Residents of Canberra will recall the 2011 Mitchell Fire when a fire in an industrial complex put potentially toxic smoke into the sky and caused widespread disruption to Northern Canberra.  (My daughters got a day off school as schools were closed due to concerns about the smoke).

The fire was on 15 September 2011.  The Coroner began an inquiry at the time of the fire. Over 7 years later the Coroner determined that there was no value in holding a public inquiry and handed down inconclusive findings based on various reports – see Inquiry into a fire at the premises of Energy Services Invironmental, 60 Dacre Street, Mitchell, ACT, on 15 September 2011 [2018] ACTCD 16 (1 November 2018).

Cause and origin of the fire

The role of the coroner was to inquire into ‘the cause and origin of the fire’ (Coroners Act 1997 (ACT) s 52(2) (as it was at the time of the fire).  The fire was investigated by ACT Police, ACT Fire and Rescue, WorkSafe ACT and the Environmental Protection Authority.  None of those agencies could identify how the fire started.   At [28] the Coroner said:

Four professional agencies investigated the cause and origin of the fire without conclusion.  I consider that there is no further evidence available to me which will bear on this point and that holding [an inquiry] would be futile.

ACT Fire Brigade and WorkSafe

One area that appeared problematic to me was findings regarding Work Health and Safety. At [45] the Coroner said:

The evidence before me suggests that on 19 February 2009 the ACT Fire Brigade advised WorkSafe ACT of its concern that the new ESI facility may not comply with AS 1940-2004 (storage and handling of flammable and combustible liquids). Enquiries were made with the ACT Fire Brigade to clarify these concerns. Ultimately WorkSafe ACT elected to take no action as they could not clarify which section of the Australian Standard had not been complied with or why the ACT Fire Brigade held these concerns.

You wonder how it could be that WorkSafe ACT and the ACT Fire Brigade (as they were then) could not communicate so that WorkSafe could understand the Fire Brigade’s concerns.  The Coroner did not address that matter any further.

Emergency alert

There were issues at this fire with the use of the emergency alert system:

Media reports in the days after the ESI explosion and fire criticised the Emergency Alert system used to advise nearby residents with some residents complaining they did not receive the warning and others saying they had received a warning despite being interstate or overseas.

(For a discussion by me on those issues, see Eburn, M., ‘Bushfires and Australian emergency management law and policy: Adapting to climate change and the new fire and emergency management environment‘ in Burton, L and Sun, L (eds) Cassandra’s Curse: Law and Foreseeable Future Disasters (Studies in Law, Politics and Society; Elsevier, 2015)).

With respect to the operation (or failure, depending on how you see it) of the emergency alert, there had been inquiries by the Senate Environment and Communications References Committee. The Coroner said (at [53]) ‘Given both the ACT Government and the Senate Committee reviews of the issue, I see no benefit in further inquiry’.


The coroner made the following findings (at [29], emphasis in original):

(a) prior to the explosion and fire on 15 September 2011, the ESI facility was appropriately managed and the operational risks were identified and managed;

(b) the response of ACT public authorities to the explosion and fire was appropriate;

(c) despite significant investigation by multiple agencies, no cause or origin of the fire is able to be established, due to the ferocity of the explosion and subsequent fire;

(d) the cause and origin of this fire is unascertained.

There were no recommendations to enhance public safety