Coroners Court New South Wales

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CORONERS COURTNEW SOUTH WALESInquiry:Fire at ‘Flagview South’ , Sir Ivan Dougherty Drive, Leadville February2017Hearing dates:24 – 28 June 2019 Mudgee Local Court,16 – 20 September 2019 Dubbo Local Court,29-30 October 2019 Mudgee Local Court.Date of findings:30 October 2019Place of findings:Mudgee Local Court, NSWFindings of:Deputy State Coroner C. ForbesCatchwords:CORONIAL LAW-General fire inquiry-catastrophic fire-cause and originof fire-Whether fire management was reasonable in the circumstanceslessons learntFile number:2017/00057731Representation:Ms D Ward, Counsel Assisting instructed by Mr A Jobe, Department ofCommunities and Justice, LegalMr N Newton, instructed by Ms H Allison, NSW Rural Fire ServiceFindings:I find that the origin of the fire was on the property known as ‘FlagviewSouth’ Sir Ivan Dougherty Drive, Leadville. The cause of the fire was alightning strike on or near the top of a wooden strainer fence postwhich caused the post to smoulder for a number of days before ignitingthe fire on 11 February 2017.Recommendations:To the Commissioner of the NSW Rural Fire Service I make thefollowing recommendations:1) That the NSW Rural Fire Service offer an information andengagement briefing with affected residents in the Dunedooarea (Castlereagh District) and Cassilis area (Liverpool RangeDistrict) to discuss the Coroner’s findings and the agreedchronology annexed to those findings. This briefing is to be ledby RFS personnel at the Assistant Commissioner/ManagerPlanning and Predictive Services level, and is to include1

anticipated changes in bushfire frequency and behaviour inthose districts (including fire thunderstorm events), howlandholders can access RFS information in advance aboutpredicted conditions for local districts, and adaptive firefightingstrategies in response to changes in bushfire frequency andbehaviour.2) That the NSW Rural Fire Service consider providing farmingcommunities with access to topographical maps and otherrelevant information held by the RFS to assist primaryproducers to prepare for fire preparedness.3) That the NSW Rural Fire Service reviews the Community FieldLiaison Team Program to incorporate rural initiatives,information sharing and joint training opportunities targeted tothe needs of particular RFS districts.4) That the NSW Rural Fire Service undertake a communityengagement campaign (including information specificallytargeted at farming communities) to reflect any revision of theFire Danger Ratings system following the current review by theNational Social Research Project. Such a campaign to includenotice that in large fire events, the RFS cannot guarantee thatevery landholder will receive assistance from the RFS and sucha campaign to be repeated (even in a modified form) prior tothe start of each statutory bush fire danger period.5) That the NSW Rural Fire Service review its Building Impact andDamage Assessment Team process to increase the earlydetection of asbestos risk in fire damaged buildings andassociated protocols to support landowners affected by fire andasbestos.To the Commissioner of the NSW Rural Fire Service and the NSWFarmers I make the following recommendations:6) That the NSW Rural Fire Service and NSW Farmers consider ajoint approach to the Bushfire and Natural Hazards CooperativeResearch Centre (or similar organisation) to conduct socialresearch into best developing a “shared responsibility” tohazard reduction, community engagement outside of bushfireseason, information sharing around predictions for moreextreme fire behaviour, and the delineation of decision makingresponsibilities on the fire ground when RFS and privatevehicles respond to a fire.7) That the NSW Rural Fire Service, in consultation with NSW2

Farmers, extend and expand primary producer engagementstrategies to include a focus on how private landholders withinfarming communities can work with the RFS, including a focuson information sharing outside of bushfire season, fire groundcommunication during a fire, fire ground managementstructure and firefighter safety.8) That NSW Rural Fire Service, in consultation with NSW Farmers,promote the use of the Rural Liaison Officer (RLO) within anIncident Management Team including information about therole of the RLO within the IMT, when a RLO is likely to beappointed, the likely experience of someone accredited as anRLO and locating the RLO on the fire ground.9) That the NSW Rural Fire Service and NSW Farmers collaborateto develop an engagement program for current NSW Farmersand future representatives serving on local and state level bushfire risk management committees, to ensure the views offarming communities are represented at regular meetingsoutside of fire season and during operational bush fire events.3

TABLE OF CONTENTSIntroduction. 5Background . 8The Sir Ivan Fire . 14Cause and origin of the fire . 22Issues . 24The aftermath of the fire . 40Conclusion . 44Findings: s.81 Coroner Act 2009 . 46Recommendations : s.82 Coroner Act 2009 . 46Annexures . 484

