Coroner's recommendations
- DELWP highlight necessity for two-way situation and weather reporting between Incident Management Team and fireground personnel in training and preseason briefings
- DELWP require more information be provided at morning and evening briefings on fire-fighting strategy at particular locations
- DELWP include information on salmon card reporting process in preseason briefings and provide feedback to persons making or affected by salmon card reports
- DELWP utilise Options Analysis template that specifically nominates and identifies safety to firefighters and human life as number one priority
- DELWP participate in national review of falling tree fatality, injury and near-miss incidents involving trees during fire response operations, and literature review
- DELWP continue implementing program of designing fire vehicles to withstand greater tree impacts
- DELWP re-emphasise purpose of red flag warnings in training and preseason briefings
- DELWP liaise with relevant agencies to develop training package for Operations Managers and Incident Controllers on liaison with Fire Behaviour Analysts, interpreting data, and disseminating weather forecasts to strike force leaders
- DELWP liaise with relevant agencies to ensure Options Analysis addresses terrain, topography, tree types and dangers, and incorporates reference to mapped areas of fire-burnt alpine ash
- DELWP liaise with relevant agencies to develop protocol ensuring firecrews not exposed to fire-affected alpine ash forests unless absolutely necessary, with removal of hazardous trees and regular weather monitoring
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