The following is a redacted (for legal reasons) version of the Coroners Court of Victoria’s “Summary of circumstances surrounding the point of origin of the Kilmore East fire on 7 February 2009.”
The State of Victoria had been subjected to exceptional heatwave conditions which peaked on Saturday the 7th of February, 2009.
As a result of the drought Victoria had been suffering and the predicted high temperatures expected, a Total Fire Ban for Victoria was broadcast on radio and television at 5.1 0am on the 7th of February, 2009.
The fire index was determined to be in excess of 110 an extremely high reading which posed a ‘high risk’ of fire occurring in the State.
Between 11.30am and 12.30pm, the Kilmore Gap Automatic Weather Station (AWS) recorded winds between 48 and 56 kilometres per hour with gusts up to 72 kilometres per hour.
At 11.31am the Melbourne Airport AWS recorded the temperature at 40.4°C with a relative humidity of 10% and winds were recorded at 48 kilometres per hour.
At 11.45am, electricity company SP AusNet recorded a power outage along the Pentadeen Spur Single Wire Earth Return (SWER) Line which subsequently cut the power supply to neighbouring rural properties. [Name redacted] was at her home at [address redacted] Kilmore East when she noticed the power go out.
Also at this time, a fire started in the vicinity of a power pole which was located on top of a rocky hill, on a rural property at [address redacted] Kilmore East.
Peter COLEMAN, a Fire Lookout Observer employed by the Department of Sustainability and Environment (DSE), was at the Pretty Sally Fire Tower, located 2 kilometres north of the township of Wallan.
At 11.47am he observed a single plume of white smoke to the north of the tower.
He then rang Phillip SEARLE, a Fire Lookout Observer at the Mount Hickey Fire Tower in the Tallarook State Forest, and alerted him to the fire.
At 11.47am, SEARLE looked out from his tower and observed smoke billowing from a paddock between Saunders Road and Sunday Creek Road, Kilmore East. At 11.47am, [name redacted] contacted ‘000’ to report the fire.
At 11.49am, CFA logged the call from SEARLE as the first call about the fire.
At 11.50am, Wallan, Kilmore, Wandong, Clonbinane and Broadford CFA were advised of the fire.
Russell COURT, the Second Lieutenant with Kilmore CFA, was on duty at the Kilmore Fire Station. At 11.50am he was alerted to a fire in the area when members’ pagers began to activate.
The pager messages indicated that the Mount Hickey Fire Tower had sighted smoke in the vicinity of Saunders Road and Sunday Creek Road, Kilmore East.
A ‘hot day’ response of five brigades was immediately dispatched along with a number of private units.
[Name redacted] was at her home at [address redacted] Kilmore East and observed a huge cloud of smoke emanating from the north from Sullivan’s Hill.
She observed that the fire was travelling in the direction of her neighbour’s property, which is located to the west of her house and at 11.50am she telephoned ‘000’ and alerted them to the fire.
[Name redacted] was at his property located at [address redacted], Kilmore East when he observed a plume of smoke emanating from the north, from the direction of Sullivan’s Hill. He observed that the fire was approximately one kilometre from him however was travelling quickly in his direction.
At 11.50am he contacted ‘000’ and reported the fire.
[Name redacted] was at her home at [address redacted] Kilmore East, when she was alerted to a “big dust storm” outside by her nine year old grand daughter. [Name redacted] looked to the west of her property and observed fire on Sullivan’s Hill and at 11.51 am she contacted ‘000’.
She observed the flames were about 10 to 15 feet high and a deep red colour. She decided to evacuate and within minutes fire trucks were in and around Saunders Road.
Ross HIBBERT, the Captain of the Clonbinane CFA, was at home in [address redacted] Kilmore East when at 11.50am he received an emergency page alerting him to a fire in Saunders Road.
He and his son Ben, also a CFA volunteer, immediately responded to the fire.
At 11.53am, they drove onto Saunders Road heading west towards Kilmore, and observed flames. He drove to a better vantage point and looked out over the fire affected area.
Using the CFA radio he immediately requested 10 tankers.
From the top of the hill, the fire appeared to be heading south. Flames were visible around the edges but due to the dense smoke, the head of the fire was not visible.
