Finding into death of William John Slade
Deceased
William John Slade
Demographics
60y, male
Date of death
2020-01-11
Finding date
2022-08-15
Cause of death
Injuries sustained in tree fall incident
AI-generated summary
William John Slade, a 60-year-old experienced Parks Victoria firefighter with 37 fire seasons, died when struck by a falling dead tree ('stag') while conducting blacking-out operations during the January 2020 Tambo Complex Fires in remote East Gippsland. The tree was not identified as hazardous despite visible signs of decay and previous fire damage, likely because hazard assessment criteria did not adequately account for recent disturbances (broken top section, nearby bulldozer activity). While correct processes were ostensibly followed, the systemic failure was the assessment criteria themselves. Clinical lessons include: hazard assessment protocols must consider recent structural damage and environmental disturbances; remote fireground operations require rapid first aid capability; and system-level reviews should precede incident investigations. DELWP subsequently implemented three key recommendations: establishing enhanced medical services trials for remote locations, deploying additional AEDs, and updating hazard assessment procedures to include recent disturbances.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Tree was not identified as being hazardous despite being dead and showing signs of rot and decay
- Impact from broken top section of tree (approximately 3 metres up)
- Multiple historical fires (at least three times in last 100 years) likely caused advanced rot and decay in roots and trunk, giving high likelihood of falling with minor intervention
- Hazardous tree assessment criteria did not adequately incorporate consideration of recent disturbances such as heavy plant driving nearby and section of tree breaking off
- Delayed Ambulance Victoria response time (approximately 1 hour 20 minutes) due to procedural requirements for attending active fire areas, though determined to be non-contributing to death
Coroner's recommendations
- FFMVic work with Ambulance Victoria to determine blockages in dispatching road and air ambulance to active fire areas and establish protocols to minimise them to reduce response times
- Explore options to provide additional defibrillators on the fire line to be available to crews working in remote locations
- Review hazardous tree assessment criteria to determine if risk assessments adequately incorporate consideration of recent disturbances such as heavy plant driving past or a section of tree breaking off, and if not adequately considered, enhance assessment criteria and associated processes
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