This incident highlights the dedication and commitment of FESA Emergency Service volunteers and the personal sacrifices not only in time, effort and training, but also to their personal well being in providing this vital service to their communities.

The events of the 1st to 3rd of April 2004 involving the death of FESA SES volunteer James Martin (Jim) Regan were tragic. The tragedy has had profound effect within his community, the Fire and Emergency Services Authority, and notably within the State Emergency Service as this death was the first loss during operations. The Review Team is of the opinion that although the initial incident
was reported as a single rescue and possibly routine, a series of other contributing factors led to it becoming a major incident.

In conducting this Major Incident Review the review team has been cognisant of working in hindsight, and the intention is not to lay blame with respect to actions of individuals. However, this review is an opportunity to analyse the current systems and procedures that were implemented, to identify areas where improvement can be achieved and make recommendations.

These recommendations should not only lessen the likelihood of such a tragedy occurring again, but also reduce the impact of such emergencies on volunteers and improve the effectiveness of FESA. Some of the recommendations made will require the cooperation and commitment of the Western Australian Police Service (Hazard Management Agency), the Department of Conservation and Land Management
(Land Manager) and FESA to achieve