[Captain] HIBBERT approximated the size of the fire at 10 to 20 acres and described it as intense and moving extremely fast. He stated the wind was extremely hot and believed the temperature was well into the 40s.
Despite being unable to see the head of the fire he estimated the smoke was only one kilometre ahead of him.
Russell COURT’s crew was amongst the first to leave the station and arrived at the fire at about 12.00pm.
Upon arrival, he observed that the fire was burning in land between Sunday Creek Road
and Saunders Road. He described the fire as a strip, 80 to 100 metres wide, running in a southerly direction towards a hill.
When the fire reached the base of the hill, it split into two fingers and continued around the hill.
The western finger of the fire ran in a southerly direction towards Saunders Road while the eastern finger was heading south-easterly towards Wandong.
He immediately began to attack the western flank of the western finger, which was threatening a heavily !reed area.
He cut down trees and fences to gain access and put water on the fire.
COURT stated that the initial plan was to stop the fire at Saunders Road, however there were a lot of trees in the area and shortly after he had arrived at the scene he was advised that the fire had already jumped Saunders Road and was spotting up to 250 metres ahead of itself.
Shortly after 12.00pm Greg MURPHY, Captain of the Kilmore CFA, was instructed to act as the Incident Controller and Kilmore Fire Station became the Incident Control Centre (ICC).
At 12.02pm, [name redacted] was at her home at [address redacted] Kilmore East when she was alerted to smoke in the area.
She looked to the north-west of her property and observed white smoke which she believed was a grass fire emanating from behind a ridge, in a gully to the west of the
[name redacted] property, located at [address redacted].
At 12.07pm, she took three photographs from the front door of her property of a power pole on top of Sullivan’s Hill. The land to the south of the pole is burnt by fire which is flanking to the east.
At 12.08pm, Colleen KEATING, a Fire Tower Operator at Kangaroo Fire Ground Tower, observed a large fire coming from Sunday Creek Road Kilmore East.
She took bearings of the fire as 336° from Kangaroo Ground Tower and around 24° to 26° from Pretty Sally. The fire was heading towards the Blue Gum Pine Plantation and she noticed that it was building fast.
KEATING then telephoned Jason LAWRENCE, the ICC controller at the Kangaroo Ground ICC, and reported her observations of the fire.
At 12.10pm, COURT utilised a dam further south on the property to refill the tanker.
He turned around to look north and observed that the fire had started to creep back against the wind and was burning in the area that he had already worked on and put out.
He and his crew then drove north in the direction of a large solitary power pole on top of a hill.
He observed that the power cable was attached to the top of the pole, however was hanging down, draped over the cable stay and was in contact with the ground.
He identified that the power line was broken but couldn’t see where it had broken and radioed it in as a hazard.
He observed that it appeared obvious the fire had originated from the area of the pole as the path of the fire leading away from the pole was quite narrow and fanned out as it got
further away.
The area to the south of the pole was burnt and the area to the north; north-west and north-east of the pole remained unburnt.
By 12.30pm KEATING was able to smell the smoke emanating from the fire and noted that it was travelling in a south easterly direction towards Pretty Sally.
At 1.00pm she released an urgent page stating that there was a strong smell of smoke from the Kilmore area. She also noted that the temperature was 41 ‘C, wind speed was 39 kilometres per hour and gusting to 55 kilometres per hour, a relative humidity of 13% and poor visibility.
John DIXON, a CFA Volunteer, communicated with the Air Attack Supervisor who was above the fire in a spotter aircraft, and requested the aircraft attack the spot fires.
At 12.45pm DIXON was advised by the aircraft crew that fires were spotting approximately 200 to 300 metres ahead of the main front.
Garry McCLUSKEY, a Fire and Forest Officer with the DSE, was directed to attend at the point of origin and conduct reconnaissance to determine the extent of the fire.
At 1.15pm, whilst en-route to the fire, he stopped at the intersection of Wandong-Broadford Road and the Hume Freeway in Clonbinane and observed thick smoke and flame.
He estimated that he was about 500 metres from the northern flank. He also observed the fire burning in the Glenburnie Pine Plantation that was heading in a south-easterly direction.
He continued south on the Hume Freeway towards Wandong and at 1.24pm he passed the head of the fire which was burning along the western edge of the freeway.
McCLUSKEY exited the freeway through a small gap in the fence line near the intersection of The Dene and Stotts Road, Wandong and drove onto The Dene.
