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Making Sense of Natural
Disasters: The Learning
Vacuum of Bushfire Public
Inquiries

Graham Dwyer
Making Sense of Natural Disasters
 Graham Dwyer

Making Sense of
Natural Disasters
The Learning Vacuum of Bushfire Public Inquiries
Graham Dwyer
Centre for Social Impact
Swinburne University of Technology
Melbourne, VIC, Australia

ISBN 978-3-030-94777-4    ISBN 978-3-030-94778-1 (eBook)

https://doi.org/10.1007/978-3-030-94778-1

© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
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 Foreword

Disasters affecting humans are not new but they are occurring more often.
This may be to do with the size of the population of homo sapiens upon the
planet but it may be something to do with the planet itself. In a world of
climate change and a wide acceptance that human actions and reactions
contribute to the Anthropocene, disasters in the twenty-first century
threaten more human life and living standards in more and more places.
Given this, what might we learn about how to organize against them?
Graham Dwyer offers in this book a way forward to enrich our under-
standing. Dwyer has concentrated upon emergency management practi-
tioners and those communities facing extreme events, especially bush fires.
His approach is based upon research in the state of Victoria in Australia
but is germane to our understanding of disaster management in many
nations, in both hemispheres. He shows that the organization of human-
ity, both in the face of such disasters and the planning that goes into
preparation for them, relies upon a process of ‘sense-making’ whereby
extraordinary conditions are fitted into everyday, ordinary frameworks
that are meant to be formal, robust, and pre-planned to deal with such
extreme conditions. Dwyer points out, however, that emotions are height-
ened in such extraordinary circumstances and formal, linear systems rarely
conceptualise this element as a matter of great consequence. Indeed, the
deliberations of Public Inquiries seek to remove emotion from their think-
ing almost altogether and to concentrate upon rationality and the alloca-
tion of blame within a legal framework of cause and effect. By ignoring the
role of human emotions in extreme circumstances, says Dwyer, Public
Inquiries offer little that is new to human understanding. Dwyer’s

v
vi FOREWORD

provocative research suggests that Public Inquiries must consider the role
of ‘emotion’ within their very ‘rational’ frameworks. Without this new
dimension, humanity faces a ‘learning vacuum’ with mortal consequences
for many.
Graham Dwyer’s book, for this reader, relates back to a tension deep
within human history, yet is in order to understand our future upon a
changing planet. In ancient Greece, the Apollonian strand of thinking
emphasised rationality and the power of thought. Apollo was the sun God
and appealed to logic, prudence and illumination. On the other hand,
Dionysus was the God of wine and dance and is associated with chaos and
irrationality. His worship appealed to those who wished to celebrate the
emotions and instincts. Some have seen this quarrel acting at the level of
the human brain where the Apollonian resides in the higher cortex,
whereas the Dionysian is to be found in the ‘reptilian’ and ‘limbic’ brains
still possessed by the human anatomy. This tension in worldviews seems
very relevant to this reader in understanding Making Sense of Natural
Disasters. Dwyer wishes for immediately experienced ‘emotions’ to be
admitted into Public Inquiries despite their legal focus being upon long,
drawn out cerebration, seeking allocation and apportionment of responsi-
bility. It is this other, fully embodied worldview of those facing extreme
danger on the front line that he offers. He leads the reader to see the value
in our understanding of a world in which, one might argue, the pre-­
eminence of legal-rational bureaucracy has created a runaway monster of
climate change ready to devour the world as we humans know it. And in
such threats to life and limb is it any surprise that sense-making might well
include the spontaneous reaction of our own viscera?
Making Sense of Natural Disasters is thus a book for today, not only for
the women and men who face the consequences of a hotter, drier world
almost every day but for us all. Emergency workers protect us, of course,
but in order to do so they must protect themselves, using not only plan-
ning in the seminar room but ‘out there’ with a mind that is fully embod-
ied in the face of terrifying conditions. Graham Dwyer has done these
emergency workers a great service in rendering the world more complex
yet more understandable, as well as those who plan for disasters, those
who seek to control events afterwards, and all of us who are beholden to
them. His readers will appreciate his subtlety and erudition in so doing.

