It took 14 months to produce and covered a broad and daunting range of highly technical and emotional subject matter. On 16 March 2012, the final report of the Queensland Floods Commission of Inquiry was handed over to former state premier Anna Bligh.

“As we contemplate this report,” she told the world’s media, “we must remember those who suffered unbearable grief and loss, hardship and suffering. For me, mayors throughout the state and others faced with tremendous responsibility, these were also difficult and tumultuous times.”

Speaking at the launch Bligh reflected on the period during which ‘Mother Nature unleashed the unthinkable’ on four Australian states. In particular, she highlighted the grim and desperate moments experienced by the people of Queensland.

“When you’ve lived through something of this magnitude it’s difficult not to ask questions,” she said. “In fact in my view it is important to ask questions and to make an effort to find the right answers. We needed to ask questions about how this event occurred, how we responded and if we can do better should such events ever occur again.

“I wanted answers and I wanted the questions to be answered truthfully,” Bligh continued. “That is why I established this commission.”

Unprecedented disaster

Prolonged and extensive rainfall over large areas of Queensland, coupled with already saturated catchments, led to flooding of historic proportions from December 2010 to January 2011.Thirty-three people died and more than 78% of Queensland (an area bigger than France and Germany combined) was declared a disaster zone. Over 2.5M people were affected and more than 29,000 homes and businesses suffered some form of inundation. The Queensland Reconstruction Authority has estimated that the cost of flooding events will be in excess of A$5B.

The scale of this unprecedented disaster led to the establishment of the commission of inquiry on 17 January 2011. The following seven areas were identified as needing investigation by the commission:

• Preparation and planning for the floods by governments, agencies and the community.

• Adequacy of flood response.

• Management of essential services.

• Adequacy of forecasts and early warning systems.

• Insurer performance and responsibilities.

• Dam operation.

• Land use planning to minimise flood impacts.

As most of the state was affected these questions had to be examined over a very large geographical area. Inquiries had to be made and hearings held in a variety of locations. The Commission was ordered to provide the Queensland government with an interim report on 1 August 2011 (see IWP&DC September 2011, pp56-61). The final report was originally required by 17 January 2012 but after two extensions to allow for further evidence, this was rescheduled for 16 March.

The weighty two-volume, 650-page document is, in Bligh’s words, ‘a blue print for future major flood events in Queensland’. The comprehensive and rigorous examination of all matters related to the floods makes 177 recommendations. One hundred and thirty six of these are government related, while others are for local government and councils.

Head commissioner Catherine Holmes admitted there is no doubt that these floods took the state of Queensland, which is more accustomed to drought, by surprise. Referring to the final report, she added: “Anyone who is genuinely interested in how we manage flood risk will read it closely – all parts of it.”

Interest in the commission’s final piece of work had been intensifying in Queensland and across Australia over preceding months. Speculation about the report’s conclusions had helped to fuel state government election campaigns. On 24 March 2012 Queenslanders took to their election booths, with all political parties pledging their support for the flood commission.

“A new labour government, if I am re-elected, will implement this report in its entirety – lock, stock and barrel,” said Anna Bligh. She also pledged A$40M to help local governments implement the much needed, and recommended, extensive flood mapping and flood plain management which is often beyond the limits of local government resources.

Opposition leader at the time, Campbell Newman, matched this pledge stating that his Liberal National Party had the energy, passion, drive and commitment to implement the flood commission’s recommendations.

Political intrigue was one of many ingredients added to the official release of the final report. At the launch of the document former premier Bligh stated that three dam engineers, who were managing Wivenhoe dam for Seqwater during the flood event, were being referred to the Crimes and Misconduct Commission. They were to be investigated in relation to submitted evidence which included oral testimony, preparation of documents surrounding the January 2011 flood event and the flood event report issued by Seqwater in March 2011.

“The commission came under criticism towards the end of its term when it had to re-convene to examine whether the account of operational strategies, to which the flood engineers responsible for Wivenhoe dam had sworn in hearings, was in fact correct,” head commissioner Holmes stated in the report. “Not all of the criticism was fair, or acknowledged the pressures under which the commission was operating, in endeavouring to cover all of its terms of reference in a limited time.