From this location he observed the fire close to the freeway and within a short time observed the medium strip commence to spot and then the east side of the freeway.
The fire then spread across the freeway and rapidly out of control.
McCLUSKEY described the weather conditions at this time as extremely hot and windy.
Kieran PURCELL, a volunteer with the Kilmore CFA, was tasked as a Fire Observer. At 1.30pm he was driving along The Dene in Wandong and observed the fire front travel towards him.
At 1.36pm, Kieran drove out of the path of the fire and onto the Hume Freeway where he observed the fire jump the freeway at The Dene overpass.
He was surprised by the speed at which the fires burnt the western embankment of Hume Freeway overpass, then jump and commence burning an acre of bush on the eastern side of the freeway.
McCLUSKEY travelled to the intersection of O’Grady’s Road and Wandong-Kilmore Road, Wandong and used a hand held Kestrel weather meter to take weather readings at ground level.
At 1.45pm the weather meter indicated the air temperature was 40’C and the wind was travelling in a north-westerly direction at 40 kilometres per hour.
He also observed a large column of smoke and flame was burning in the Overdale Pine Plantation.
At approximately 4.45pm, [name redacted] a Kilmore East local resident, was fighting the fires on [name redacted] property at [address redacted] and observed a power pole on top of [name redacted] hill.
He noticed that the conductor was broken on the western side of the pole, approximately a metre from the top of the pole, and still connected to the insulators. At this stage, the area surrounding the pole was not burnt and there was no fire within 100 metres of Pole 39.
The fire continued to burn throughout Upper Plenty, Arthurs Creek, Humevale, Strathewen, Steels Creek, Kinglake, Kinglake Central, Kinglake West, Pheasant Creek, St Andrews, Strath Creek, Reedy Creek, Toolangi, Hazeldene, Flowerdale and Yarra Glen.
The fire was reported as “Contained” on the 5th of March, 2009, and finally declared “Safe” on the 7th of April, 2009.
On Sunday the 8th of February, 2009, Fabian CROWE, CFA Wildfire Investigator, commenced an investigation into the location of the origin of the fire.
He attended the area that was highlighted by persons who were witness to the early stages of the fire, which was commonly referred to as the power pole situated on top of Sullivan’s Hill, located at [address redacted] Kilmore East.
The power pole was further identified as pole 38 of the Pentadeen Spur SWER Line (Single Wire Earth Return).
CROWE examined the burn and char patterns surrounding the area and considered potential causes such as lightning, power lines, electric fences, machinery, escaped campfire or barbeque, escaped spotting from existing fires, rubbish or debris or deliberate ignition.
He concluded that there was only one area of origin which was immediately adjacent to power Pole 38 and was contained within an area approximately 3 metres by 5 metres.
This area was concentrated around the southern stay wire.
Michael LEAHY, an electrical investigator with Energy Safe Victoria (ESV) attended Pole 38. He observed that the conductor attached to the east side of the pole had fallen down around the southern stay wire and was lying on the ground.
LEAHY examined the stay wire and located signs of electrical arcing on the eyebolt of the southern stay anchor rod.
LEAHY followed the conductor from Pole 38 in an easterly direction towards Pole 39. He observed that where the conductor had moved in some areas since the fire there was an unburnt line of grass.
LEAHY located the broken end of the conductor and estimated it was approximately 200 metres west of Pole 39 (it was later measured at 135 metres west of Pole 39).
LEAHY then attended Pole 39. He observed the pole had burnt down at the base and had fallen to the east.
He noted that the conductor on the supply side of Pole 39 had broken at the end of the helical termination.
With SP AusNet’s assistance, the disc insulator assembly at Pole 39, together with the helical termination and the end of the broken conductor were handed to police as an exhibit.
LEAHY advised the SP AusNet linesmen of the broken end of the conductor lying in the paddock. The linesmen, then attended the broken end, cut off a section and handed it to police.
The SP AusNet linesmen then replaced the conductor and fittings between
Poles 38 and 39.
On the 14th of February, 2009, Rachel NOBLE, a Scientist with Victoria Police Forensic Services Centre (VPFSC), attended the area that had been identified by CROWE as the origin of the fire and conducted an investigation into the cause of the fire.
