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CFA.001.027.0013<br />

<strong>Report</strong> <strong>of</strong> <strong>the</strong> <strong>Investigation</strong> <strong>Team</strong><br />

<strong>Bulla</strong> <strong>Tanker</strong><br />

7 <strong>February</strong> <strong>2009</strong><br />

Kilmore East Fire Complex<br />

Disclaimer<br />

This is a report to <strong>the</strong> Chief Officer <strong>of</strong> CFA. The report has been prepared in accordance with <strong>the</strong> Terms <strong>of</strong><br />

Reference, and <strong>the</strong> authorisation issued by <strong>the</strong> Chief Officer. The object <strong>of</strong> <strong>the</strong> investigation was to identify in a timely<br />

manner, matters that needed to be considered by <strong>the</strong> Chief Officer.<br />

The report is <strong>the</strong> findings <strong>of</strong> <strong>the</strong> author(s) based on <strong>the</strong> information available at <strong>the</strong> time <strong>the</strong> report was compiled.<br />

Given <strong>the</strong> restraints <strong>of</strong> time and circumstance, <strong>the</strong> report may not have identified all relevant facts and issues. The<br />

author(s) acknowledge <strong>the</strong>re may be inaccuracies or omissions in <strong>the</strong> document.<br />

The report is for <strong>the</strong> use <strong>of</strong> <strong>the</strong> intended recipients and may contain information that is confidential or privileged. If you<br />

are not <strong>the</strong> intended recipient <strong>of</strong> this report you are hereby notified that any use, dissemination, distribution or<br />

reproduction <strong>of</strong> this report is prohibited and that you must not take any action in reliance on it.<br />

If you have received this report in error, please notify CFA immediately.<br />

DRAFT – CFA internal working document


CFA.001.027.0014<br />

TABLE OF CONTENTS<br />

1. EXECUTIVE SUMMARY 4<br />

1.1 Date <strong>of</strong> <strong>the</strong> Incident 4<br />

1.2 Location <strong>of</strong> <strong>the</strong> Incident 4<br />

1.3 Jurisdiction 4<br />

1.4 Summary <strong>of</strong> Findings 4<br />

2. SCOPE 5<br />

2.1 <strong>Investigation</strong> 5<br />

2.2 Duration <strong>of</strong> <strong>the</strong> <strong>Investigation</strong> 5<br />

2.3 Authority to Undertake <strong>the</strong> <strong>Investigation</strong> / Terms <strong>of</strong> Reference 5<br />

2.4 Sources <strong>of</strong> Information 5<br />

2.5 Constraints Affecting <strong>the</strong> <strong>Investigation</strong> 5<br />

3. DESCRIPTION OF THE INCIDENT 5<br />

3.1 Vehicle Involved 5<br />

3.2 Area Affected by <strong>the</strong> Fire 5<br />

3.3 Wea<strong>the</strong>r at <strong>the</strong> Time <strong>of</strong> <strong>the</strong> Incident 6<br />

3.4 Fire Behaviour 6<br />

4. ANALYSIS – OBSERVATIONS 6<br />

4.1 Incident Sequence 6<br />

4.1.1 Appointment <strong>of</strong> Crew for <strong>Bulla</strong> <strong>Tanker</strong> 6<br />

4.1.2 Briefing <strong>of</strong> <strong>the</strong> <strong>Tanker</strong> Crew 6<br />

4.1.3 Arrival at Whittlesea Fire Station and Briefing 6<br />

4.1.4 Arrival and Tasking 7<br />

4.1.5 Fire conditions deteriorate 7<br />

4.1.6 Radio Message to make up and move out <strong>of</strong> <strong>the</strong> Fire Area. . 7<br />

4.1.7 Entering <strong>the</strong> Property at 600 Whittlesea-Yea Road 7<br />

4.1.8 Assessment by <strong>the</strong> Crew Leader 8<br />

4.1.9 Burn Over incident 8<br />

4.1.10 Moving From <strong>the</strong> Property 8<br />

4.1.11 Regrouping 9<br />

4.1.12 Crew Replacement 9<br />

4.2 Individual Human Factors 9<br />

4.2.1 Crew Experience and Training 9<br />

4.3 Management Factors 9<br />

4.3.1 Overall Fire Management 10<br />

4.3.2 Supervision <strong>of</strong> ST 1402 10<br />

4.4 Equipment Factors 10<br />

4.4.1 <strong>Bulla</strong> <strong>Tanker</strong> 10<br />

4.5 Personal Protective Equipment 10<br />

4.5.1 Wild Fire Jackets 10<br />

4.5.2 Helmets 10<br />

5. FINDINGS 10<br />

5.1 Vehicle Crewing 10<br />

5.2 Brigade Strike <strong>Team</strong> History 11<br />

5.3 Earlier Burn-over Experience 11<br />

5.4 Assessment <strong>of</strong> <strong>the</strong> fire situation at <strong>the</strong> property 11<br />

5.5 Fire Storm Conditions 11<br />

5.6 Actions by Crew and Vehicle Protection Systems.. 11<br />

5.7 Welfare <strong>of</strong> Crew and Condition <strong>of</strong> <strong>the</strong> <strong>Tanker</strong> Post Burn-Over 12<br />

5.8 Effectiveness <strong>of</strong> <strong>the</strong> Intercom System 12<br />

5.9 Perception <strong>of</strong> Crew Needs Post Incident 12<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page2<br />

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CFA.001.027.0015<br />

5.10 <strong>Bulla</strong> <strong>Tanker</strong> Returned to Active Duties 12<br />

