5 minute read
Complacency can lead to the coroner
A focus on compliance instead of safety puts people and properties at risk.
PHOTO: NEWS LIMITED
Inset above Retired Deputy Coroner Hugh Dillon
Above Major incidents such as the Bankstown apartment fire and the Quakers Hill Nursing Home fire have led to significant fire safety reforms.
PAUL WATERHOUSE
FPA Australia
Building fires can have catastrophic effects on both people and property. Every year, people are injured or killed in preventable fires, and these cases often make it to the Coroner’s Court.
Retired Deputy Coroner Hugh Dillon served on the NSW Coroner’s Court for nine years and, in that time, he conducted at least 15 investigations into fire-related incidents. He was the presiding coroner responsible for two of the most high-profile cases of recent times—the Quakers Hill Nursing Home fire and the Bankstown apartment fire— which he said were among the most touching and moving cases he heard.
Both cases had a human impact. Both cases raised questions about the safety of the buildings and the culpability of those who designed and managed them.
And in both cases a single individual had an immediate and direct effect on the fire itself.
Quakers Hill
In the Quakers Hill Nursing Home, 11 elderly residents died when a nurse, who wanted to cover up the theft of drugs, started fires in two rooms in separate wings in the early hours of 18 November 2011.
Up to 100 residents were evacuated and approximately 32 people were taken to hospital with smoke inhalation.
The nurse who started the fires pleaded guilty to the murder of the deceased residents and was sentenced to life without parole.
He was a drug addict, and he started the fires to destroy evidence because he was under investigation. While he may not have intended to kill the residents, he acted recklessly and with disregard for those in his care.
Bankstown
The Bankstown apartment fire appears to have occurred when a cigarette in an ashtray, sitting on top of an airconditioning unit on the balcony, was not properly extinguished.
When the residents saw flames on top of the unit, the male smoker attempted to douse the flames, but they increased in the windy conditions and sent black smoke into the unit.
In fleeing the apartment, the man left the balcony and unit doors open, increasing the intensity of the flames.
Two of his flatmates, Connie Zhang and Ginger Jiang, were trapped in one of the bedrooms.
There were no sprinkler systems in the unit, so the fire achieved flashover in very fast time—the ambient heat was so intense that the glass and aluminium window frames were starting to melt.
The two girls eventually jumped, because they had nowhere to go.
Connie died, and Ginger was paralysed by the fall.
These cases were important, not just because of the direct effects on those who were killed or injured, but also because they revealed systemic issues that, if they had been addressed beforehand, might have prevented the fires or resulted in them being less intense and more manageable.
They also showed the significant risk posed by fire in modern buildings containing modern materials.
Synthetic furnishings can burn very quickly and generate massive amounts of heat and highly toxic gases, making them very difficult to subdue and extinguish, and hampering attempts to rescue people.
Other cases
Mr Dillon said there were other inquiries that have influenced his outlook.
Some of these were arson cases, committed for insurance payments, which were not very expertly carried out and revealed interesting insights into the mindset of the perpetrators.
Another was a catastrophic fire in the Warrumbungle National Park, which started with a campfire and burnt out 50,000 hectares—black as far as eye can see—and which showed the devastating effect of climate change and Australia’s need to become more resilient.
A boarding house fire in Petersham showed the potential for catastrophe, because building owners had paid no attention to how the residents behaved in the building. While there were no deaths, negligent management could have ended in disaster.
Key lessons
A common theme from these events has been complacency about fire safety.
There is a lot of regulation and administration designed to keep people safe, but Mr Dillon said that they can too often focus on the process of compliance.
Put simply: you are not protected because you tick boxes on a document—the boxes are there to remind you what is at stake.
So, while councils may regularly receive annual fire safety statements, if these are simply filed and never audited, unskilled people are able to claim to be fire inspectors with no oversight or challenge from the single council clerk.
It has happened time and time again. An explosion in a winery that Mr Dillon investigated in the Hunter Valley occurred because of this compliance mentality. The two people who died ticked all the boxes but did not make the connection between compliance and safety.
Mr Dillon observed that very often, catastrophic fires occur because people do not pay attention to the reason for the regulations, not because the regulations are bad.
Fires are not common events, so it is easy for practitioners and owners to become complacent and lose focus on safety.
Safe design
The Bankstown case found that it would have only cost $500,000 to install sprinklers in the building at the time of construction, resulting in a small additional cost to each apartment owner.
Yet, the developer of that building designed it to be just two centimetres below the height at which a sprinkler system would have been required.
With 50 units in the building, the additional cost of a sprinkler system would have been just $10,000 per unit—hardly significant in Sydney’s property market.
If the developer had set out to build a good, protected building, and sold the units for a slightly higher amount, the fire would not have reached the high heat and dangerous conditions that led to Connie’s death and Ginger’s injury, and two lives would not have been ruined.
Complacency and cost-cutting put people at risk and disregard the fire safety meant to be central to building design. You only have to see one terrible fire to understand the value of fire prevention—but we should not need to. Hugh Dillon will be presenting a keynote speech at Fire Australia 2022.