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Implement Procedures for Dealing with Hazardous Events

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2.1 What particular procedures; a) were implemented and b) were NOT

implemented (or implemented unsatisfactorily) on the day in question?

The procedures that were implemented on Black Saturday, 7 February 2009 had

become known as 'stay or go' but is more accurately described by its full title,

'Prepare, Stay and Defend or Leave Early'.

The 'stay or go' policy did not prove satisfactory as the policy assumed that

people had a fire plan and knew what to do when there was a bush fire threat.

The policy options of leaving early or staying to defend do not cover future plans

and did not help many people who found either option acceptable in their


2.2 How was the bushfire tragedy analysed by the Commission and what

significant information was identified and collected in regards to the

probable cause/s of the fires?

The bushfire tragedy was analysed by the most damaging, or potentially

damaging, fires that burned on 7 February, including those in which people died.

Many of these fires were significant because of their size and impact; some of the

smaller ones, however, provide insight into the differing circumstances and

demands of the day.

The fire season was long and demanding, placing considerable pressure on

firefighters even before the worst fires began in early February.

Spotting was an important factor in the spread of some fires. Firebrands carried

by the strong winds spread from one ridge top to the next in areas of broken

terrain. They were carried across sparse eaten-out pasture or areas where grass

was less than fully cured and might otherwise have arrested the fires' spread.

Although they varied in their size and impacts, the most



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