She noted that the area of origin was within a grassy paddock on private property with trees scattered throughout the property. The power pole was on a rise that was surrounded by scattered rocks and grass.
The area directly underneath the power pole was relatively clear and consisted mainly of dirt and rocks whereas the area around the stay wire was grass.
On the south eastern side of the mound among the grass was a patch of bracken fern running down the slope towards more open grass paddocks containing scattered patches of grouped trees.
The land was undulating with steep inclines (dropping approximately 100 metres) and a small creek running through a gully, approximately two
thirds of the way between Poles 38 and 39.
NOBLE noted that the scene had been cleaned up and the damaged conductor cable had been replaced.
The power line of interest was a single wire earth return (SWER) which conducted 12.2kV of electricity and consisted of 3 strands of 12 gauge steel over a span of approximately 1 kilometre between Poles 38 and 39.
The conductor had apparently broken approximately 1 metre from Pole 39 and had recoiled back and wrapped around the stay wire on the southern side of Pole 38.
Although the damaged conductor had been removed prior to her examination the original southern stay wire and anchor bar were still present.
NOBLE conducted an examination of the dirt and debris around the area of origin.
She identified positive responses in burnt patches which tended to support the proposition that arcing had occurred either at the stay with hot metal reaching the ground or arcing directly to ground in the ferrous areas.
Furthermore, she conducted examinations in relation to other possible sources of ignition such as mechanical sparks, cooking/camp fires, cigarette butt, lightning and deliberate ignition. However there
was nothing identified to suggest any of these.
NOBLE concluded that the fire started in the vicinity of Pole 38 of the Pentadeen Spur as a result of the power line breaking near Pole 39.
The broken conductor then recoiled around Pole 38 and its southern stay wire.
In her opinion, the contact between the conductor and the stay wire and/or the ground in the vicinity of the stay wire, caused arcing which ignited dry grass on the ground around Pole 38.
She further concluded that the probability of ignition by other sources was regarded as remote.
On the 24th of February, 2009, Trevor LAYZELL and Harry BETTER from HRL Technology, an engineering company specialising in metallurgical testing, attended the point of origin to gain an appreciation of the scene as well as the possible causes leading to the conductor breakage.
They viewed the damaged conductor and electrical hardware that had been seized by police and commenced their investigations into the cause of the conductor breakage.
After an extensive preliminary examination, they determined the scope of their investigation to be:
• Conductor strand fractures at Pole 39,
• Incorrectly installed helical termination assembly over the thimble fitting at Pole 39,
• Arc damage on the stay at Pole 38, and;
• Arc damage on the conductor in the vicinity of Pole 38.
HRL conducted further laboratory testing and examinations and concluded the following:
• The conductor fracture at Pole 39 was due to fatigue of two strands with the third strand failing in ductile tensile overload;
• The cyclic stresses required to cause fatigue were caused by wind-induced vibration of the conductor;
• The helical termination at Pole 39 was incorrectly seated in the thimble and would have altered the end conditions of the span and is likely to have further influenced the vibrations;
• Dampers were not fitted to the conductor span to reduce vibration.
• At the helical termination end, depressions in the conductor wires were lined with a hard layer (or “white layer”) which is brittle and susceptible to cracking. Cracks act as a significant stress concentrator for the development of fatigue;
• The incorrectly installed helical termination assembly was in place since the line was last resagged and should have been detected during routine inspection of the line; and
• Inspection of the stay at Pole 38 showed evidence of arc marks on the stay wire and at the stay wire thimble/anchor bar eye connection;
Examination of the conductor in the vicinity of Pole 38 also showed arc marks.
• Examination of the stay and conductor in the vicinity of Pole 38 suggest that arcing had occurred between the conductor and the stay.
The arc marks on the stay wire and the anchor bar eye included well defined craters, indicative of material being ejected during arcing.
Professor David SWEETING, a Consulting Electrical Engineer, was tasked to examine the point of origin and determine whether arcing from the damaged conductor on to the southern stay wire of Pole 38 could cause a fire.
Professor SWEETING’s examination concluded that there was a strong
likelihood that if there was entwined dry vegetation on the stay rod then it could have been ignited by plasma from the thimble eye arc.