REASONS FOR DECISIONIntroduction1. This is an Inquiry held pursuant to s. 30 of the Coroners Act 2009 (NSW) into a fire whichcommenced on Saturday, 11 February 2017 on a property known as ‘Flagview South’, Sir IvanDougherty Drive, Leadville. The fire was not controlled until Monday, 13 February 2017 and notlisted as being ‘out’ until Monday, 6 March 2017. The jurisdiction to hold a general inquiryincludes an examination of the fire’s cause and origin and extends to an examination of thecircumstances concerning the fire.2. The Commissioner of the NSW Rural Fire Service, Mr Shane Fitzsimmons (‘the Commissioner’),stated that the fire burnt during the worse fire weather conditions ever recorded in NSW. The fireconsumed 55,372 hectares of land, destroyed 35 houses and damaged 11 others.1 People sufferedhuge losses; together with the loss of their homes, there was also loss of sheds, farmingmachinery, fencing and agricultural land. Over 4,700 sheep were lost, 440 cattle, 4 horses, 325goats, 35 poultry, 4 alpacas and 20 domestic animals. Miraculously, no persons were killed orseriously injured as a result of the fire. The emotional, physical and financial impact on the peoplewho suffered losses and assisted in fighting the fire should not be underestimated.3. On Saturday, 11 February 2017, when the fire started, the conditions had been declared by theNSW Rural Fire Service (‘RFS’) as high to very high fire danger. On Sunday, the fire conditions weredeclared ‘catastrophic’. On Saturday, the fire travelled approximately 5 kilometres, and onSunday, in the catastrophic conditions, the fire travelled more than twice that area in a one hourperiod. At its peak on Sunday, the fire grew by approximately 6,000 hectares in an hour and bythe end of that terrible day, approximately 50,000 hectares of farmland and forest had beenburnt. A copy of the RFS Rate of Spread map is annexed and marked ‘Annexure A’.1Exhibit 275

Photo of the Sir Ivan pyro-convective column on 12 February 20194. On Sunday, 12 February 2017, a pyro-convective column was generated by the fire. These oncerare events are now, unfortunately, becoming more frequent and pose an extraordinary risk toanyone on the fire ground. It is only as this phenomenon is becoming more frequent thatscientists are developing a body of evidence. Previous pyro-convective columns have triggeredfire-thunderstorm events which have caused devastating loss of life, such as the bushfires inVictoria on 7 February 2009, and the Canberra bushfires in January 2003. A wind change on theafternoon of Sunday, 12 February 2017 fortunately decoupled the thunderstorm from the column,preventing the worst case scenario at the Sir Ivan fire. Had the worst case scenario eventuated,resulting in fire tornados of the kind seen in the Canberra fires, loss of human life was likely, nomatter how well defended the structure in which people were seeking refuge.5. On 3 August 2017, the Commissioner requested the State Coroner for a general inquiry to be heldinto the fire pursuant to s.32 Coroners Act 2009 (NSW).2 He was of the view that there is a needfor a broader understanding that in declared catastrophic fire conditions, no home or structure isdesigned or constructed to withstand such fire conditions. Fires in these rare conditions burnaggressively and simply cannot be controlled.2Exhibit 266