6. SCHEDULES 13<br />

6.1 Sources <strong>of</strong> Information 13<br />

6.2 Topographical Map <strong>of</strong> <strong>the</strong> Area 14<br />

6.3 Wea<strong>the</strong>r Conditions 14<br />

6.4 Area <strong>of</strong> Incident showing Terrain and Vegetation 15<br />

6.5 Photographs 17<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page3<br />

DRAFT – CFA internal working document


CFA.001.027.0016<br />

1. EXECUTIVE SUMMARY<br />

This investigation was carried out at <strong>the</strong> request <strong>of</strong> <strong>the</strong> Chief Officer <strong>of</strong> CFA in<br />

response to a report <strong>of</strong> a burn over <strong>of</strong> CFA <strong>Bulla</strong> <strong>Tanker</strong> during <strong>the</strong> Kinglake Fire<br />

Complex on <strong>February</strong> 7 th <strong>2009</strong>. <strong>Bulla</strong> <strong>Tanker</strong> 1 is a 2001 Isuzu 3.4D (Reg. No.<br />

MBD880) and was crewed by six <strong>Bulla</strong> volunteer firefighters at <strong>the</strong> time <strong>of</strong> <strong>the</strong><br />

incident.<br />

1.1 Date <strong>of</strong> <strong>the</strong> Incident<br />

The incident occurred on Saturday 7 <strong>February</strong> <strong>2009</strong> at approximately 1630 hours.<br />

1.2 Location <strong>of</strong> <strong>the</strong> Incident<br />

The incident occurred at 600 Whittlesea – Yea Road., Humevale.<br />

(VicRoads, Map 61 W9)<br />

1.3 Jurisdiction<br />

The fire was part <strong>of</strong> what was originally known as Kinglake East fire and this part<br />

was burning on private land. The control agency for <strong>the</strong> fire at <strong>the</strong> time <strong>of</strong> <strong>the</strong><br />

incident was CFA.<br />

1.4 Summary <strong>of</strong> Findings<br />

• On <strong>the</strong> day <strong>of</strong> <strong>the</strong> fire Victoria was experiencing some <strong>of</strong> <strong>the</strong> most severe fire<br />

wea<strong>the</strong>r conditions ever encountered<br />

• The ferocity <strong>of</strong> <strong>the</strong> fire and its rapid rate <strong>of</strong> spread created hostile conditions<br />

and stretched resources over vast areas<br />

• As part <strong>of</strong> ST1402 <strong>Bulla</strong> <strong>Tanker</strong> was tasked at a fire burning ahead <strong>of</strong> <strong>the</strong><br />

main fire on <strong>the</strong> south-eastern side <strong>of</strong> Whittlesea – Yea Road<br />

• Strong wind gusts and localised fire behaviour severely hampered <strong>the</strong><br />

conditions around where this strike team was operating<br />

• As conditions deteriorated <strong>the</strong> Strike <strong>Team</strong> Leader gave clear instructions to<br />

all crew leaders that <strong>the</strong>y were withdrawing from this area<br />

• A retreat towards Whittlesea commenced with vehicles in convoy being led by<br />

<strong>the</strong> ST Leader<br />

• During retreat <strong>Bulla</strong> <strong>Tanker</strong> was directed on to a private property at 600<br />

Whittlesea-Yea Road, following Sunbury <strong>Tanker</strong> 2<br />

• <strong>Bulla</strong> <strong>Tanker</strong> passed Sunbury <strong>Tanker</strong> 2 and made its way to <strong>the</strong> rear <strong>of</strong> <strong>the</strong><br />

house on this property<br />

• At this location <strong>the</strong> crew observed an open area with light vegetation<br />

• <strong>Bulla</strong> <strong>Tanker</strong> was directed to <strong>the</strong> front <strong>of</strong> <strong>the</strong> house where Sunbury <strong>Tanker</strong> 2<br />

had turned around to face outwards<br />

• A sudden increase in erratic fire behaviour (fire storm conditions) occurred<br />

without warning shortly after <strong>the</strong> <strong>Bulla</strong> <strong>Tanker</strong> pulled up behind Sunbury<br />

<strong>Tanker</strong> 2<br />

• The <strong>Bulla</strong> Crew Leader recalled a previous experience some years earlier<br />

where his <strong>Tanker</strong> was caught behind ano<strong>the</strong>r CFA <strong>Tanker</strong> as a burn-over<br />

occurred<br />

• This prompted <strong>the</strong> Crew Leader to direct <strong>the</strong> driver to reverse <strong>the</strong> tanker to<br />

<strong>the</strong> open area at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house<br />

• The crew implemented safety and survival procedures including water spray<br />

protection and woollen blankets<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page4<br />

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CFA.001.027.0017<br />

• The sustained impact from fire lasted for approximately 20 minutes<br />

• <strong>Bulla</strong> <strong>Tanker</strong>, on hearing Sunbury <strong>Tanker</strong> 2 radio that <strong>the</strong>y were leaving <strong>the</strong><br />

property, <strong>the</strong>n drove back to <strong>the</strong> front <strong>of</strong> <strong>the</strong> house and followed Sunbury<br />

<strong>Tanker</strong> 2<br />

• Both <strong>Tanker</strong>s travelled back towards Whittlesea until <strong>the</strong>y caught up with<br />

Greenvale and Epping <strong>Tanker</strong>s<br />

• No injuries, apart from minor ember burns, were sustained by <strong>Bulla</strong> crew<br />

members<br />

• The <strong>Bulla</strong> <strong>Tanker</strong> did not sustain any damage<br />

2. SCOPE<br />

2.1 <strong>Investigation</strong><br />

The <strong>Investigation</strong> <strong>Team</strong> comprised David Nichols and Ken O’Brien representing<br />

CFA.<br />

2.2 Duration <strong>of</strong> <strong>the</strong> <strong>Investigation</strong><br />

The investigation commenced on 3 rd April <strong>2009</strong> and was completed on 24 th June<br />

<strong>2009</strong>.<br />

2.3 Authority to Undertake <strong>the</strong> <strong>Investigation</strong> / Terms <strong>of</strong> Reference<br />

The investigation was undertaken at <strong>the</strong> request <strong>of</strong> CFA Manager Operations<br />