Trevor LAYZELL, Harry BETTER and Geoff GOONAN from HRL Technology identified that the helical termination assembly was not correctly seated in the thimble at Pole 39, which would have altered the
end condition of the span and was likely to have influenced the vibrational mode.
They opined that the incorrectly installed helical termination assembly was likely to have been present since the line between Poles 38 and 39 was most recently sagged.
SP AusNet are unable to provide any evidence of the bay of conductor being re-sagged since 1999, therefore the fault should have been detected
during routine inspections.
On the 26th of August, 2009, a partial reconstruction of Pole 39’s assembly was conducted at the GippsTafe, Energy Training Centre Chadstone in the presence of HRL Technology personnel, Phoenix Taskforce investigators, Victoria Police Forensic Service Centre experts, Energy Safe Victoria
personnel and GippsTafe senior instructors.
The reconstruction was such that it replicated the conditions that an Asset Inspector, utilising their standard-issue· equipment, would confront during their routine cyclic maintenance checks.
GippsTafe Senior Instructor, Kelven BARNBROOK provided procedural expertise as to how the Asset Inspector should have conducted their routine inspection.
He stated that whilst conducting a visual overhead inspection of distribution assets, it is imperative that inspectors use binoculars so they can identify faults and defects which would not be visible to the naked eye.
During the reconstruction, he stated that if he had observed this type of fault he would have classified ii as a priority one job and reported it to be fixed immediately.
Furthermore, Asset Inspectors were taught to use stabilised binoculars at every pole to pick up faults including cracked insulators, broken ties, corroded cables etc.
The defects demonstrated in the partial reconstruction were clea[ly visible to the naked eye and with the 8X stabilised binoculars and the 1OX standard binoculars.
Denis McCROHAN, the Maintenance Planning lead Consultant for SP AusNet, stated that SP AusNet contracted Utility Asset Management (UAM) to provide asset inspection services of SP AusNet’s power distribution system.
The contract was valid from the 11 of April 2007 until the 31 of March
2010 and stated that UAM were required to conduct the inspection of SP AusNet’s distribution assets in accordance with SP AusNet’s Line Inspection Manual.
Furthermore, UAM were required to supply and maintain a trained and competent workforce at all times.
SP AusNet’s Asset Inspection records detailed that the most recent inspection of the Pentadeen Spur SWER line, including Poles 38 and 39 was conducted by Asset Inspector, Jason LEECH on 25th of February 2008 (almost a year prior to the fire of the 7th February 2009).
During the inspection process, LEECH was required to check all aspects of the distribution asset, including the overhead pole top structure according to the Asset Inspection Manual and report any defects.
However, on this occasion, LEECH did not observe, note or report any defects relating to the faulty conductor or conductor fittings.
On the 20th of January, 2010, BARNBROOK was tasked to conduct a review of the entire Asset Inspection conducted by LEECH in the Kilmore/Broadford area during February 2008, which included Poles 38 and 39 of the Pentadeen Spur SWER Line.
He concluded that LEECH conducted his Asset Inspection in a methodical way however the techniques that he used were in complete contrast to standard practise as stipulated in the Line Inspection Manual.
Not all correct techniques were used, important hazards were not properly identified, bushfire problems were not rectified, private residences and adjacent properties were exposed to dangerous risk of bushfire.
Furthermore, an audit was conducted of LEECH’s workplace training and assessments and found that it fell well below industry standard.
BARNBROOK noted that documentation did not follow a set format and it lacked detail in relation to the competency of which LEECH was being assessed against.
LEECH’s Asset Inspector Competency Test did not reflect a high degree of literacy, numeracy or understanding which would otherwise deem him competent.
LEECH’s lack of understanding and competency should have also been identified through regular audits of his daily Asset Inspection work.
The contractual agreement between SP AusNet and UAM stipulated that internal audits (conducted by SP AusNet and UAM) and independent audits (conducted by another contractor of SP AusNet) were regularly scheduled to ensure work was at industry standard, however on two occasions, LEECH failed the audits and was not satisfactorily held to account by either UAM or SP AusNet.
Phoenix Taskforce investigators retained the services of Subject Matter Consultant Alex FRAZER provided expert evidence in relation to training within the electricity industry.
FRAZER’s investigation concluded that LEECH’s training and practises as well as the training procedures and processes of UAM were well below industry standards, however no legislative requirements were breached.