6. On 29 November 2017, the State Coroner directed that a general inquiry be held.7. The NSW Farmers’ Association, (now known as NSW Farmers) on behalf of affected landholders,also requested a coronial inquiry. NSW Farmers expressed the view that farmers affected by thisfire have reported feeling a sense of isolation and disengagement from the RFS and that an inquirywould be an opportunity for them to put their story forward and to have their questions answeredin a public forum. A particular area of concern was communication breakdowns between the RFSand landholders, which may have played a part in the initial responses and strategic managementof the fire.8. A large amount of evidence was subsequently collated including witness statements, expertstatements, maps, photos and video footage all relating to the fire. The brief of evidence runs towell over 2,000 pages. The scope of the coronial inquiry extends far beyond the people called togive oral evidence. The Court has read and considered statements from 54 people together withadditional reports obtained by court appointed experts. The fact that not all witnesses or allexperts have been called to give evidence does not diminish the accounts of their experiences setout within each statement. The inquiry heard oral evidence from the following witnesses:a. Detective Senior Constable Darian Hardy, Officer in Charge of the coronial investigation;b. Mr David Seis, Dunedoo resident and Deputy Captain Leadville Brigade;c. Mr Stirling Fergusson, Dunedoo resident;d. Mr David Bowman, Dunedoo resident;e. Mr Max Weis, Cassilis resident;f.Mr Murray Coe, Dunedoo resident and Deputy Captain Leadville RFS Brigade;g. Mr Dusty Rawlinson, Dunedoo resident and member Leadville RFS Brigade;h. Mr Kim Rawlinson, Dunedoo resident and member Leadville RFS Brigade;i.Mr John McDonald, Binnaway resident and RFS Group Captain;j.Mr Anthony Waldron, Bugaldie resident and RFS Group Officer;k. Mr Garry Wilson, Operations Manager Castlereagh District RFS;l.Mr Paul Martin, Cassilis resident;m. Mr Michael Robinson, then District Services Officer Castlereagh District RFS;n. Dr Simon Heemstra, Manager for Planning and Predictive Services RFS;o. Mr Corey Phillip, Superintendent and District Manager Castlereagh District RFS;p. Mr Paul Jones, Superintendent and District Manager RFS, appointed Incident Controller;7

q. Mr Robin Rogers, Executive Director Operations RFS; andr.Mr Geoff Conway, an independent court appointed expert in fire investigation whoreviewed the fire.39. Assistant Commissioner Heffernan attended this inquiry in person and provided ongoinginformation and clarification throughout the inquiry as well as participating in discussions with thelocal landholders who were also in attendance.10. Due to the volume of the material, I have referred in these findings only to the issues, evidenceand submissions that I consider most significant. This inquiry and to some extent the investigationfocussed on examining the fire’s cause and origin and the circumstances in the first two days ofthe fire that highlighted the issues of concern raised by both the RFS and the local landholders.11. A coronial general fire inquiry is intended to be an independent, objective, fair examination of theavailable evidence that relates to the fire. It is not the function of this inquiry to apportion blamebut rather, to make findings as to the origin and cause of the fire, and also to makerecommendations that are considered necessary or appropriate as a result of the circumstancessurrounding the fire.Background12. The RFS operates from headquarters at Homebush, incorporating the State Operations Centre,and four regions comprised of 45 districts across the state.413. Leadville falls within the Castlereagh District, comprised of the Gilgandra and Warrumbungle LocalGovernment Areas.514. The Liverpool Range District, comprising Gunnedah, Liverpool Plains and Upper Hunter sitsbroadly to the east of the Castlereagh District and the Cudgegong District sits to the south. The SirIvan fire spread beyond the Castlereagh District into these neighbouring RFS Districts.3Exhibit 1 Volume 6, Tab 125Exhibit 1 Volume 2, Tab 29, pp 550-5 at [16]5Exhibit 1 Volume 2, Tab 29 p 1048

15. The Castlereagh Bush Fire Risk Management Plan (BFRMP) prepared by the Bush FireManagement Committee notes the following issues likely to impact upon community ability toprepare for bush fire within the District:a. Large numbers of absentee landowners in remote areas;b. Ageing population, particularly in rural areas;c. An increase in commuting workers; andd. An increase in rural residential subdivisions in fire prone areas.616. Mr Geoff Conway, the court appointed independent expert, was asked to review the CastlereaghBFRMP and concluded that it and the Operations Co-ordination Plan provided adequate guidanceto the emergency services on preparedness for bushfire.717. The Castlereagh District covers an area of 17,888.5 square kilometres, the vast majority of which(84.03%) is privately owned land.8 This highlights the need for the RFS to work closely with privateland holders.18. This also highlights the challenge in trying to manage fuel loads in the lead up to bush fire seasonin the District (generally from October to March although the worst months for large fires areusually mid-November to the end of December).9 The RFS provides advice to landholders onmanaging fuel loads on their properties but this is ultimately a matter for the individualsconcerned. Healthy pastures are assets in their own right that land holders might be reluctant toreduce in order to try and mitigate fire risk.19. Mr John McDonald was the volunteer Group Captain for the RFS division that included a numberof the brigades directly involved in the Sir Ivan fire (Leadville, Hannah’s Bridge, Uarbry,Dunedoo).10 He was also “Ivan Control” (IC), the senior fire ground control leading the RFSresponse on the fire ground on Saturday 11 February and again on Sunday 12 February. He gaveevidence that:6Exhibit 1 Volume 2, Tab 29 p 155Exhibit 1 Volume 6, Tab 125 pp 1454-6 at [49]8Exhibit 1 Volume 2, Tab 29 p 1559Exhibit 1 Volume 2, Tab 29 p 15510Exhibit 1 Volume 2, Tab 28 pp 549-2 at [7]79