Performance Improvement - Deputy Chief Officer Greg Esnouf.<br />

2.4 Sources <strong>of</strong> Information<br />

During <strong>the</strong> investigation, personnel identified in Schedule 6.1 were interviewed.<br />

2.5 Constraints Affecting <strong>the</strong> <strong>Investigation</strong><br />

As a result <strong>of</strong> <strong>the</strong> ST Leaders Vehicle being destroyed, all logs including radio<br />

communications, times and activities for <strong>the</strong> strike team deployment were also<br />

destroyed.<br />

Due to <strong>the</strong> high number <strong>of</strong> investigations and o<strong>the</strong>r operational activity following<br />

<strong>the</strong> conditions <strong>of</strong> <strong>February</strong> 7 it was not practical to commence this investigation<br />

until almost seven weeks later.<br />

The driver <strong>of</strong> <strong>Bulla</strong> <strong>Tanker</strong> was also not available for interview.<br />

3. DESCRIPTION OF THE INCIDENT<br />

3.1 Vehicle Involved<br />

<strong>Bulla</strong> <strong>Tanker</strong> is a 2001 Isuzu Single Cab, 3.4D fitted with a Roll Over Protection<br />

System. It does not have Crew Protection Sprays fitted but does have Fog Spray<br />

Protection capabilities.<br />

3.2 Area Affected by <strong>the</strong> Fire<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page5<br />

DRAFT – CFA internal working document


CFA.001.027.0018<br />

The fire was part <strong>of</strong> <strong>the</strong> large Kilmore East Fire Complex which originated near<br />

Kilmore East and was reported by <strong>the</strong> Mount Hickey Fire Tower at 1149 hours.<br />

The fire destroyed 255,000 hectares <strong>of</strong> private and public land in <strong>the</strong> Kinglake,<br />

Kinglake West, Stra<strong>the</strong>wen and numerous o<strong>the</strong>r communities resulting in 159<br />

fatalities and destroyed 1639 buildings.<br />

3.3 Wea<strong>the</strong>r at <strong>the</strong> Time <strong>of</strong> <strong>the</strong> Incident<br />

The wea<strong>the</strong>r conditions were generally as expected with extreme temperatures in<br />

<strong>the</strong> mid 40’s and gusty N-NW winds ahead <strong>of</strong> a strong S-SW wind change which<br />

occurred shortly after <strong>the</strong> incident. (Refer to Schedule 6.3)<br />

3.4 Fire Behaviour<br />

Fire behaviour on <strong>the</strong> day was extreme with spotting activity many kilometres<br />

ahead <strong>of</strong> <strong>the</strong> main fire. Rates <strong>of</strong> spread were up to 8 to 12 kilometres per hour<br />

according to post incident analysis conducted by fire behaviour analysts. Despite<br />

<strong>the</strong> large number <strong>of</strong> fire fighting resources deployed, control <strong>of</strong> fires under <strong>the</strong><br />

prevailing conditions was considered impossible. Crews resorted to <strong>the</strong> protection<br />

<strong>of</strong> individual assets and people while undertaking procedures to ensure <strong>the</strong>ir own<br />

safety and survival. At <strong>the</strong> time <strong>of</strong> <strong>the</strong> burn over crews described <strong>the</strong> fire<br />

behaviour as “a fire storm” which hit with little warning and from at least two<br />

directions with a very loud roaring noise. The “fire storm” consisted <strong>of</strong> a very loud<br />

roaring noise, strong winds, dark smoke and severe ember attack.<br />

4. ANALYSIS – OBSERVATIONS<br />

Note: For fur<strong>the</strong>r information on ST 1402 Deployment and Background this<br />

<strong>Report</strong> should be read in conjunction with <strong>the</strong> Craigieburn Car <strong>Report</strong>.<br />

4.1 Incident Sequence<br />

4.1.1 Appointment <strong>of</strong> Crew for <strong>Bulla</strong> <strong>Tanker</strong><br />

The crew members for <strong>Bulla</strong> <strong>Tanker</strong> were selected at <strong>the</strong> time <strong>of</strong> deployment<br />

from Brigade members who were at <strong>the</strong> station at <strong>the</strong> time (approx 1500 Hrs).<br />

The selection was based on having a good mix <strong>of</strong> experienced members plus<br />

providing an opportunity for a young member to gain experience. This<br />

resulted in six members being selected as <strong>the</strong> crew. There was also<br />

consideration that enough experience was left to provide protection to <strong>the</strong><br />

township <strong>of</strong> <strong>Bulla</strong> with members experienced and trained in <strong>the</strong> operation <strong>of</strong><br />

<strong>the</strong> Brigades Quick Attack appliance.<br />

4.1.2 Briefing <strong>of</strong> <strong>the</strong> <strong>Tanker</strong> Crew<br />

The <strong>Bulla</strong> <strong>Tanker</strong> Crew did not receive any briefing at any stage though it was<br />

noticed <strong>the</strong> Strike <strong>Team</strong> Leader was having trouble getting any useful<br />

information on <strong>the</strong> requirements <strong>of</strong> <strong>the</strong> Strike <strong>Team</strong> while <strong>the</strong>y were stopped<br />

at Wallan <strong>the</strong>n Whittlesea. Any information received by <strong>the</strong> Crew Leader was<br />

passed on to all members <strong>of</strong> his Crew as required.<br />

4.1.3 Arrival at Whittlesea Fire Station and Briefing<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page6<br />

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CFA.001.027.0019<br />

The <strong>Bulla</strong> <strong>Tanker</strong> arrived with ST1402 at <strong>the</strong> Whittlesea FS at approximately<br />

1540 hours. After <strong>the</strong> STL received a short briefing at <strong>the</strong> Fire Station he<br />

quickly briefed all <strong>the</strong> crew leaders and advised that <strong>the</strong>y were to go up to a<br />

location on <strong>the</strong> Whittlesea-Yea Road where <strong>the</strong> fire was burning on <strong>the</strong> side<br />