University of Manchester Gibson Burrell,

Manchester, UK
 Preface

Victoria, Australia, is arguably the most fire-prone area in the world.

Scientists and climatologists claim that with climate change we will increas-
ingly experience longer drought periods, higher wind speeds and warmer
temperatures, giving rise to a greater bushfire threat in an already extremely
bushfire-prone environment. Given such circumstances, it is likely that
Victoria’s emergency management organizations will increasingly find
themselves responding to bushfires characterized as complex, harmful and
rare. This book examines the public inquiries conducted after some worst-­
ever bushfires witnessed in Australia, in order to understand how emer-
gency management organizations make sense of and learn from bushfires
in Victoria so that they can be better prepared for bushfires in the future.
Despite its long history of bushfires post-European settlement, Victoria
has struggled to make sense and learn from its experience. While the in-­
depth findings of public inquiries into major bushfires have resulted in
various recommendations being developed and implemented in emer-
gency management organizations, there continues to be a perception that
learning from such events rarely occurs.
This book examines some of Victoria’s most significant bushfire inqui-
ries and the ways in which emergency management organizations made
sense of their findings and recommendations. I show that while public
inquiry findings do shape bushfire planning and preparedness, they have
also created a learning vacuum because their recommendations tend to
have a retrospective focus. This keeps government, emergency manage-
ment organizations and the community looking back at tragic bushfires
without focusing on learning lessons when they need to look forward to

vii
viii PREFACE

future bushfire and other natural hazard events, as well as human-­

made crises.
Given the impact of these fires, I also reflect on the emotions that sur-
rounded these inquiries. I find that negative emotions have surrounded
the implementation of these inquiry recommendations because they have
increased accountability demands on emergency management practitio-
ners at a time when their efforts need to be focused on developing a shared
responsibility for managing risk in partnership with government and com-
munities. Accordingly, I suggest that future research should seek to
develop new ways to conduct public inquiries in a more inclusive and
meaningful manner, which will result in recommendations that facilitate
more effective planning for future bushfires. This means moving beyond
the existing quasi-judicial approach towards a public review process shared
across government, emergency management organizations and the
community.
As Victoria faces a future of unknowns surrounding bushfires, it is
important that we move beyond the learning vacuum with its retrospec-
tive learning, towards a more prospective approach where we prepare as a
community and society – not only for bushfires, but for all the natural
hazards and challenges we are likely to face in the future. Such an approach
may yield better ways of learning and, consequently, more meaningful
organizational change in our emergency management organizations.
Although history may dim the memory of just how devastating bushfires
can be (Griffiths, 2010), it is important that political leaders, emergency
management practitioners and private citizens continue to be mindful of
bushfire risk so that they can help each other to prepare for the inevitable
fire events of the future. The experiences of those who have lived through
the bushfire events at the core of this book remind us of the need to con-
tinue to heed the lessons from them:

The scene that confronted me when I first saw Strathewen was—it was inde-
scribable. There literally wasn’t anything that wasn’t burnt, that wasn’t
destroyed … We came over the hill and the young chap that was driving for
me, he saw his parents’ house fully enveloped in flames … it was very diffi-
cult. I got further up Chads Creek Road … and I met a resident on the road
and he said, ‘There’s a body up there’. I went up and there was a chap I had
known for 40 years dead in the middle of the oval. (Mr. David McGahy,
captain of the Arthurs Creek CFA brigade, describing his observation when
 PREFACE ix

he arrived at Strathewen in the aftermath of the Black Saturday bushfires,

quoted in Parliament of Victoria, 2010: 83)

