Back in February 2009, I wrote a number of posts on the disastrous Victorian bush fires.
- Feb 8 2009, Victoria's fires - at least 14 dead
- 11 Feb 2009, Fires - stay and defend or leave early
- 14 Feb 2009, Saturday morning musings - issues raised by the Victorian fires.
Since I wrote, the official inquiry into the fires has been grinding away. Now on its last day, the focus has been on failures in leadership. You will get a feel for the coverage here, here, here and here.
At this point, Counsel Assisting is arguing that those at the top failed to provide leadership and that, consequently, the system failed. I would put it a little differently.
Based just on the little evidence I have heard, the system itself failed; failures in leadership were a symptom, not a cause of that failure.
I do not know to what degree systemic failure added to loss of life and property. No doubt the Commission will report on this in due course. However, the fact that the system failed is itself of obvious concern.
But why do I say that the system itself failed?
To begin with, we are dealing with a centralised system that appears to have suffered from two key weaknesses. First, there appears to have been a lack of definition in responsibilities, essentially who was responsible for what. Secondly, those a little further down the chain appear to have lacked the authority, or felt that they lacked the authority, to take action at critical points.
Here let me quote from one story:
Police oversight was non-existent during the height of the fires, with Christine Nixon going out to dinner at a crucial time and her deputy, Kieran Walshe, unable to replace her until almost three hours later.
Political oversight was threadbare at best, with Police and Emergency Services Minister Bob Cameron absent from the Melbourne emergency control centre until 8pm. Those who were there, led by Country Fire Authority chief Russell Rees, were, in the words of Rush, "unable or unwilling to influence or attempt to influence the tragedy that was unfolding".
The first question to ask is what is the role of political oversight in an event like this?
This is a large scale operational matter. The role of ministers in these circumstances is to facilitate, to support. This is certainly a leadership function. However, if the presence of a minister is necessary to run the operation, to overcome problems, to coordinate, then it seems to me that you have a systemic problem.
The second question to ask is just who had final authority, who was responsible for what? The answer appears to be no-one. Again, this is a systemic problem.
Much of what I have written on administrative and management matters over the last few years has been concerned with what I see as inbuilt systemic weaknesses in current approaches to management, including the use of command and control systems. I know that this gets pretty boring from a reader perspective, but it is something I feel very strongly about.
I would hope that in reporting, the Commission will focus not just on leadership issues, but on the actual system design features and on associated cultural aspects. I have put it in this way because the type of problems that appear to have occurred do not just happen, they develop with time. For example, why were people not prepared to act to get a warning out, in so doing to ignore chains of command?