This report includes an update on the implementation progress of the final 2 recommendations from the Independent Investigation of the Lancefield-Cobaw Fire, which concludes IGEM’s monitoring and reporting of its 22 recommendations.

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History of the Lancefield-Cobaw fire investigation

Reducing the risk of bushfire to the community and environment is a fundamental part of DELWP's work, at the core of providing service that creates a liveable, inclusive and sustainable Victoria.

The Lancefield-Cobaw fire demonstrated that more work was needed to rebuild trust with tangible actions and change.

Key findings and recommendations focused on:

Community engagement

DELWP will ensure the right people are actively and meaningfully communicated with in a way that suits their needs


Better integrate operational burn planning and operational implementation

Systems and processes

DELWP should focus on improving systems and processes, to ensure risk assessment reflects the broader landscape and resourcing is appropriate to that risk

Risk management

DELWP should thoroughly review its risk management and approvals processes, with risk assessments and outputs clear, current and useful


The department should build a better identity for fire management and planned burning on public land so it can build stronger and more sustainable relationships with the community

Independent investigation into Lancefield-Cobaw fire [PDF File - 527.2 KB]
Independent investigation into Lancefield-Cobaw fire (accessible) [MS Word - 72.8 KB]

DELWP response to independent investigation [PDF File - 308.1 KB]
DELWP response to independent investigation (accessible) [MS Word - 180.8 KB]

Summary of recommendations from the independent investigation [PDF File - 209.7 KB]
Summary of recommendations from the independent investigation (accessible) [MS Word - 81.8 KB]

What will change – summary of DELWP response [PDF File - 133.9 KB]
What will change – summary of DELWP response (accessible) [MS Word - 80.0 KB]

During the investigation, several areas were identified as 'out of scope' for the planned burn. These have been provided to Emergency Management Victoria.

Emergency Management Victoria (EMV) responded to the community's queries. The Community Report represents EMV and the sector's commitment to sharing, exploring and addressing these community observations.

Out of scope document [PDF File - 295.6 KB]
Out of scope document (accessible) [MS Word - 23.8 KB]

Many of the recommendations in the independent investigation are being implemented as part of Safer Together: a new approach to reducing risk of bushfire in Victoria.

A review into our Approvals and Oversight Process – December 2015 Report

In December 2015, an independent workplace consultancy undertook a review of our approvals and oversight procedures and ran interviews with DELWP and Parks Victoria staff directly involved with the Lancefield-Cobaw burn.

They produced the following report into the conduct of the approvals and oversight process relating to the Lancefield-Cobaw planned burn.

Independent Investigation into the Conduct of the Approvals and Oversight Process relating to the Lancefield-Cobaw Planned Burn [PDF File - 1.0 MB]
Independent Investigation into the Conduct of the Approvals and Oversight Process relating to the Lancefield-Cobaw Planned Burn (accessible) [MS Word - 468.2 KB]

Several recommendations were made in this report, and focused on:

  • A thorough review and update of DELWP's Fire Management Manual
  • DELWP consider options to improve the culture of decision making and promote peer review
  • DELWP consider a review of higher level district and regional responsibilities
  • Assess individuals' roles in approvals and oversight of the burn and target increased training to those involved in the burn.

Many of the recommendations overlapped with DELWP's response to the October 2015 report (link) and other organisational changes and DELWP will built these into its implementation of the October 2015 report.

Additional audits of DELWP's planned burning program

As part of extra commitments that DELWP made in addition to the 22 recommendations from  the Lancefield-Cobaw fire investigation, the department commissioned two additional audits of aspects of its planned burning which were completed in March-April 2016.

The first of these two additional audits assessed the extent to which DELWP's standards, directions, instructions and guidelines relating to approval and oversight of planned burns is complied with across DELWPs Regions and Districts.

It recommended DELWP improve its documentation of formal delegation of approvals, standardise its burn plan document formats and review its burn approval checklists.

The report also recommended that DELWP review its list of burn controllers and burn officers in charge after finding some burns had been approved by a controller or officer whose accreditation had expired.

Compliance Audit Approval and Oversight of Planned Burns report [PDF File - 565.6 KB]

The second additional audit examined the implementation of recommendations from previous reports into escaped planned burns between 2003 and 2015.

It found that in some cases reviews of planned burn escapes had not been undertaken and that of the 189 recommendations made from the investigations that did take place, 23 had not been actioned.

The auditors recommended stronger requirements to ensure burn escapes are investigated and strict processes to ensure these requirements are complied with.

Implementation of Recommendations Arising from Prior Reports into Escaped Planned Burns audit report [PDF File - 289.0 KB]
Implementation of Recommendations Arising from Prior Reports into Escaped Planned Burns audit report (accessible) [MS Word - 1.8 MB]

DELWP has accepted all recommendations and committed to implement them by 30 September this year. This includes assessing all outstanding recommendations arising from the review of past planned burn escapes to determine if they remain relevant and should now be implemented.

Croziers Track planned burn

The Croziers Track planned burn conducted by DELWP broke containment lines on 3 October 2015.

It was brought under control by DELWP and CFA firefighters over the next two days but again broke containment lines on 6 October.

On 8 October, then-Minister for Environment and Climate Change Lisa Neville requested an independent investigation into the fire; and for findings to be provided to DELWP within three to four weeks.


The investigation was led by an external, independent expert, Murray Carter, Director of Western Australia's Office of Bushfire Risk Management, and examined all aspects of the planned burn and what happened once it began.

Profile: Murray Carter - Director Office of Bushfire Risk Management, Western Australia

Scope of investigation

The investigation provided a written report to the Secretary regarding:

  1. the adequacy of planning and resourcing of the 'Lancefield – Cobaw Croziers Track' planned burn (the planned burn)
  2. the appropriateness of the weather and other conditions for conduct of the planned burn on 30 September 2015
  3. what caused the planned burn to break containment lines on 3 October 2015 and on 6 October 2015
  4. decision making, management and control of the planned burn, including the adequacy of the patrol strategy adopted following its ignition
  5. the adequacy of communication with the community in the lead up to the planned burn and after it broke containment lines

The investigation team extensively consulted with the community, from community meetings, one-on-one meetings, and feedback provided via email. More than 100 submissions were received from the community and stakeholders as part of the investigation.

Full terms of reference for the investigation:

Terms of Reference [PDF File - 67.2 KB]
Terms of Reference (accessible) [MS Word - 17.1 KB]

Support and assistance

DELWP will provide appropriate support to those members of the community that have suffered damage as a result of this fire.

If you require any support or assistance from the government, please contact Our Community Liaison Officer on 5336 6674.

For more information about accessing the various types of assistance and support, these FAQs [MS Word - 84.2 KB] may assist.

Lancefield insurance fact sheet:

Lancefield-Cobaw: Insurance information [PDF File - 56.8 KB]
Lancefield-Cobaw: Insurance information (accessible) [MS Word - 9.2 KB]

Page last updated: 04/09/19