Inquest into the Deaths of Judith Lesley Ward and Lorraine Melia

Contributing factors

• Long bay length (181 metres) exceeding design standards
• Running disc angle bay configuration
• Different material and co-efficient of expansion between phase conductors and earth wire
• Poor conductor tensioning practices by linesmen
• Inadequate maintenance and repair work at adjacent bays
• Failure by Western Power to act on prior incidents in 1983, 1991, 2000, and 2002
• Western Power's deficient records and lack of system knowledge
• Failure to share information with Energy Safety
• Lack of conductor monitoring and inspection
• Extreme weather conditions on the day (40°C, winds gusting to 60 km/h)

Coroner's recommendations

1. Western Power should review its management structure to ensure adequate supervision and technical input to regional workers, noting the significant reduction in engineering oversight in the Great Southern Region compared to 40 years prior
2. Western Power should upgrade information about its own network system as a priority, developing accurate records of bay lengths and maintenance history to enable strategic planning
3. Western Power should implement regular conductor inspections throughout its network to identify issues such as past conductor clashing, excessively tight earth conductors, and excessive sag on phase conductors
4. Western Power should review its network and put in place strategic plans to ensure power poles and conductors are replaced before the end of their safe working life
5. Western Power should develop a strategy for introducing changes in technology and configuration practices into old lines to ensure reasonable compliance with current practice within a reasonable timeframe
6. Western Power should develop a strategy for identifying cases where significant differences exist between existing and current practice and determine whether upgrades are necessary
7. The Fault Outage Report Form should be redrafted to make it easier for linesmen to use and to ensure multiple causes for faults are adequately identified, with serious faults investigated by qualified senior officers
8. Western Power should put in place systems to adequately investigate and report on notifiable incidents in a timely fashion, with serious incidents investigated shortly after they occur and comprehensive reports provided to Energy Safety within 20 working days
9. Western Power should adopt the 1996 rider recommendations requiring immediate investigation by Western Power of any case of death or serious injury caused by Western Power equipment, with reports prepared to ascertain whether immediate action should be taken to prevent repetition
10. Urgent legislative action should be taken to empower Energy Safety to make orders directed to network operators requiring surveys, investigations, and remedial action for safety reasons
11. Consideration should be given to resourcing the Energy Safety regulator at a sufficient level to enable review of safety standards of network operators and identification of systemic network problems
12. All local governments in areas prone to bushfires should regularly upgrade and maintain radio communication infrastructures, including backup batteries, in consultation with FESA to ensure reliability in the absence of mains power
13. All local governments should develop adequate communication plans which include contingency plans in the event of repeater failure
14. Steps should be taken to establish compatible radio communication systems across FESA, CALM, local governments, and the Western Australian Police Service
15. Local governments should adopt and implement the State Wildfire Emergency Management Plan, especially aspects relating to AIIMS-ICS, as the management plan for bushfire control
16. Consideration should be given to enacting legislation to ensure statewide implementation of the State Wildfire Emergency Management Plan
17. The Bushfires Act 1954 should be reviewed with a view to amending section 13(4) to provide FESA with power to take control of a bushfire in appropriate circumstances
18. Local governments should work with CALM and FESA to develop and implement a process whereby both organisations would be notified of potentially major bushfires as quickly as possible