Melbourne, VIC, Australia Graham Dwyer

References
Griffiths, T. (2010). An unnatural disaster: Remembering and forgetting bushfire.
History Australia, 6(2), 35.1–35.2.
Parliament of Victoria. (1939). Report of the royal commission to inquire into the
causes of and measures taken to prevent the bush fires of January, 1939, and to
protect life and property, and the measures taken to prevent bush fires in Victoria
and protect life and property in the event of future bush fires 1939, Parliamentary
paper (Victoria. Parliament); T. Rider, Acting Government Printer, Melbourne.
 Acknowledgements

I acknowledge the Traditional Owners of the lands where I respectively live

and work. I pay my respects to their Elders past, present and future. I recog-
nize that these lands have always been places of teaching, research and
learning.
I would like to acknowledge the following people for their support over
the course of my journey so far into academia.
First and foremost, I would like to thank Cynthia Hardy, Laureate
Professor Emerita, University of Melbourne (and collaborator on several
publications) for your guidance, support and mentorship in all matters
academic relating to research, writing, publication, teaching and learning.
Your generosity (and patience) knows no bounds, for which I am ever so
grateful. Such generosity (and patience) was always present as my lead
PhD supervisor during my time at University of Melbourne. I would also
like to thank Professor Susan Ainsworth and Professor Graham Sewell
(both University of Melbourne) for your support as co-PhD supervisors
and your considerable investment in my topic, which has given me so
much content to work with as a basis for writing this book. More broadly,
I would like to thank all of the staff at the Department of Management &
Marketing, University of Melbourne, for their support during my PhD
and Teaching Fellowship journey, as well as the team at the Bushfire and
Natural Hazards Cooperative Research Centre (now Natural Hazards
Research Australia).
At Swinburne University of Technology (SUT), I would like to thank
all the team at the Centre for Social Impact (CSI) and more broadly col-
leagues at the School of Business Law and Entrepreneurship. A very special

xi
xii ACKNOWLEDGEMENTS

thanks to Dr Michael Moran, National Education Director, CSI, Associate

Professor Emma Lee, tebrakunna country, Indigenous Leadership, CSI,
SUT, and Professor Timothy Marjoribanks, SUT for their guidance and
support which has contributed enormously to helping me develop over the
course of my early career as an academic. I also extend this thanks to Dr
Warren Staples, University of Melbourne and Professor Michael Dowling,
Dublin City University.
A special thanks to my collaborators who have helped, are helping and
will (continue to) help explore the knowledge frontier related to many of
the issues at the core of this book. Specifically, I would like to acknowledge:

• Professor Cynthia Hardy, Laureate Professor Emerita, University of

Melbourne, Australia
• Professor Steve Maguire, University of Sydney, Australia
• Professor Haridimos Tsoukas, University of Cyprus, Cyprus &
University of Warwick, UK
• Professor Leanne Cutcher, University of Sydney, Australia
• Professor Gibson Burrell, University of Manchester, UK
• Professor Markus Höllerer, University of New South Wales, Australia
& WU Vienna, Austria

A very special thanks to all of the police and community of emergency

management practitioners who continue to help us understand so many of
the nuances surrounding the work that you do and the challenges which
you face as you plan for and respond to fire in our landscape.
Finally, for everything, míle buíochas to my family and community of
friends in Melbourne and Dublin.
 Contents

1 Introduction  1
1.1 What Happens After Disasters?  5
1.2 Structure of the Book  8
References 10

2 Learning as Sensemaking 15
2.1 What Is Sensemaking? 18
2.2 Equivocality and Sensemaking 23
2.3 What Happens After Disaster and Public Inquiry
Sensemaking? 28
2.4 Sensemaking and Emotion 30
2.5 Conclusion 33
References 34

3 Bushfires and Public Inquiries: A Case Study of Victoria 43

3.1 Making Sense and Learning from Public Inquiries 44
3.2 Victoria: Case Study of a Bushfire Society 45
3.3 Conclusion 62
References 62

4 Sensemaking and Learning from Public Inquiries 65

4.1 Findings 66
4.2 Conclusion 81
References 81

xiii
xiv CONTENTS

5 Discussion and Conclusions 83

5.1 Models of Post-Inquiry Sensemaking 87
5.2 Reflections 88
5.3 Areas for Future Consideration 98
5.4 Practical Contributions100
5.5 Personal Reflection107
References110

References117

Index133
 List of Figures

Fig. 4.1 Sensemaking and learning from public inquiries.