“It would have been quite impracticable for the commission to take all the evidence given on oath before it and check it for inconsistency against the mountain of documents received. Time simply did not allow that,” she explained, adding that the commission had not been seeking to attribute blame or seek out wrong-doers. Its primary goal was to make recommendations to improve the preparation, planning and emergency response for future floods, as well as highlight any legislative change required.

“But the need to examine these particular allegations was made all the more acute,” Holmes continued, “by the fact that a commission of this kind is so dependent, given its time constraints, on truthful evidence.”

However, the commission was mindful of the fact that dam operators do also work under increasing pressure and time constraints. “Dam operators do not have the gift of foresight,” the report states. “A large flood is indistinguishable from a small flood when the first rain falls. Operators’ ability to respond to flooding is hindered by the inaccuracy of rainfall forecasts and gauges, river level gauges and modelling. All that can be asked is that they act competently on the best information available to them and report faithfully on what they have done.”

Indeed, in January 2012, it was the accuracy of such reporting that brought into question the evidence which had been given on the operation of Wivenhoe and Somerset dams a year earlier. Prompted by evidence provided by a newspaper article published in The Australian on 23 January 2012, there were queries whether the operational strategies set out in the flood mitigation manual for the dams had been engaged at the correct time.

In a media statement issued on 23 January 2012 dam operator Seqwater stated that reports suggesting it had breached its operational manual during the January 2011 flood, were ‘inaccurate and unfounded’. Furthermore the company stated that “the implied allegation that Seqwater (and its engineers) gave misleading evidence to the Queensland Floods Commission of Inquiry is baseless and is utterly rejected.”

Nonetheless, the commission found that there was sufficient cause to re-open public hearings. It wanted to obtain sworn evidence from those who were involved in the operation of Wivenhoe dam in January 2011 and in the preparation of recorded decisions. Oral evidence was heard from 27 witnesses over ten additional days of public hearing in February 2012.

The commission concluded that section 2.7 of the interim report (a source of information regarding the deployment of operational strategies as derived from the March flood event report) must now be disregarded. Furthermore any opinion in section 2.6 of the interim report (which reflected favourably on the flood engineers) must now be subject to further investigation.

As stated in its final report, the commission said it never intended to conduct forensic investigations into whether all those connected with the flood response were telling the truth and had given consistent accounts of their actions. It states that chapter 16 of the report, which sets out the results of such a forensic exercise, is ‘exceptional’. It goes on to add that: “Once raised, the issue of whether those connected with the operation of the dam were telling the truth had to be resolved; it was fundamental to how the response to the January 2011 flood was managed.”

Public comment

On 5 April 2012 Seqwater issued a statement saying that: “Given the circumstances, including the ongoing investigation by the Crimes and Misconduct Commission, Seqwater does not presently intend to make any public comment on the Commission of Inquiry’s final report.”

Stephen Durkin, CEO of the professional body Engineers Australia, re-iterated the critical role engineers have to play in protecting the community, especially in times of crisis. But he added: “We demand that our members adhere to Engineers Australia’s Code of Ethics, and perform their jobs in accordance with the highest standards.”

Even with the benefit of hindsight, the commission report does not clarify the nature of an optimum release strategy for Wivenhoe dam, president of the Queensland division of Engineers Australia Steven Goh said on 23 March. “This highlights the complexity and challenges faced by the dam engineers in responding to this crisis. The operation of major flood mitigation dams is heavily dependent on the skills of the operators,” he stated. “The report has not questioned the technical competence of the engineers involved in the floods. Several of the commission’s own experts have concluded that the dam management processes were appropriate under the circumstances.

“It has been recommended that the Crimes and Misconduct Commission investigate issues surrounding the reporting of events. All parties involved should be afforded their natural justice rights, and we need to let the CMC investigation takes its course. Engineers Australia will continue to work to develop the preparedness of the community to deal with all kinds of natural disasters, including protecting the standards in our profession,” Goh concluded.


