Black Saturday commission misses the mark


A year on from the Black Saturday fires and the royal commission established in their aftermath is wearily wending it’s way towards a conclusion.         

Given the passing of the anniversary last saturday I thought I’d sit down and read through all 51 of the commissions interim findings. For those interested you can find the recommendations collated together in the interim report’s executive summary.  While the commission has certainly been busy, I guess you could say that I was left unsatisfied by the results presented in the interim recommendations. They were, how shall I put it, somewhat predictable in having plenty to say about systems, organisations and procedures, but rather less to say on the role of the individual survivors. In fact after reading the report one could be excused for thinking that the actions of individuals on the day had little to do with their fate.

So what should the commission have also considered?     

Let me ask a another question first, who were the real first responders? In the majority of cases it wasn’t the CFA, police or anyone in a uniform, they were spread way too thin on the day. No, the first responders were the survivors themselves. So if the people who responded first were the survivors of Black Saturday perhaps our focus should be on what they did and how to make the first response more effective? Or to put it another way what makes a survivor a survivor?  As this is the case then we would be better off in first carefully studying and understanding the psychological response of people to bushfires before we add more layers of bureaucratic process and technology. Unfortunately what we have in the commission’s interim report is a focus upon the failures and shortcomings of the state, it’s agencies and persons rather than an attempt to firstly understand how people behave in a situation such as Black Saturday.

Thats why the current stay or go debate misses the point

The current debate, captured within the interim report, over whether a ‘stay or go’ is an appropriate public policy provides a perfect illustration of how failing to identify these issues subverts the conclusions made. The principal of ‘stay or go’ policy of the CFA assumes that people will, well before a bush fire, rationally plan their response and, when the fire arrives, the execute that plan.  There’s nothing much wrong with this assumption of rationality, except that it’s simply not based on the way the people behave in a disaster.  For example, the US NIST found that during the World Trade Center (WTC) disaster, WTC One occupants on average delayed their evacuation by upto 5 minutes, even though they knew there had been a major disaster (1).

One, but not sole, reason for this apparently irrational behaviour is a fundamental psychological bias that people exhibit. Called the normalcy bias, we tend to believe things are normal because, normal is well, normal (2) (3). As a result we tend to underestimate both the possibility of a disaster occurring and it’s severity. Closer to home a study of people’s beliefs about evacuation versus defending in bushfires found, guess what, that 60% of the respondents said they’d wait (Rhodes 2005). Unfortunately you are not going to find any such analysis of how people really behave and whether ‘stay or go’ is therefore a rational public policy in the commissions interim report.

The missing conclusion

Human’s are not rational decision makers, we’d like to be, and try to be, but in reality our rationality is bounded by the limits of our knowledge, time and cognitive ability, and as a result we are the heirs to a whole series of cognitive biases. So before we attempt to re-design our systems and procedures perhaps we should understand how people really behave. The commission would do us all a great service by both recognising the limits to human rationality in such extreme circumstances and determining their impact, before it pronounces it’s recommendations, that unfortunately is not going to happen.


1.  In WTC 1 the median (geometric average) evauation time was 3 minutes for lower floors, ground floor to floor 76, and 5 minutes for floors near the impact site, floors 77 to 91. Occupants observed various impact indications throughout the building (Averill et al. 2005).

2.  This works well most of the time (it’s why we have such a bias in the first place) but in the pre-disaster phase it leads to cognitive dissonance  between the warnings of impending disaster and the belief that, ‘it won’t affect me’. People with a strong normalcy bias then act to eliminate this cognitive dissonance by interpreting circumstances in the most favourable way.

3.  Nor is the normalcy bias the only cognitive effect that we should consider. The affect heuristic, milling (conformity bias) and stress (flight, fight or freeze) responses can all significantly affect the response of those exposed to a crisis situation.


Averill, J., Groner, N., Proulx, Guylene., Mileti, D. Reneke, P.A., Peacock, R., Kuligowski, E., Nelson, H., Occupan Behaviour, Egress and Emergency Communication, Federal Building and Fire Safety Investigation, WTC Disaster, NIST Report NCSTART 1-7, 2005.

Rhodes, Alan., Stay or Go: What do People Think of the Choice?, Presentation, Bushfire CRC/AFAC Conference, Auckland, New Zealand, 2005.