Inquest into the Death of Wendy BEARFOOT

Contributing factors

• omission of critical wind change timing (3:00pm) from spot weather forecast broadcast
• incident management team belief wind change would occur at 5:00pm not 3:00pm
• personnel conducting fire suppression in 'dead man zone' (unburnt ground at risk of burnover)
• extreme fire intensity due to 50+ year unburnt fuel load
• topography: firefighters positioned at top of ridge allowing fire to approach rapidly uphill
• engine failure of fire vehicles due to heat-damaged brake systems and electrical components
• lack of thermal shielding on critical vehicle components
• lack of in-cabin activation of deluge/spray protection systems
• inadequate personal protective equipment (PPE) at time of incident—some personnel not wearing full fire retardant suits
• sudden, unexpected wind change with no visual warning signs due to layered smoke conditions
• vehicle positioning creating 'truck jam' that hindered escape
• fax terminator failure in incident control van preventing access to hard copy weather forecast for verification
• communication difficulties preventing real-time verification of forecast details
• lack of comprehensive burnover survival training at the time

Coroner's recommendations

1. Prioritise upgrading all DFES fire appliances fleet (not just Albany) on an urgent basis with thermal shielding, in-cabin deluge systems, in-cabin breathing apparatus, fire blankets, and other crew protection measures
2. Implement in-cabin activation capability for deluge/spray protection systems on fire appliances
3. Continue installation of radiant heat shields, fire blankets, and critical component heat shielding across all fire vehicles
4. Establish coordinated purchasing and design specifications across Australian states via AFAC (Australasian Fire and Emergency Services Authorities Council) to encourage manufacturers to build fire trucks with better protective features
5. Ensure comprehensive annual mandatory training for all firefighting personnel on burnover survival, interpretation of spot weather forecasts, LACES principle, and the 'dead man zone'
6. Mandate that spot weather forecasts, particularly significant wind change information, are communicated as 'red flag warnings' to all field personnel
7. Establish standard operating procedures across all WA fire agencies requiring adoption of 'red flag warnings' linked with LACES
8. Ensure fire appliances are equipped with accessible fire blankets (one per person) and fire-resistant protective gear
9. Conduct pre-season training for all firefighting staff prior to 30 September each year to ensure 100% capture
10. Maintain centralised coordination of training syllabi across fire agencies with mandatory content covering PPE, fire attendance, LACES, dead man zone awareness, red flag warnings, spot forecast interpretation, and fire blanket access/use
11. Continue improvements to incident control van communications infrastructure to enable real-time access to weather forecasts and eliminate reliance on verbal relay of critical information
12. Implement automatic verification/cross-checking procedures for spot weather forecast dissemination to ensure critical details such as significant wind change timing are not omitted
13. Ensure incident management teams have direct access to hard copies of spot weather forecasts at the control point and that these are reviewed and compared with verbal briefings
14. Formalise joint incident management team protocols across City of Albany, DFES, and Parks and Wildlife with documented trigger points for assuming control and clear communication pathways
15. Establish regular (e.g. weekly) inter-agency coordination meetings between local government, DFES, and Parks and Wildlife to improve communication and identify emerging fire management issues