“In 2016 there were terrific spring rains in the Castlereagh RFS Zone, including the agriculturalareas near Sir Ivan Doherty Drive, leading to extensive pasture growth in those agricultural areas.This was then followed by a hot, dry summer which dried out the pastures, however after aprolonged drought; the farmers were enjoying having feed for their stock.”1120. Mr Murray Coe, Deputy Captain of the Leadville RFS brigade, also gave evidence of unprecedentedrain from January to October 2016, leading to unprecedented pasture growth, growth in timberedareas and growth in scrub.1221. Mr Coe was asked whether there was an opportunity to complete hazard reductions after thisunprecedented growth and prior to the Sir Ivan fire, and he said:“No too late by that stage .I don’t know in what area you would do the hazard reduction, they’remostly all grazing properties around. No one’s going to burn the feed, burn the grass. Butcertainly there’s an operation that needs to take place in the winter months, not spring orsummer”1322. The fuel load did prove to be more than a theoretical problem in the extraordinary circumstancesof the Sir Ivan fire. Having reviewed witness statements, images of affected properties and videomaterial Mr Conway concluded:“There was significant variation in the fire prevention and mitigation works undertaken bylandholders on those properties impacted or at threat from the fire some images provided withthese statements show areas of fuel reduction around homesteads and farm buildings. Theseappear to be the exception rather than the rule.”1423. On Saturday, 11 February 2017, weather forecasts predicted extreme conditions with an expectedmaximum of 42 degrees, relative humidity of 10, and wind for most of the day expected from thewest, north west at 45kph with gusts up to 70 kph.1511Exhibit 1 Volume 2, Tab 28 p 549-2 at [11]Mr Murray Coe Transcript 26/06/19 p 4313Mr Murray Coe Transcript 26/06/19 p 69 at [36]14Exhibit 1 Volume 6, Tab 125 p 1454-3 at [21] and [22]15Exhibit 1 Volume 1, Tab 9, p 208 [7]1210

24. The main concern was for Sunday, 12 February 2017 when catastrophic conditions werepredicted.25. The categories used to classify fire danger ratings were introduced after the 2009 VictorianBushfires Royal Commission as part of a national revision of ratings.1626. A catastrophic fire danger rating indicates the worst possible fire weather. Fires in catastrophicconditions are uncontrollable, fast moving, erratic, and have large spotting distances.17 They arenot like “typical” fires and strategies used to successfully fight lesser fires are unlikely to succeedin containing fires burning in catastrophic conditions.27. Of course, catastrophic conditions might not actually eventuate even when predicted andconditions might only reach the catastrophic rating for parts of any given day. But the potentialconsequences of a fire burning in such conditions are so dire it warrants warning the communityof that possibility. One has to balance the probability of the event occurring against the gravity ofthe risk that arises if it does.1828. The Catastrophic Fire Danger Rating carries with it a descriptor that reads:“These are the worst conditions for a bush or grass fire. Homes are not designed or constructed towithstand fires in these conditions. The safest place to be is away from bush fire prone areas.”1929. The risk of catastrophic conditions is increasing as long term weather patterns change. DrHeemstra gave evidence that:“The climate is changing and we are getting more extreme fire behaviour as a result as theatmosphere is hotter and more unstable. The 2018 State of the Climate Report prepared by the[Bureau of Meteorology] showed that NSW is the state with the greatest deviation from mediantemperature in the country. The hotter atmosphere also extends the fire season.”2016Exhibit 1 Volume 2, Tab 29, page 550-9 at [40]Exhibit 1 Volume 3, Tab 30, page 551-3 at [11]18Dr Heemstra transcript 17/09/19 p 719Exhibit 1 Volume 2, Tab 29 p 13220Exhibit 1 Volume 3 Tab 32A p 553-18 at [32]1711