<strong>of</strong> <strong>the</strong> road. The Strike <strong>Team</strong> task was to try and suppress <strong>the</strong> fire and<br />

provide asset protection from spot fires from <strong>the</strong> south-east side <strong>of</strong> <strong>the</strong> road.<br />

4.1.4 Arrival and Tasking<br />

The Strike <strong>Team</strong> arrived at a turn around point on <strong>the</strong> Whittlesea-Yea Road<br />

about 20 minutes later (approximately 1600 hours). While travelling up hill to<br />

<strong>the</strong> turnaround point <strong>the</strong> crew noticed <strong>the</strong> fire down in <strong>the</strong> gully burning up to<br />

<strong>the</strong> roadside on <strong>the</strong> south side with flame heights <strong>of</strong> 2 to 3 metres.<br />

At <strong>the</strong> turnaround point <strong>the</strong> crew leaders were again briefed by <strong>the</strong> STL and<br />

instructed to spread out about 30 metres apart along <strong>the</strong> side <strong>of</strong> <strong>the</strong> road and<br />

try to stop <strong>the</strong> fire crossing <strong>the</strong> road form <strong>the</strong> sou<strong>the</strong>rn side into <strong>the</strong> unburnt<br />

area on <strong>the</strong> north side. Crews were to work from <strong>the</strong> vehicles and not run<br />

hose lines. The aim was to keep <strong>the</strong> road open as <strong>the</strong>re was a lot <strong>of</strong> traffic in<br />

both directions.<br />

At this point <strong>Bulla</strong> <strong>Tanker</strong> was second in <strong>the</strong> line <strong>of</strong> <strong>Tanker</strong>s behind Sunbury<br />

<strong>Tanker</strong> 2 heading down hill towards Whittlesea.<br />

4.1.5 Fire conditions deteriorate<br />

Before long (5-10 minutes) at approximately 1555 hours, <strong>the</strong> wind started to<br />

streng<strong>the</strong>n and <strong>the</strong> fire had now jumped <strong>the</strong> road. All four tankers were<br />

directed to move in behind one ano<strong>the</strong>r on <strong>the</strong> right hand side <strong>of</strong> <strong>the</strong> road<br />

away from <strong>the</strong> heat. <strong>Bulla</strong> tanker had used about 600 – 700 litres <strong>of</strong> water<br />

during this time. There were still many cars moving in both directions along<br />

Whittlesea-Yea Road.<br />

4.1.6 Radio Message to make up and move out <strong>of</strong> <strong>the</strong> Fire Area.<br />

The Crew Leader copied a radio message on radio CFA channel 64 from<br />

STL that as <strong>the</strong> situation is deteriorating all ST1402 <strong>Tanker</strong>s were to make up<br />

and move out <strong>of</strong> <strong>the</strong> fire and smoke down <strong>the</strong> road to a safer location towards<br />

Whittlesea. The ST Leaders vehicle <strong>the</strong>n moved to <strong>the</strong> front <strong>of</strong> <strong>the</strong> strike team<br />

and <strong>the</strong>y all moved <strong>of</strong>f down <strong>the</strong> hill within two minutes <strong>of</strong> <strong>the</strong> decision to<br />

move out.<br />

4.1.7 Entering <strong>the</strong> Property at 600 Whittlesea-Yea Road<br />

The <strong>Bulla</strong> Crew Leader noticed that Greenvale and Epping <strong>Tanker</strong>s had<br />

stayed well back from <strong>the</strong> leading two tankers and <strong>the</strong> Strike <strong>Team</strong> Leaders<br />

Vehicle. He <strong>the</strong>n heard <strong>the</strong>m advise <strong>the</strong> STL via radio that <strong>the</strong>y were<br />

assisting residents on a property on <strong>the</strong> left side <strong>of</strong> <strong>the</strong> road.<br />

At 600 Whittlesea-Yea Road both Sunbury <strong>Tanker</strong> 2 and <strong>Bulla</strong> <strong>Tanker</strong> were<br />

directed by <strong>the</strong> STL to enter <strong>the</strong> property.<br />

Sunbury <strong>Tanker</strong> 2 entered first and pulled up near <strong>the</strong> front <strong>of</strong> <strong>the</strong> house.<br />

<strong>Bulla</strong> <strong>Tanker</strong> followed and <strong>the</strong>n passed Sunbury <strong>Tanker</strong> 2 who were<br />

attempting to turn <strong>the</strong> vehicle around so as to point out towards <strong>the</strong> roadway.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

Page7<br />

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CFA.001.027.0020<br />

<strong>Bulla</strong> <strong>Tanker</strong> continued to <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house where <strong>the</strong>y found an open<br />

area with low vegetation and only one large tree that could pose any problem<br />

if <strong>the</strong> fire front passed. The tanker turned around this tree and, on hearing a<br />

radio call from Sunbury <strong>Tanker</strong> 2 for assistance, made its way back towards<br />

<strong>the</strong> front <strong>of</strong> <strong>the</strong> house, again pulling up behind Sunbury <strong>Tanker</strong> 2.<br />

4.1.8 Assessment by <strong>the</strong> Crew Leader<br />

At this stage <strong>the</strong> fire was burning up towards <strong>the</strong> house from a number <strong>of</strong><br />

directions because <strong>of</strong> spotting activity and wind gusts affected by <strong>the</strong> terrain.<br />

The Crew Leader was very uncomfortable with where his <strong>Tanker</strong> was located<br />

as he had noticed some large trees along <strong>the</strong> front <strong>of</strong> <strong>the</strong> property.<br />

