David Andrews
18 September 2015

The implications of complacency with fire and life safe matters in residential buildings

David Andrews


Tel: 02 9233 9023

Mob : 0425 208 915


Building and Construction

Corporate and Commercial

Dispute Resolution


Deputy State Coroner Dillon today handed down his recommendations following the Inquest and Inquiry into the death of Connie Zhang and the fire at 4 West Terrace, Bankstown. Makinson d’Apice Lawyers represented the Owners Corporation of the building from which Ms Zhang tragically fell to her death on 6 September 2012, after being trapped by a fire in her apartment with her friend Ginger Jiang. Ms Jiang survived the fall but suffered terrible injuries.

The Inquest and Inquiry was conducted in June and August this year, and heard evidence from various parties involved in the construction and management of the building at 4 West Terrace, Bankstown, and also Bankstown Council and NSW Fire and Rescue. The outcome serves to remind those involved in the construction and management of residential buildings that fire and life safety measures in a high rise building are important features, which need to be carefully considered. 

Issues Considered

1. Breach of the Building Codes?

Two critical issues emerged during the Inquest and Inquiry. Firstly, whether the building’s ‘effective height’ was greater than 25 metres; and secondly, whether the central void area in the building was an ‘atrium’ or a light well.  If the building was greater than 25 metres in effective height, or contained an atrium, then sprinklers were required to be installed in the building to comply with the relevant building codes.

The Coroner was satisfied that the effective height of the building was less than 25 metres (or alternatively, if the rule was breached, the developer should not be criticised because it was advised by architects, engineers, planning authority and certifiers that the building complied). However, the Coroner was also satisfied that the building did contain an atrium at the time the building was completed, and at the time of the fire. This meant that the building was required to have further fire safety systems in installed, unless an alternate fire-engineered solution had been built.

The Coroner expressed the firm view (and has made recommendations accordingly) that the most effective fire safety measure in any building housing multiple occupants is a fire sprinkler system. The Coroner went on to say that had “such a system been installed…it is almost certain than Connie would not have perished nor would Ginger have suffered such terrible injuries.”

2. Regulatory system failure

The Coroner found that that the “regulatory systems and processes intended to ensure large residential buildings are constructed according to strict standards failed.”  The facts of this case revealed failures at every step of the way from the moment the building was completed. However, none of these matters caused the fire in the buildings (which was speculated to have been caused by a smouldering cigarette butt being blown under or into a bin on the balcony).

Critically, the Coroner pointed out that although problems with the building’s fire safety had been first identified in 2010, nothing substantial had been done to make the building safer before the fire in September 2012. Although Bankstown Council had issued a Fire Safety Order to the Owners Corporation, it was not followed up in the first instance (and may not have been received). Following a second Fire Safety Order issued by the Council, the Council and the developer engaged in a paper war, with no action being taken by the Council to enforce any Fire Safety Order. This was compounded by a Fire Order issued by NSW Fire & Rescue in April 2012, which was also not followed up or enforced in any way. The executive committee of the Owners Corporation relied upon its Strata Managing Agent to address the orders.

In relation to the “red-tape labyrinth”, the Coroner remarked: 

“It appears to me a combination of an ineffective or only very slowly effective system of regulation and enforcement of fire safety standards, and a cost-conscious developer who (despite his claims in evidence) was reluctant to comply with orders, resulted in a stand-off that jeopardised the safety of residents in the building for about two years. It was only the fire itself that result in real action”

Lessons for Owners Corporations

The facts of this case could, disturbingly, occur in any high-rise residential building in NSW. 

Furthermore, evidence was provided by NSW Fire & Rescue to the effect that the fire stations in the Sydney Metropolitan area were constructed when flashover times were much longer. Because Flashover (when everything burns) can now occur in minutes, it is unlikely that they can attend a fire before flashover occurs. This places more emphasis and reliance on the fire and life systems in buildings because in case of fire, they are the frontline defence.

This Inquest and Inquiry is a salutary reminder for all those involved in the construction and management of residential buildings. Do not fall into the complacency trap when dealing with fire and life safety matters. It is important that an Owners Corporation ensures than annual fire safety checks are performed, and performed properly by qualified persons, as the primary consideration should be the risk, not cost and convenience.

For more information click here to read

To read the Coroner’s Reasons for Decision click here 

David Andrews

18 September 2015

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