30. The Commissioner made a s.44 Rural Fires Act declaration to take effect from 0800 on Saturday,11 February 2017 for the Castlereagh District. This is a declaration under the Rural Fires Act, givingthe RFS Commissioner the authority to take such measures as he considers necessary to control orsuppress any bushfire in any part of the State. These declarations are made in circumstanceswhere a fire is likely to “exceed the capacity of local resources to effectively contain the fire.”2131. It wasn’t just the Castlereagh District that was dry and at increased risk of fire. According to MrRobin Rogers, Executive Director Operations of the RFS:“January and February 2017 saw some of the worst bush fire conditions ever forecast for the State,fuelled by record breaking heat, one of the hottest summers on record and low humidity. EarlyFebruary saw temperatures consistently rising about 40 degrees across many parts of the Stateand crews dealt with a large number of bush and grass fires over this period.”2232. A state-wide total fire ban was declared for that weekend.23 The RFS were understandablyconcerned with preparations throughout NSW, including but extending far beyond the Dunedooarea and the wider Castlereagh District.33. This inquiry is conducted with the benefit of hindsight. Those involved in making preparations inadvance of 11 February 2017 had no way of knowing if, let alone where, fires might eventuateunder the difficult conditions. Indeed there was an earlier fire within the Castlereagh District thatstarted on Saturday morning before the Sir Ivan fire. This was near New Merrigal, west ofGilgandra and crews were deployed. This fire was successfully contained but was at ‘patrol’ statusat the time the Sir Ivan fire commenced.2434. A number of incidents eventuated across the state. Between 10 and 19 February 2017, RFS crewsin NSW attended 697 bush/grass fires, including 223 incidents across the weekend of 11-12February 2017. Over 1,800 fire fighters (the vast majority of them volunteers) were deployed perday between 10 and 19 February, including an estimated 2,500 fire fighters deployed on 12February 2017.2521Exhibit 1 Volume 2 Tab 29 p 550-11Exhibit 1 Volume 2, Tab 29 p 550-1123Exhibit 1 Volume 3, Tab 31 p 552-524Exhibit 1 Volume 3, Tab 31 p 552-625Exhibit 1 Volume 2, Tab 29 p 550-112212

35. Large areas of northern NSW including the Greater Hunter, Central Ranges and North Westernareas were also predicted to reach catastrophic fire danger rating levels on 12 February 2017.2636. When the Commissioner makes a s.44 declaration, he appoints an Incident Controller (‘IC’) to actas his delegate. For the Castlereagh District on Saturday, 11 February 2017, Mr Paul Jones wasappointed. The IC manages the Incident Management Team (‘IMT’) and issues operational ordersvia Situation Reports, Incident Action Plans (‘IAP’) or direct radio or telephone communications.2737. Pre-emptive arrangements within the Castlereagh District included:a. Messages to all RFS brigades and Group Officers putting them on notice of the expectedconditions and likelihood of call outs.28b. RFS support brigades (volunteer communication officers who provide support within theRFS Fire Control Centre in Coonabarabran) asked to confirm availability.29c. RFS aerial resources activated to be on standby out of Coonabarabran, with aerialmonitoring across the whole Coonabarabran area to commence Saturday morning.30d.Volunteers then came into the Coonabarabran Fire Control Centre on Saturday morning,prior to the Sir Ivan fire commencing.e. Once the fire commenced and the scale of the fire became apparent, the IMT increased insize. It ultimately included a local emergency operations controller from NSW Police and alocal emergency management officer from the Warrumbungle Shire Council.26Exhibit 1 Volume 2, Tab 29 p 550-11Exhibit 1 Volume 2, Tab 29, pp 550-1828Exhibit 1 Volume 3, Tab 31, pp 552-629Exhibit 1 Volume 3, Tab 31, pp 552-930Exhibit 1 Volume 3, Tab 31, pp 552-62713