He also recalled an earlier event in his CFA experience where a <strong>Tanker</strong> he<br />

was on was caught in a burn-over. At that time he and his crew were<br />

convinced <strong>the</strong>ir situation was made worse by <strong>the</strong> fact that <strong>the</strong>y were behind<br />

ano<strong>the</strong>r CFA <strong>Tanker</strong> which meant that <strong>the</strong>ir movements to any o<strong>the</strong>r area <strong>of</strong><br />

safety was quite restricted.<br />

Now at this location he again found himself and his crew in a potential burnover<br />

and again <strong>the</strong>ir movement restricted by a CFA <strong>Tanker</strong> in front.<br />

Therefore <strong>the</strong> Crew Leader advised <strong>the</strong> Driver to reverse <strong>the</strong> <strong>Bulla</strong> <strong>Tanker</strong> to<br />

<strong>the</strong> open area at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house which he felt <strong>of</strong>fered a much better<br />

level <strong>of</strong> safety plus a better opportunity to move if necessary for fur<strong>the</strong>r<br />

protection.<br />

4.1.9 Burn Over incident<br />

All members <strong>of</strong> <strong>the</strong> <strong>Bulla</strong> <strong>Tanker</strong> felt relatively comfortable throughout this<br />

ordeal even though visibility was poor, embers were flying everywhere and<br />

radiant heat levels were very high.<br />

The crew were keen to point out that <strong>the</strong>y at no time considered that <strong>the</strong>y<br />

were in ‘survival mode’ but were taking actions based more on precautionary<br />

measures.<br />

These actions included using two short 38mm hose lines in short bursts <strong>of</strong><br />

fog as required, <strong>the</strong> use <strong>of</strong> blankets which had been readied prior to entering<br />

<strong>the</strong> property and having <strong>the</strong> monitor ready in case <strong>the</strong> large tree in <strong>the</strong> middle<br />

<strong>of</strong> <strong>the</strong> open area caught fire.<br />

The use <strong>of</strong> any water for protection was very minimal as <strong>the</strong> crew members<br />

on <strong>the</strong> back <strong>of</strong> <strong>the</strong> <strong>Tanker</strong> were all relatively comfortable with <strong>the</strong> protection<br />

<strong>of</strong>fered by <strong>the</strong> heat shields and blankets; however some adjustment to <strong>the</strong><br />

positioning <strong>of</strong> <strong>the</strong> blankets was needed to keep out burning embers. This<br />

could be attributed to having three blankets providing protection for four<br />

members.<br />

4.1.10 Moving From <strong>the</strong> Property<br />

After most <strong>of</strong> <strong>the</strong> fire had passed <strong>the</strong> CL overheard a radio message that<br />

Sunbury <strong>Tanker</strong> 2 were leaving and so directed <strong>the</strong> driver to move forward<br />

towards where Sunbury had been parked. There <strong>the</strong>y caught up with<br />

Sunbury <strong>Tanker</strong> 2 and followed it <strong>of</strong>f <strong>the</strong> property back on to Whittlesea-Yea<br />

Road where <strong>the</strong>y turned left.<br />

On leaving <strong>the</strong> property <strong>the</strong> driver <strong>of</strong> <strong>the</strong> <strong>Bulla</strong> <strong>Tanker</strong> was quite startled to<br />

see <strong>the</strong> Craigieburn Car well alight behind a shed.<br />

O<strong>the</strong>rs on <strong>the</strong> passenger side <strong>of</strong> <strong>the</strong> rear <strong>of</strong> <strong>Bulla</strong> <strong>Tanker</strong> also noticed some<br />

burning vehicles along Whittlesea-Yea Road.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0021<br />

When <strong>the</strong> crew left <strong>the</strong> property <strong>the</strong>y felt relieved and happy that <strong>the</strong>y would<br />

be able to regroup and restart <strong>the</strong>ir firefighting activities.<br />

After a very short time <strong>the</strong> vehicles found <strong>the</strong>mselves in an unburnt area with<br />

clean air and bright conditions. Here <strong>the</strong>y pulled over on <strong>the</strong> side <strong>of</strong> <strong>the</strong> road<br />

with Sunbury <strong>Tanker</strong> 2 and were soon joined by Greenvale and Epping<br />

<strong>Tanker</strong>s.<br />

4.1.11 Regrouping<br />

The <strong>Bulla</strong> crew noted that <strong>the</strong> Craigieburn crew were all accounted for and<br />

had travelled from <strong>the</strong> property on Sunbury <strong>Tanker</strong> 2. All crew members from<br />

all <strong>Tanker</strong>s were also accounted for and a quick check was carried out on <strong>the</strong><br />

condition <strong>of</strong> each <strong>Tanker</strong>.<br />

<strong>Bulla</strong> noticed that <strong>the</strong>re <strong>Tanker</strong> had escaped unharmed apart from a short<br />

recirculation hose on <strong>the</strong> pump which had burst.<br />

The Strike <strong>Team</strong> <strong>the</strong>n headed back to Whittlesea where <strong>the</strong> <strong>Bulla</strong> crew felt<br />

<strong>the</strong>y would simply get refreshments, fill up <strong>the</strong> tanker and, after minor<br />

maintenance to mend <strong>the</strong> recirculation hose, <strong>the</strong>y would return to firefighting<br />

duties.<br />

4.1.12 Crew Replacement<br />

The <strong>Bulla</strong> Crew were dismayed to learn when at Whittlesea that <strong>the</strong>y were to<br />

return home. They were advised that, as members <strong>of</strong> Strike <strong>Team</strong> 1402 who<br />

had just experienced a traumatic event, <strong>the</strong>y were all to return via<br />

Craigieburn to <strong>the</strong>ir home locations.<br />

The <strong>Bulla</strong> Crew felt that, due to <strong>the</strong> location <strong>the</strong>y selected to wait out <strong>the</strong> fire<br />

storm, <strong>the</strong>y had not been impacted to <strong>the</strong> same degree as o<strong>the</strong>r crews and,<br />

as <strong>the</strong>y had not been at <strong>the</strong> fire ground for very long, <strong>the</strong>re working day was<br />

still just beginning.<br />

Again at Craigieburn <strong>the</strong> <strong>Bulla</strong> Crew were advised that <strong>the</strong>y were not to crew<br />