(Adapted from Dwyer and Hardy (2016)) 76
Fig. 5.1 Sensemaking and learning in emergency
management organizations 86

xv
 List of Tables

Table 3.1 Sources of textual data 47

Table 3.2 Illustration of codes and quotes for key themes 56
Table 4.1 Summary of findings from Black Friday 1939 71
Table 4.2 Summary of findings from Ash Wednesday 1983 72
Table 4.3 Summary of findings from Black Saturday 2009 74
Table 4.4 Summary of findings from Black Summer Inquiry Part 1 75
Table 4.5 Emotions surrounding public inquiry sensemaking
and learning 78
Table 5.1 Recurring focus of Victorian bushfire inquiries 87

xvii
 CHAPTER 1

Introduction

Abstract This chapter presents an overview of the key concepts related to

the ways in which sensemaking and learning unfold following significant
natural hazard events. While scholarly and practitioner work has high-
lighted the damage and losses that occur as a result of natural hazard
events, there has been less focus on what happens afterward. Accordingly,
the focus of this book is to bring attention to the ways that government,
emergency management and community stakeholders seek to make sense
of and learn from natural hazard events through public inquiries. I do so
by focusing on the case study of bushfire in Victoria, Australia, specifically
on the ways in which emergency management practitioners use the find-
ings and recommendations from public inquiries to plan for the risks asso-
ciated with future bushfires.

Keywords Natural hazard events • Bushfires • Public inquiries •

Sensemaking • Learning

Recent history has provoked a high level of concern over the earth’s natu-
ral environment and the extreme events, grand challenges and wicked
problems surrounding natural hazards (Dwyer, 2021b; Gephart, 2021).
Higher temperatures, intensifying wind speeds and rain deficits are being
attributed to climate change, and are subsequently prompting floods,
droughts and bushfires which are increasingly endangering the lives of

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
G. Dwyer, Making Sense of Natural Disasters,
https://doi.org/10.1007/978-3-030-94778-1_1
2 G. DWYER

those practitioners who must respond to them (Dwyer, 2021c). These

have become increasingly regular, complex and devastating, giving rise to
novel societal risk (Nohrstedt & Bynander, 2019; Glade et al., 2010;
Birkman, 2006) and placing communities in the path of considerable dan-
gers (Zuccaro et al., 2020). The increased incidence and severity of disas-
ters has also been challenging for the broader community of emergency
management practitioners, including government ministers, policymakers,
police officers, firefighters, weather forecasters and geospatial analysts, cre-
ating three forms of uncertainty described as “known, unknown and
unknowable” (Chow & Sarin, 2002: 127). In many instances there have
been long-term effects on communities, landscapes and ecosystems
(Waldmüller, 2021).
Globally, disasters such as hurricanes (e.g. Katrina, USA, 2005: 1464
lives lost), earthquakes (e.g. Haiti, 2012: 223,000 lives lost) and tsunamis
(e.g. Southeast Asia, 2004: 250,000 lives lost) have revealed insights into
the difficulties facing community, government and industry organizations
as they cope with, manage and respond to adversity in challenging envi-
ronments (Birkman, 2006; Dwyer, 2015; Kates et al., 2006; March &
Olsen, 1983; Pauchant & Douville, 1993). Such events have highlighted
the importance of implementing science- and evidence-based approaches
to Disaster Risk Reduction and Climate Change Adaptation as identified
in the Sendai Framework for Disaster Risk Reduction 2015–2030
(SFDRR) (Zuccaro et al., 2020). While SFDRR requires “the adoption of
policies, strategies and plans and the further review and development of
normative instruments at local, national, regional and global levels as well
as quality standards and practical guidelines” (UNISDR, 2015: 3), there
remains little by way of insight to guide practitioners as they seek to
develop such instruments. Experience has shown that even well-prepared
emergency management organizations struggle to respond effectively to
natural hazard events and the disasters they bring into existence (see
Dwyer et al., 2021; Mileti, 1999), because their learning from previous
events is undermined when new or unfamiliar conditions unfold. While
SFDRR begins to train attention on the need to move towards a multi-­
hazard and multi-sector approach to mitigating natural disaster risk, the
case study of bushfires in Victoria shows that, even with increased scientific
knowledge and robust policies in place, bushfire events still give rise to
significant damage and losses. Ultimately, no two events are the same, so
it becomes problematic to apply yesterday’s learning to present-day disas-
ters (Dwyer, 2021a). Disasters are also typically events with a high impact
 1 INTRODUCTION 3