The Sir Ivan Fire38. Saturday, 11 February 2017 was Dunedoo show day. Many of the people in the district hadalready taken precautions around their properties in light of the bushfire risk. They had movedstock, cleared vegetation and checked that pumps were working. This was a community who hadlived with the threat of bushfires over generations. Many residents had extensive experience infire-fighting, whether in a private or volunteer RFS capacity.39. Sometime close to midday on 11 February 2017, residents in the vicinity of ‘Flagview South’noticed smoke from a grass fire on that property. ‘Flagview South’ is a 1,600 acre mixed-farmingproperty, which is predominantly used for sheep grazing with some winter cropping, and isuninhabited. Various locals including Mr Keith Ghent, Mr Peter Quera, Ms Sara Fergusson, MrGeorge Simmons, Mr Jamie Bauer, Mr Will Gaden, Mr Murray Coe and many others either noticedthe smoke or heard about the fire and travelled out to the vicinity of ‘Flagview South’ to help theowners, Mr David and Ms Tori Seis with the fire on their property. The RFS also responded; theLeadville, Dunedoo and Hannah’s Bridge Brigades were contacted, a firefighting aircraft wasdeployed and messages were sent to relevant RFS volunteers.40. Later that evening, the grass fire was finally extinguished once the wind died down. However,nearby scrub was already well alight. The fire burnt predominantly east under a westerly windtowards the village of Uarbry. The terrain varied from grassland to undulating rocky hills and thickwooded scrub that is largely inaccessible to vehicles.41. The prevailing winds also pushed the fire from ‘Flagview South’ out to the north east. Initial effortsto fight the blaze included attempts to get in front of the fire through a property owned by Mr Coeand mount a direct attack on the fire edge.42. The Hannah’s Bridge brigade, Dunedoo 7, Birriwa 1 and a group of local fire fighters had someearly success along Bald Ridge Road and Warden’s Road. But it became apparent to those on thefire ground that direct attack would not be effective in the long run or possible along the entirefire perimeter.43. Different strategies were used at different times and in different locales. According to the IC, asthe fire moved from grassland to inaccessible bush, up steep and rugged hills, the strategychanged to parallel and indirect attack. During this initial phase from first alarm until 1900 hours,14

crews on the southern flank were tasked to direct attack as the fire came out onto open grassland,crews on the northern flank were tasked to conduct a parallel attack with existing and new trails,and indirect attack was used on the head of the fire (the eastern edge) using plant to constructcontainment lines.44. But intense and erratic fire behaviour continued to test the control lines constructed parallel tothe fire line. Regular shifts in wind direction caused spot overs, which firefighters (both privateand RFS) were able to supress on occasion. Changes in fuel load and fuel type as the fireprogressed across the landscape generated varying degrees of spotting. The fire was burningquickly into scrub, down gullies and eventually along ridges that were inaccessible.45. The fire did not proceed in a uniform way along the entire fire line. Differing situations confrontedfirefighters in different locales. People on the ground were understandably focused on what wasin front of them but conditions varied from place to place and fire response to suppressiontechniques likewise varied from place to place.46. A detailed chronology of the fire has been agreed by the parties involved in this inquiry. I attach acopy to these findings for the interest of persons who could not attend this inquiry.47. Mr Conway, the independent expert, gave evidence that even though the strategies applied in theinitial period from detection to about 1900 hours were appropriate, they were not successful. Thecombination of terrain, vegetation and weather made it unlikely that any strategy would havebeen successful in containing the fire until weather conditions moderated.48. The Liverpool Range and Cudgegong Districts were also subject to pre-emptive s.44 declarationsand separately had an IC and IMT responding to anticipated demands within each District. Once afire commenced in Leadville, Mr Paul Jones would assume the overarching IC role in the event thatthe fire spread into other Districts. This was because the fire had started in the CastlereaghDistrict.49. Mr Jones said prior to the fire actually entering the other Districts, he had discussions with the ICfor the Liverpool Range District and the Cudgegong District. Discussions with the Liverpool RangeDistrict included reference to Cassilis because it was within that District, and discussions with theCudgegong District included reference to an underground mine within that District. There were no15

specific discussions about resources available in either of those Districts and Mr Jones recalls basicdiscussions as to where each of those Districts might be looking to place fall back lines.3150. Mr Conway agreed that the strategy adopted on 12 February 2017 was appropriate even thoughthere was a real prospect that it would not be successful because of the terrible conditions.3251. Witness accounts set out in the attached chronology describe the situation when conditions didactually deteriorate as predicted on 12 February 2017. A few references will be included here.52. Mr Coe described being present to put out spot fires but,“it was impossible blowing the water was actually spreading the flames it was burning that hotand that ferocious that the water wasn’t actually putting the fire out.”33 He said once the weatherchange came through at 1030 hours or thereabouts “nothing would have controlled it it literallyjumped from hill to hill it was horrific.” 3453. Mr James Sweeney from the Leadville RFS Brigade described spo

CORONERS COURT NEW SOUTH WALES Inquiry: Fire at Flagview South , Sir Ivan Dougherty Drive, Leadville February 2017 Hearing dates: 24 - 28 June 2019 Mudgee Local Court, 16 - 20 September 2019 Dubbo Local Court, 29-30 October 2019 Mudgee Local Court. Date of findings: 30 October 2019 Place of findings: Mudgee Local Court, NSW

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