<strong>the</strong>ir vehicle though ano<strong>the</strong>r <strong>Bulla</strong> Crew was assembled to continue with <strong>the</strong><br />

<strong>Bulla</strong> <strong>Tanker</strong> which was still in good operational condition.<br />

4.2 Individual Human Factors<br />

4.2.1 Crew Experience and Training<br />

The Crew Leader has 22 years experience and had, previous to this incident,<br />

been away on many campaign fires as a crew leader and crew member. He<br />

is a qualified and endorsed crew leader. He also has previous experience in<br />

a burn-over situation at a fire at Cobaw in <strong>the</strong> Macedon Ranges.<br />

This incident has had a long lasting effect on members involved from <strong>Bulla</strong><br />

with a long established Brigade member leaving <strong>the</strong> Brigade soon after <strong>the</strong><br />

Cobaw event. The Crew Leader recalled this event during this incident and<br />

used this experience to identify a better, safer anchor point for his crew and<br />

vehicle. The driver <strong>of</strong> <strong>the</strong> vehicle, who could not be available for <strong>the</strong><br />

interview, was also involved in <strong>the</strong> Cobaw incident.<br />

All Brigade members regularly train in crew safety and practice survival<br />

procedures. Brigade members participated in a Group Exercise about a<br />

month before 7 th <strong>February</strong>.<br />

4.3 Management Factors<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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4.3.1 Overall Fire Management<br />

There did not appear to be a management structure in place at Whittlesea<br />

Fire Station to assist with <strong>the</strong> deployment <strong>of</strong> ST1402.<br />

4.3.2 Supervision <strong>of</strong> ST 1402<br />

The strike team was under <strong>the</strong> control <strong>of</strong> ST Leader Paul Elso who had<br />

briefed and communicated regularly with all crew leaders. His task during <strong>the</strong><br />

burn over period was extremely difficult and stressful as he was also<br />

monitoring a burn-over incident involving ano<strong>the</strong>r two tankers from his Strike<br />

<strong>Team</strong> at a location 400 metres away.<br />

4.4 Equipment Factors<br />

4.4.1 <strong>Bulla</strong> <strong>Tanker</strong><br />

• <strong>Bulla</strong> <strong>Tanker</strong> is a 3.4D<br />

• The installed crew protection systems performed without fault.<br />

• The intercom system between <strong>the</strong> ROPS and <strong>the</strong> cabin worked as<br />

expected. <strong>Bulla</strong> members were surprised to hear <strong>of</strong> criticism <strong>of</strong> this<br />

device on o<strong>the</strong>r tankers and so questioned <strong>the</strong> training and<br />

understanding <strong>of</strong> its operation by o<strong>the</strong>r crews.<br />

• The short recirculation hose on <strong>the</strong> pump failed at some stage during<br />

<strong>the</strong> event but did not impact on <strong>the</strong> pumps operation or <strong>the</strong> availability<br />

<strong>of</strong> water to <strong>the</strong> spray nozzles or monitor. However <strong>the</strong> nozzles and<br />

monitor were used very lightly. If <strong>the</strong> need to use <strong>the</strong>se was <strong>of</strong> a more<br />

urgent nature it is not known if <strong>the</strong> hose failure would have had an<br />

impact. The hose was quickly replaced when <strong>the</strong> vehicle returned to<br />

Whittlesea on its way back home.<br />

4.5 Personal Protective Equipment<br />

4.5.1 Wild Fire Jackets<br />

Members on <strong>the</strong> back <strong>of</strong> <strong>the</strong> tanker noticed that some burning embers were<br />

able to get within <strong>the</strong> sleeves <strong>of</strong> <strong>the</strong>ir Wild Fire Jackets. However this could<br />

be due to <strong>the</strong> velcro tabs not being adjusted correctly. Once readjusted <strong>the</strong><br />

problem seemed to be remedied.<br />

4.5.2 Helmets<br />

Some heat was detected by <strong>the</strong> crew on <strong>the</strong> rear <strong>of</strong> <strong>the</strong> vehicle on <strong>the</strong>ir<br />

heads indicating it had entered <strong>the</strong> space between <strong>the</strong>ir skulls and <strong>the</strong> shells<br />

<strong>of</strong> <strong>the</strong>ir helmets.<br />

5. FINDINGS<br />

5.1 Vehicle Crewing<br />

The crew <strong>of</strong> <strong>Bulla</strong> <strong>Tanker</strong> was a good mix <strong>of</strong> experienced members and young<br />

members keen to pick up from <strong>the</strong>ir more senior counterparts. This resulted in<br />

six members making up <strong>the</strong> crew <strong>of</strong> this vehicle.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0023<br />

The sixth member meant that, at <strong>the</strong> time <strong>the</strong> fire passed, four members were in<br />

<strong>the</strong> ROPS area on <strong>the</strong> rear <strong>of</strong> <strong>the</strong> vehicle, under <strong>the</strong> protection <strong>of</strong> just three<br />

blankets.<br />

5.2 Brigade Strike <strong>Team</strong> History<br />

<strong>Bulla</strong> Brigade are very proud <strong>of</strong> <strong>the</strong>ir Brigade history as a Brigade that has been<br />

involved in Region 14 Strike <strong>Team</strong>s at any large fire over <strong>the</strong> past number <strong>of</strong><br />

years. Their pride extends to <strong>the</strong> understanding that every crew that has<br />

represented <strong>the</strong> Brigade has done so in an exemplary manner showing a high<br />

degree <strong>of</strong> skill, dedication and hard, honest work ethics.<br />

5.3 Earlier Burn-over Experience<br />

Some members <strong>of</strong> <strong>the</strong> <strong>Bulla</strong> Crew, including <strong>the</strong> Crew Leader and <strong>the</strong> Driver,<br />

had previous experience involving a <strong>Bulla</strong> <strong>Tanker</strong> caught in a burnout situation.<br />