Despite the confusion surrounding accurate accounts of operational procedures adopted throughout the flood event, the commission concluded that Wivenhoe dam was operated in breach of the flood mitigation manual from 8am on 8 January 2011 until the evening of 9 January.

“The commission has found non-compliance with the manual under which the dam was to be operated,” Catherine Holmes said. “What should not be overlooked is that the manual itself was ambiguous, unclear and difficult to use, and was not based on the best, most current research and information.”

Indeed breaching the protocol of the manual does throw up other issues. The commission’s independent advisor, hydrologist Mark Babister, perceived that the flood engineers ‘managed Wivenhoe dam so that its flood mitigation effect was very close the maximum achievable within the constraints of the manual’. However the problem does exist, the commission stated, that “because the engineers failed to consider releases open to them within the parameters of the correct strategy, an opportunity may have been lost for earlier releases.”

While flooding would undoubtedly have been worse in the region in the absence of the dams, the report says it is not disputed by any party that releases from Wivenhoe dam contributed significantly to flooding downstream of Wivenhoe, in combination with tributary inflows from Lockyer Creek, the Bremer river and other catchments. As the report states: “There is, it is obvious, plenty of scope for argument about whether adherence to the manual strategies would have made a difference to the way in which the flood engineers actually operated the dam; but the possibility certainly exists that they would have responded more quickly to the developing conditions of 9 January had their mindset been one of applying strategy W3. Ascertaining the practical result of acting more quickly also is subject to the uncertainties inherent in the modelling; but again, the possibility exists of at least some improvement in the flooding outcome for Brisbane and Ipswich.”

Even without changes to the Wivenhoe manual, the commission believes that a reduction in lake level to 75% full supply level means that peak river heights would have been lower than experienced in the January 2011 flood event. Indeed if the operating strategies in the manual had also been amended it is likely that peak river heights would have been even less, although major flooding would still have occurred.

“Even a large dam such as Wivenhoe has a limited flood mitigation capacity when the volume of water entering it is significantly larger than its storage capacity,” Commissioner Holmes acknowledged. “Its flood mitigation effect for Brisbane was further limited by the fact that floodwaters from other parts of the Brisbane river catchment entered the river downstream of the dam, through the Bremer river and the Lockyer Creek. The flooding in Brisbane and Ipswich could, as Mr Babister’s study has shown, have been reduced to some degree had the dam had its capacity reduced to 75% prior to the December rains; but to appreciate what the magnitude of the rain would be and that it would fall in the dam area would have required a more than human capacity of prediction. What is concerning, though is the apparent inertia of government when the possibility was raised.”


There are also other implications of breaching the dam manual which have to be considered. As former Queensland premier Anna Bligh commented on 16 March: “The dam operations manual was breached during this event and does open the potential for legal action against Seqwater, but does not itself establish liability. The state government expects Seqwater to be a model litigant with any considered claims. And they must treat people fairly and openly, and settle and mitigate where appropriate.”

To date hundreds of flood victims have reportedly signed up for potential class action. “If the action proceeds,” says Rod Hodgson from legal firm Maurice Blackburn, “it’s likely to be the largest class action that Australia has ever seen.”

Note of caution

“There is certainly a good deal of room for improvement in planning for emergency response, as the many recommendations in this report and the interim report demonstrate. But this note of caution must be sounded,” Commissioner Catherine Holmes warned. “The disastrous floods which struck southeast Queensland in the week of 10 January 2011 were unprecedented, in many places completely unexpected, and struck at so many points at once that no government could be expected to have the capacity to respond seamlessly and immediately everywhere, and in all ways needed.

“A great deal can be done to improve readiness to deal with disaster generally, but it is impossible that any government could be permanently ready to come at once to the assistance of everyone needing help in a disaster of that scale and suddenness, unless it were to maintain a standing force of rescue personnel beyond the present capacity of society to fund.”

The commission hopes that this report and the interim report will serve as a detailed record for the future, of what happened in the floods and where things went wrong. However, it is in looking to the future and at longer term strategies that worries Holmes.

“Years of drought did not promote rigour in flood planning, whether in relation to disaster response, dam management or land use. Complacency about flood prevailed, at least in parts of the state, over many years,” she said. “And there is a risk that the recommendations made here will be enthusiastically taken up in the short term, but, absent another flood disaster in the next few years, priorities will drift and the lessons will be forgotten.”