but a low probability of occurring, meaning that they interact with actors,
systems, processes, procedures and routines in the organizational environ-
ment in a manner that is often rapid and unpredictable (Landgraf &
Officer, 2016; Thatcher et al., 2015; Kruke & Olsen, 2005; Weick, 1988,
1999). Such scenarios create a high cognitive load (Sweller, 1994), as
individuals’ ability to understand and manage what is occurring begins to
diminish in the face of escalating danger. Individuals move between emo-
tional states such as anxiety, panic, fear and stress as they seek to take
meaningful action to ameliorate the emerging danger and avoid significant
losses and damage to communities. Such disasters also have an emotional
impact on individuals who work in emergency management organizations,
who may experience feelings of regret, shame and sadness after these
events because of a perception created by media commentaries and public
inquiries that their actions were unable to ameliorate the harmful effects
of disaster (Dwyer, 2021a; Dwyer et al., 2021). Risk management and
capacity-building focused on integrating climate change into hazard miti-
gation planning offer the potential to ameliorate the harmful effects of
natural disasters (Stults, 2017; Buergelt & Paton, 2014). However, this
book shows that there are challenges with achieving an integrated approach
to hazard mitigation through deliberative forums such as public inquiries.
I show that, despite the fact that they span 80 years of learning and signifi-
cant innovation in Victoria, public inquiries as a sensemaking device have
given rise to a learning vacuum, insofar as there is little new that emerges
from their deliberation.
The focus of this book is the way in which emergency management
organizations and the organizational actors that comprise them make
sense of and learn from the paradoxes, predicaments and problems which
arise from disasters. I do so by examining four case studies of bushfires and
the public inquiries that were held after them in the state of Victoria,
Australia. Its unique combination of landscape, climate and vegetation
makes Victoria one of the most fire-prone areas in the world. Consequently,
and not surprisingly, Victoria has had a long history of bushfires (Griffiths,
2010). Four such bushfires continue to live in the collective memory of
Victorians and are the focus of my study: the Black Friday fires of 1939;
the Ash Wednesday fires of 1983; the Black Saturday fires of 2009; and the
Black Summer fires of 2019. In each case, the organizations responsible
for managing these fires faced surprising, overwhelming and novel situa-
tions that, despite their experience with bushfires, were difficult to manage
4 G. DWYER

