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

The Lancefield-Cobaw fire 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.

The investigation provided a written report to the Secretary regarding:

  • The adequacy of planning and resourcing of the 'Lancefield – Cobaw Croziers Track' planned burn (the planned burn).
  • The appropriateness of the weather and other conditions for conduct of the planned burn on 30 September 2015.
  • What caused the planned burn to break containment lines on 3 October 2015 and on 6 October 2015.
  • Decision making, management and control of the planned burn, including the adequacy of the patrol strategy adopted following its ignition.
  • 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, 67.2 KB)
Terms of Reference (DOCX, 17.0 KB)

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 Report

Independent investigation into Lancefield-Cobaw fire (PDF, 527.2 KB)
Independent investigation into Lancefield-Cobaw fire (DOCX, 157.5 KB)

Responses and recommendations

DELWP response to independent investigation (PDF, 308.1 KB)
DELWP response to independent investigation (DOCX, 180.0 KB)

Summary of recommendations from the independent investigation (PDF, 209.7 KB)
Summary of recommendations from the independent investigation (DOCX, 81.6 KB)

What will change – summary of DELWP response (PDF, 133.9 KB)
What will change – summary of DELWP response (DOCX, 80.0 KB)

Out of scope

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, 295.6 KB)
Out of scope document (DOCX, 52.6 KB)

Independent review of approval and oversight process

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 review of approval and oversight process to the Lancefield-Cobaw Planned Burn (PDF, 1.0 MB)
Independent review of approval and oversight process to the Lancefield-Cobaw Planned Burn (DOCX, 467.3 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 planned burning program

Two additional audits of aspects of its planned burning which were completed in March-April 2016, in addition to the 22 recommendations from the Lancefield-Cobaw fire investigation. The two additional audits assessed our standards, directions, instructions, and guidelines relating to approval and oversight of planned burns is complied with across DELWPs Regions and Districts.

Audit One

The first additional audit recommended to improve documentation of formal delegation of approvals, standardise its burn plan document formats and review its burn approval checklists. The report also recommended to 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, 565.6 KB)

Audit Two

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, 289.0 KB)
Implementation of Recommendations Arising from Prior Reports into Escaped Planned Burns audit report (DOCX, 2.0 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.

Lancefield-Cobaw progress report

The third and final report by the Inspector-General for Emergency Management on the implementation of recommendations from the Independent Investigation of the Lancefield-Cobaw Fire and the additional 10 commitments of the Department of Environment, Land, Water and Planning (DELWP).

As of 5 August 2016, IGEM found that DELWP had satisfactorily implemented 19 of the 22 recommendations and all of the 10 commitments.

Lancefield-Cobaw Fire Progress Report

Bushfire Fuel Management Report

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

Summary of DELWP bushfire fuel management 2017-18

Safer together

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. We have modelled our commitment to continuous improvement in bushfire fuel management through its ongoing delivery and improved programs within Safer Together.

Supporting documents

Lancefield-Cobaw: Insurance information 2015 (PDF, 56.8 KB)
Lancefield-Cobaw: Insurance information 2015 (DOCX, 16.2 KB)

Page last updated: 02/07/21