This is now where newly elected state premier Campbell Newman can prove his worth. Prior to election he declared that his political party was ‘the only team’ that could implement the flood inquiry’s recommendations fully, and help to rebuild people’s lives and businesses.

While Australia keenly awaits Newman’s next action, the investigation being carried out by the Crimes and Misconduct Commission is still underway. Further industry-wide responses to the commission’s findings are also anticipated. As IWP&DC went to press, organisations such as ANCOLD and Engineers Australia were still conducting thorough reviews of the document before making any public comment.

This may well be the final report of the Queensland Floods Commission of Inquiry, but it is definitely not the final word we will hear on the subject.

Flood mitigation manuals

The operation of Wivenhoe and Somerset dams during floods is governed by a flood mitigation manual which prescribes procedures for operating the dams to reduce the effects of flooding, with the prime purpose to reduce flooding in the urban areas of the floodplains below Wivenhoe dam. This is achieved by the proper control and regulation in time of the flood release infrastructure. The manual sets out “˜strategies”™ for use during flood events at Wivenhoe dam (W1, W2, W3 and W4) and explains how flood engineers should decide which strategy they should operate the dams in at any time, and how much water to release.
The manual states that it must be used for the operation of the dam, but there is no legislative requirement to that effect. However, section 374 of the Water Supply (Safety and Reliability) Act confers on Wivenhoe dam”™s operators protection from civil liability for acts and omissions done or made honestly and without negligence in observing the operational procedures in the manual.
Taken from Section 16.2: The flood mitigation manual for Wivenhoe dam and Somerset dam, Queensland Flood Commission of Inquiry Final Report, pp442-3.

The recommendations: Appropriate, feasible and cost-effective

The Queensland Floods Commission of Inquiry wanted to make recommendations that were “˜appropriate, feasible and cost-effective”™ in order to improve the response to any future floods or other natural disasters. Where the commission identifies a recommendation that has significant cost implications, the report details this in the relevant part and frames the recommendation appropriately. However, in the time available to it, the commission said it was not in a position to exhaustively seek evidence on the cost of various alternatives. Instead, it focussed on making recommendations about what might usefully be achieved.
The recommendations covered areas such as floodplain management; development and flood considerations; the performance of insurers; the operation of Wivenhoe dam and other dam related issues. Listed below is a small selection of recommendations from the extensive 177 that are contained in the final report.
1) Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include:
“¢ Ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties.
“¢ Ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology.
“¢ Putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate.
2) The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season.
3) Seqwater should ensure that any future peer review process:
“¢ Is co-ordinated by someone independent of those who wrote the report.
“¢ Entails the provision of all relevant information to the peer reviewers.
“¢ Permits sufficient time for the review.
“¢ Documents all contact between those whose actions are under review and the reviewers.
4) The Queensland government should ensure that, when it considers options for the operational strategies to be employed at Wivenhoe and Somerset dams, and North Pine dam, it is presented with a wide range of options which prioritise differing objectives. The Queensland government should determine the operational strategies by considering the implications of each option over a range of flood events for at least:
“¢ Inundation of urban and rural areas.
“¢ Water supply security.
“¢ Dam safety.
“¢ Submerging of bridges.
“¢ Bank slumping and erosion.
“¢ Riparian fauna and flora.
5) The Queensland government should ensure that all flood mitigation manuals include the requirement that those operating the dam during flood events hold current registrations as professional engineers.
6) Seqwater should consider engaging a technical writer to develop completely new manuals after the operational strategies for Wivenhoe, Somerset and North Pine dams are set by the Queensland government.
7) The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved.
8) The Department of Environment and Resource Management should conduct periodic dam safety information and education sessions with emergency management personnel including those from Emergency Management Queensland, local and district disaster management groups and local councils. Priority should be given to sessions if the Bureau of Meteorology forecasts a wet season with a greater than 50% chance of above median rainfall.
9) As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe dam and Somerset dam the Queensland government should consider whether the dam operators should be able to extend the drawdown of the lake beyond seven days in order to reduce downstream bank slumping.