At <strong>the</strong> Cobaw Fire <strong>Bulla</strong> <strong>Tanker</strong> was part <strong>of</strong> a Strike <strong>Team</strong> that were overrun by<br />

fire in such a traumatic scenario that at least one long term, well respected and<br />

experienced firefighter resigned from <strong>the</strong> Brigade almost immediately afterwards.<br />

During this incident it was believed by <strong>the</strong> <strong>Bulla</strong> Crew that <strong>the</strong> vehicle was in this<br />

predicament because it was trapped behind ano<strong>the</strong>r CFA <strong>Tanker</strong> which made it<br />

impossible to relocate to a more protected location.<br />

5.4 Assessment <strong>of</strong> <strong>the</strong> fire situation at <strong>the</strong> property<br />

The Crew Leader assessed that <strong>the</strong> location <strong>of</strong> <strong>the</strong> <strong>Bulla</strong> <strong>Tanker</strong> when fire was<br />

approaching <strong>the</strong> property at 600 Whittlesea-Yea Road did not <strong>of</strong>fer his crew <strong>the</strong><br />

best protection due to a number <strong>of</strong> factors such as:<br />

• Trees lined <strong>the</strong> front <strong>of</strong> <strong>the</strong> property<br />

• Fires approaching from a number <strong>of</strong> directions due to spotting and erratic<br />

wind conditions<br />

• The vehicle was behind ano<strong>the</strong>r CFA <strong>Tanker</strong> allowing <strong>Bulla</strong> <strong>Tanker</strong><br />

nowhere to move forward if required to do so<br />

• A more appropriate anchor point had already been identified by <strong>the</strong> crew<br />

at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house<br />

The Crew Leader directed <strong>the</strong> Driver to reverse <strong>the</strong> vehicle to this safer location<br />

in an open area at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house.<br />

5.5 Fire Storm Conditions<br />

The conditions at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house provided better protection than those at<br />

<strong>the</strong> front <strong>of</strong> <strong>the</strong> house where Sunbury <strong>Tanker</strong> 2 and Craigieburn Command<br />

Vehicle were located.<br />

With <strong>the</strong> exception <strong>of</strong> a large tree <strong>the</strong> area at <strong>the</strong> rear <strong>of</strong> <strong>the</strong> house was open<br />

with light vegetation.<br />

The crew are quite adamant that <strong>the</strong>ir location assisted <strong>the</strong>m getting through this<br />

ordeal as well as <strong>the</strong>y did.<br />

5.6 Actions by Crew and Vehicle Protection Systems.<br />

When <strong>the</strong> burn-over occurred <strong>the</strong> crew took refuge in <strong>Bulla</strong> <strong>Tanker</strong> (3.4D) and<br />

correctly deployed <strong>the</strong> crew protection systems which operated without fault. The<br />

protection blankets used in <strong>the</strong> ROPS area provided a very effective barrier to <strong>the</strong><br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0024<br />

heat and ember attack with <strong>the</strong> four crew saying <strong>the</strong>y felt quite comfortable and<br />

safe. Two spray nozzles were also prepared for extra protection.<br />

At no stage did <strong>the</strong> crew feel that <strong>the</strong>ir lives were in real danger nor did <strong>the</strong>y<br />

consider that <strong>the</strong>ir actions constituted being in survival mode.<br />

Their actions were more to do with providing extra comfort and being prepared in<br />

case <strong>the</strong> situation deteriorated fur<strong>the</strong>r.<br />

5.7 Welfare <strong>of</strong> Crew and Condition <strong>of</strong> <strong>the</strong> <strong>Tanker</strong> Post Burn-Over<br />

• None <strong>of</strong> <strong>the</strong> crew sustained any injuries or burns except for some<br />

minor ember burns which entered through <strong>the</strong> sleeves <strong>of</strong> <strong>the</strong>ir jackets.<br />

Embers stopped entering once <strong>the</strong> velcro on <strong>the</strong> jacket sleeves were<br />

readjusted.<br />

• The tanker did not sustain any fire or heat damage however a<br />

recirculation hose was found to have burst following <strong>the</strong> incident.<br />

5.8 Effectiveness <strong>of</strong> <strong>the</strong> Intercom System<br />

The Intercom system installed to provide communication between <strong>the</strong> cabin crew<br />

and <strong>the</strong> crew in <strong>the</strong> ROPS on <strong>the</strong> rear <strong>of</strong> <strong>Bulla</strong> <strong>Tanker</strong> worked as expected.<br />

5.9 Perception <strong>of</strong> Crew Needs Post Incident<br />

The <strong>Bulla</strong> crew felt that one <strong>of</strong> <strong>the</strong>ir main obligations when responding to a fire<br />

was to represent <strong>the</strong>ir Brigade, and CFA, in an appropriate manner and provide<br />

<strong>the</strong> highest level <strong>of</strong> support to communities threatened by fire.<br />

The Strike <strong>Team</strong> had only been deployed to actual firefighting duties for a short<br />

time before <strong>the</strong>y were directed to a safe point for regrouping but <strong>the</strong>n diverted to<br />

<strong>the</strong> property on Whittlesea-Yea Road for protection.<br />

Following this incident <strong>the</strong>ir priority was to get back to firefighting as soon as<br />

possible as <strong>the</strong>re were many reports still being heard over <strong>the</strong> radio calling for<br />

<strong>Tanker</strong> assistance.<br />

Instead <strong>the</strong>y were told that <strong>the</strong>y had undergone an unusual experience and that<br />

<strong>the</strong>y were to return home, taking no fur<strong>the</strong>r part in firefighting activities.<br />

