Coroner's Court of Western Australia

Inquest into the Death of Wendy BEARFOOT

Inquest into the Death of Wendy BEARFOOT

Delivered on :12 June 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On the morning of 12 October 2012 a bush fire, later known as the Black Cat Creek Fire, was reported in Kalgan in the Great Southern region of Western Australia.  That afternoon a number of Department of Environment and Conservation staff performing fire suppression tasks in the area became trapped in a burnover in their vehicles.  The deceased was one of those people.  She was severely burnt in the incident.  Despite medical treatment at Albany Regional Hospital and the Royal Perth Hospital State Burns Unit the deceased died from complications of her injuries.

The scope of the inquest largely focussed on how the deceased and her colleagues became placed where they could be caught in the “dead man zone”. The inquest included consideration of public safety issues.

The dead man zone is the area directly around a bushfire that is likely to burn within 5 minutes and encompasses the distance the fire can travel in 5 minutes if the wind changes direction, turning flank fire into a head fire. While conducting fire suppression in the dead man zone, there is a risk that the fire intensity and spread can suddenly increase dramatically if the wind direction changes, leaving little or no time for firefighters to seek refuge before being enveloped in a burnover.

The Coroner heard evidence that Department of Environment and Conservation staff are trained to address all of the necessary considerations to maximise safety when working away from burnt ground, Lookout Awareness Communications and Escape Routes and Safety Zones (LACES). Evidence at the inquest hearing was the deceased and another staff member had spent much more time on the fireground on the day, and had turned their minds to aspects of LACES such as the lack of an escape route east.  Although they had left the safety of the burnt zone, their plan was to make their own safety zone by the lighting of the spot fires to create a line of burnt vegetation around them.  There was evidence at the inquest, and the Coroner noted, that if they had had more time before the wind change, that plan would have worked.

The Coroner further accepted the evidence that the coalescence of their location on the top of a ridge, the long unburnt fuel type and the timing of the wind change meant that they were all sitting in the worst place at the worst time when what had been a flank fire changed to a head fire and they were well and truly caught in the ‘dead man zone’. The timing of the wind change was everything as if they had anticipated the wind would change at that time, training would have indicated that they should not be in that location at that time.  Training in reading the spot weather forecasts was crucial.

The Coroner concluded that there was not one event or person’s conduct which was a sole contributor but rather a combination of circumstances, acts done and matters overlooked that together led to the deceased’s death.

The Coroner noted three agencies which were involved had individually conducted their own investigation which found deficiencies, and these agencies had implemented changes and improvements prior to the commencement of the inquest hearing.

The Coroner concluded the deceased died on 1 November 2012 at Royal Perth Hospital resulting from multiple organ failure following thermal injury and death occurred by way of accident.

Catch Words : Multiple Agencies involved in firefighting : Response to fire : Incident Management Team : Weather Forecast and Wind Change : Burnover : Personal Protective Equipment Clothing : Dead Man Zone : Training : Accident.


Last updated: 30-Apr-2019

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