Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 1

Unknown·Thermal injury and burns from bushfire exposure; smoke inhalation

The 2019/2020 NSW bushfire season was catastrophic, with 25 deaths investigated by the State Coroner through inquests and 41 fires through inquiries. Over 5.52 million hectares burned, destroying 2,476 homes and damaging 1,034 more. Deaths resulted from residents attempting to defend properties or evacuate during extreme fire conditions, and seven firefighters killed in action. Fire causes included lightning strikes and accidental welding ignition. The Coroner made 28 major recommendations targeting the NSW Rural Fire Service, NSW Police, and Essential Energy, addressing fire prediction modeling accuracy, Large Air Tanker tasking procedures, aviation communications, inter-agency coordination, vegetation management, vehicle safety for firefighting appliances, and response procedures. The inquiry examined systemic issues in emergency management during simultaneous large-scale fires, noting the unprecedented nature of fire behavior including long-distance spotting and pyrocumulonimbus events that exceeded predictive capabilities.