This caused all members <strong>of</strong> <strong>the</strong> <strong>Bulla</strong> Crew considerable grief as <strong>the</strong>y believed<br />

that <strong>the</strong>y did not experience any stressful situation, did not suffer any injuries and<br />

<strong>the</strong>ir vehicle was still fully operational as <strong>the</strong> burst recirculation hose had been<br />

replaced at Whittlesea Fire Station.<br />

5.10 <strong>Bulla</strong> <strong>Tanker</strong> Returned to Active Duties<br />

On returning to station <strong>Bulla</strong> <strong>Tanker</strong> was re-crewed with different personnel from<br />

<strong>Bulla</strong> and returned to <strong>the</strong> fire ground.<br />

In one way this confirmed <strong>the</strong> feelings within <strong>the</strong> original crew members that <strong>the</strong>y<br />

had let <strong>the</strong> Brigade down however <strong>the</strong>y did feel some comfort in knowing that<br />

<strong>the</strong>ir Brigades representation on <strong>the</strong> fire ground was now continuing.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0025<br />

6. SCHEDULES<br />

6.1 Sources <strong>of</strong> Information<br />

The following personnel were interviewed. The table details <strong>the</strong>ir roles and <strong>the</strong><br />

time and location <strong>of</strong> interview.<br />

Name<br />

Larry Pelly<br />

Craig Ettwell<br />

Chris Kieselbach<br />

Ge<strong>of</strong>f Schwarz<br />

Emanuel Bonett<br />

Role/Unit<br />

Crew Leader<br />

Crew Member<br />

Crew Member<br />

Crew Member<br />

Crew Member<br />

Location<br />

<strong>Bulla</strong> FS<br />

<strong>Bulla</strong> FS<br />

<strong>Bulla</strong> FS<br />

<strong>Bulla</strong> FS<br />

<strong>Bulla</strong> FS<br />

Time<br />

1930<br />

03/04/09<br />

1930<br />

03/04/09<br />

1930<br />

03/04/09<br />

1930<br />

03/04/09<br />

1930<br />

03/04/09<br />

Martin Pelly was <strong>the</strong> driver <strong>of</strong> <strong>Bulla</strong> <strong>Tanker</strong> but was not available to take part in <strong>the</strong><br />

interview.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0026<br />

6.2 Topographical Map <strong>of</strong> <strong>the</strong> Area<br />

The arrow shows <strong>the</strong> approximate position <strong>of</strong> 600 Whittlesea - Yea Rd., Humevale.<br />

6.3 Wea<strong>the</strong>r Conditions<br />

Kilmore Gap AWS (Elevation 528 metres ASL)<br />

Time Temp RH Wind FDI<br />

1030<br />

1100<br />

1130<br />

1200<br />

1230<br />

1300<br />

1330<br />

1400<br />

1413<br />

1430<br />

1445<br />

1500<br />

1530<br />

1600<br />

1630<br />

32.8<br />

34.1<br />

35.8<br />

36.6<br />

39.4<br />

39.6<br />

40.1<br />

42.0<br />

41.0<br />

41.1<br />

41.7<br />

41.4<br />

41.8<br />

41.6<br />

40.5<br />

22.9<br />

20.0<br />

17.0<br />

15.0<br />

11.9<br />

11.0<br />

10.0<br />

10.0<br />

10.0<br />

10.0<br />

9.0<br />

10.0<br />

10.0<br />

8.9<br />

9.0<br />

N 52 G 67<br />

N 56 G 73<br />

N 52 G 69<br />

N 56 G 72<br />

N 48 G 67<br />

N 69 G 81<br />

NNW 57 G 85<br />

NNW 46 G 69<br />

N 72 G 91<br />

NNW 62 G 80<br />

NNW 65 G 82<br />

NNW 63 G 91<br />

NNW 57 G 82<br />

NW 54 G 80<br />

NW 54 G 72<br />

57<br />

72<br />

78<br />

93<br />

96<br />

161<br />

130<br />

107<br />

190<br />

147<br />

169<br />

155<br />

138<br />

130<br />

125<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0027<br />

1700<br />

1730<br />

1800<br />

1810<br />

1813<br />

1819<br />

1830<br />

40.6<br />

40.5<br />

40.1<br />

39.9<br />

33.1<br />

30.3<br />

28.8<br />

10.0<br />

10.0<br />

10.0<br />

10.0<br />

23.9<br />

29.6<br />

34.0<br />

NW 44 G 69<br />

NW 46 G 70<br />

NW 37 G 61<br />

W 17 G 54<br />

SW 26 G 50<br />

SSW 32 G 67<br />

SSW 32 G 59<br />

97<br />

102<br />

81<br />

50<br />

30<br />

26<br />

21<br />

The above table <strong>of</strong> wea<strong>the</strong>r observations were recorded at <strong>the</strong> AWS at Kilmore<br />

East. This is approximately 30 kilometres north west <strong>of</strong> <strong>the</strong> incident area at<br />

Humevale. As indicated by <strong>the</strong> highlighted area <strong>the</strong> wind change did not pass<br />

through this area until about 1800 Hrs<br />

6.4 Area <strong>of</strong> Incident showing Terrain and Vegetation<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0028<br />

The area at front <strong>of</strong> house where<br />

Sunbury <strong>Tanker</strong> 2 were<br />

positioned when <strong>the</strong> fire<br />

approached.<br />

The area at rear <strong>of</strong> house where<br />

<strong>Bulla</strong> <strong>Tanker</strong> were positioned<br />

when <strong>the</strong> fire approached.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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CFA.001.027.0029<br />

6.5 Photographs<br />

Fire conditions just prior to <strong>the</strong> incident. Photo taken by <strong>Bulla</strong> <strong>Tanker</strong> crew from <strong>the</strong> rear <strong>of</strong> <strong>the</strong>ir vehicle.<br />

<strong>Bulla</strong> <strong>Tanker</strong> Burnover – 600 Whittlesea-Yea Road – 07/02/<strong>2009</strong><br />

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