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

systemic inquiry into 2019-2020 NSW bushfire season deaths - no single death examined

Volume 2 of a comprehensive coronial inquiry into systemic issues arising from the 2019-2020 NSW bushfire season. The State Coroner examined 41 fires through Stage 1 hearings and conducted Stage 2 representative case study hearings on 10 fires to investigate key systemic failures. The inquiry identified critical deficiencies in fire investigation coordination between NSW Police and RFS, communication infrastructure failures during emergencies, inadequate fire prediction modeling, vehicle designs that inadequately protected firefighting personnel (particularly cabin crushing in RFS appliances), and issues with planning and execution of strategic backburning operations. The coroner made 26 recommendations addressing investigation protocols, inter-agency information sharing, emergency communications systems, aerial firefighting resources and coordination, fire prediction capabilities, vehicle safety standards, and specialist personnel training. The inquiry notes that while agencies have undertaken significant work implementing recommendations from earlier inquiries, several systemic vulnerabilities requiring urgent attention remain.