and gave rise to widespread damages and losses – leading to close examina-
tion by subsequent public inquiries.
This book reflects on the ways that emergency management organiza-
tions understood and acted following these bushfire disasters. We know
from the existing literature that such sensemaking occurs as individuals
seek to understand a situation that is rapidly and unpredictably unfolding
(Dwyer, 2021b). Often, because of the nature of a disaster, this initial
attempt at understanding fails, as Weick (1993) famously showed in the
rapid onset of wildfire at Mann Gulch in 1939. This had fateful conse-
quences as firefighters failed to make sense of what was happening. A long
list of other studies has shown how problems with sensemaking and the
failure to generate plausible meanings about what may be unfolding can
lead to or exacerbate disasters (Brown, 2000, 2004; Gephart, 1984, 1993,
2007; Turner, 1976; Vaughan, 2006; Weick, 1990, 1993, 2010).
We also know that, in order to make sense of what happened during a
disaster, and how and why it occurred, governments will usually commis-
sion a public inquiry (e.g. see Gephart, 1984, 1993; Gephart et al., 1990;
Elliot & McGuiness, 2002; Lalonde, 2007). Studies of such inquiries have
shown that they often identify how people’s behaviour in emergency situ-
ations is frequently a contributing factor to the disaster – because they
failed to make sense of it at the time (Leveson et al., 2009; Perrow, 1981,
1983; Vaughan, 1990, 2006). They also show that the inquiry itself
involves a retrospective form of sensemaking around what happened dur-
ing the disaster (Boudes & Laroche, 2009; Colville et al., 2013; Brown &
Jones, 2000; Brown, 2000, 2004, 2005; Gephart, 1984, 1993, 1997).
This has been no different in a Victorian context, where public inquiries
have been used to make sense of bushfires since 1939 (Dwyer & Hardy,
2016; Dwyer et al., 2021).
There is, then, a rich body of literature about sensemaking, both during
a disaster and afterward when an inquiry takes place. However, there is less
work on learning and how it occurs. We know little in terms of how the
individuals, groups and organizations charged with responding to the
public inquiries make sense of their recommendations after commissioners
have concluded their deliberations (Dwyer, 2021a). Moreover, recent
work has even called for new ways of conducting public review processes
which seek to foster new cultures of learning within emergency manage-
ment organizations (Dwyer, 2021a; Dwyer et al., 2021). This, then, is a
key focus of this book: How should public review processes be conducted
after major bushfires? By exploring this question, I provide an evidence
 1 INTRODUCTION 5

base for exploring how a broader range of stakeholders can become

involved in planning for, responding to and recovering from bushfires in
the future.

1.1   What Happens After Disasters?

It is important to understand what happens after disasters that usually arise
from bushfires (as well as other natural disasters) and how organizations
respond to them for both practical and theoretical reasons, and studying
public inquiries helps us to do this. Practically speaking, inquiries are
ostensibly intended to either reduce the likelihood that disasters will re-­
occur or, if that is not possible, to improve the way organizations respond
to them through learning for the future. Inquiries into bushfire disasters
have significantly informed the practice of emergency management in
Victoria, but we know very little about how this takes effect and whether
and how inquiries engender change and learning in organizations (Dwyer
& Hardy, 2016). Bushfire management in Victoria involves a complex
arrangement of plans, structures and hierarchies that have been estab-
lished and refined over many years as a result of lessons from a range of
bushfires and other natural disasters. Anecdotal evidence thus suggests
that public inquiries and their recommendations do play an important role
in shaping the ways in which Victorian emergency management organiza-
tions respond to and prepare for bushfires, although how they do so is not
clear. Some researchers suggest that public inquiry recommendations can
make a “staunch commitment to a particular set of meanings” that may, in
fact, create “substantial blindspots that impede action” such as organiza-
tional change and learning (Maitlis & Sonenshein, 2010: 562). In other
words, public inquiries may inhibit the future attempts of organizations to
deal with disasters as much as they help them, and this has proved to be
the case over time (Dwyer, 2021a).
Theoretically speaking, it seems likely that individuals who work in
emergency management organizations will have to make sense of inquiry
recommendations before they can implement them (Botterill, 2014).
They therefore engage in sensemaking and sensegiving (Gioia &
Chittipeddi, 1991) as they seek to interpret the recommendations, influ-
ence each other’s perceptions and implement change in their organiza-
tion. However, to date there has been limited involvement of broader
emergency management stakeholders in society (see Williamson et al.,
2020). The bulk of evidence from public inquiries has been generated by
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