Building more resilient flood warning services

In its interim report in August 2011, the flood inquiry commission discussed Seqwater”™s flood preparedness in some detail. “˜The prediction of the La Nina wet season by the Bureau of Meteorology (BOM) in October 2010 had (or should have had) implications for Seqwater, as an owner and operator of dams,”™ the report stated.
However in its evidence presented to the commission in March 2011, Seqwater stated that the rainfall forecast it receives from the bureau to assist in making operational decisions during flood events “˜are not sufficiently accurate to be used as the basis for making decisions on releasing flood water from dams. Currently a degree of uncertainty exists in all weather forecasts, particularly in quantitative forecasts, and the longer the forecast lead times the higher the degree of uncertainty in the forecast”™.
Seqwater also claims that BOM quantitative forecasts for the dam catchments issued over the key days of the flood event underestimated the actual rainfall, which was between 160-340% of the available quantitative forecast for the dam catchment.
Indeed the flood commission did acknowledge the unpredictable nature of weather forecasting. The interim report said that it accepts that “˜primarily because of uncertainties associated with rainfall predictions, the achievement of an ideal strategy is possible only with the benefit of hindsight.”™
Welcoming the release of the final report, Services Division Head of the Bureau of Meteorology, Dr Ray Canterford, said the bureau has continued to strengthen its working relationships with state and local government authorities on a number of fronts, including improved information sharing during severe weather and flood events.
“˜The extensive flood events of last year were tragic and unprecedented. The bureau supports the thorough examination of these events through the Queensland Floods Commission of Inquiry, Canterford said. “˜The bureau”™s flood warning services represent a partnership with all levels of government and we will continue to assist Queensland state and local governments with its technical expertise in order to build more resilient flood warning services now, and into the future.”™
He continued: “˜The bureau is actively contributing to a statewide review of river and flood monitoring networks, which is being led by the Queensland Reconstruction Authority, and has also established closer working relationships with local governments in their implementation of systems for localised flash flooding alerts. This includes improved river height and rainfall collection methods, to ensure capacity is being built at the local level.”™
“˜Together these initiatives have contributed to the collection of more comprehensive information, and ultimately built stronger links in the flood forecasting and warning network,”™ Canterford concluded.
In October 2011, the bureau participated in pre-season disaster management workshops in 13 towns and regional centres across Queensland, strengthening a partnership approach in emergency planning and response. It says it will continue to work closely with Queensland authorities to assist in preparing for and delivering services during severe weather and flood events.
The commission”™s interim report focused on those matters that had been identified as needing to be addressed before the 2011/2012 wet season. In particular, it dealt with preparation and planning for floods and steps needed to ensure an emergency response that would prevent the loss of life and property. It also recommended that should the Bureau of Meteorology predict with confidence equal to or greater than 2010″™s prediction another wet season of similar proportions, the full supply level of Wivenhoe dam should be lowered to 75% in the 2011/2012 wet season: a step which was in fact taken.
The Bureau of Meteorology will respond formally to the recommendations as part of the Australian government”™s overall response.

Fact file on the commission of inquiry

The commission”™s findings and recommendations in its final and interim reports were the result of an examination of an enormous amount of information. More than 700 written submissions were received and community meetings were held in 16 locations in central, southern and western Queensland. The commission also used its powers under the Commissions of Inquiry Act 1950 to obtain statements and documents from members of the public, experts, public servants and members of non-government organisations. Some of those individuals were also called as witnesses in the public hearings which were held around the state. The commission sat for 68 days in total and 6133 pages of transcripts of evidence were produced from 345 witnesses. Fifteen experts were also engaged by the commission and included engineers, hydrologists and research associates.
At all times the flood commission said it wanted to ensure that its work was open and accessible. Its website ( provided information about the progress of the inquiry as well as email, postal and telephone contact details so that anyone, regardless of geographical location, could provide information or submissions. Daily transcripts from the public hearings were placed on the website within 24 hours. In the six months from September 2011 to February 2012, the website received over 66,000 visits and nearly 280,000 page views.