• Aisling Salisbury

Errors Like This Means A State Full of Holes

Updated: Feb 16

The state of affairs in my home state of Victoria isn't black and white (if I can say that nowadays?), it's Swiss Cheese! All courtesy of Government bungling and mismanagement.


Ash, what do I mean by Swiss Cheese?


I'm referring to the Swiss Cheese model which was proposed by James Reason. Effectively each layer of cheese is a level of defence or a decision made. If a mistake made or an error isn't seen then it slips through the hole, by itself it probably isn't major, but as it passes to the next level of defence if another fault is made it slips through the hole and so on and so on. Eventually, the threat lines up with all the holes and it gets through resulting in disaster. An interesting fact here, I understand that Reason likened it to cogs in an engine all having to match up, but Swiss Cheese is what we got.

Victoria is a classic example of the Swiss Cheese model with the threat being a mass outbreak of COVID-19. The layers of defence in place have failed or never existed and then combine that with poor decision making then it was inevitable Victoria would find itself where it is today.


To start with let's look at the timeline of Victoria.

  • March 16th: A "State of Emergency" was declared, the only state to do so. It was deemed necessary to "flatten the curve" (remember that saying?) it appeared that Victoria was trying to get ahead of the spread.

  • March 29th: Stage 3 restrictions. Victorians are locked down and can only leave their house for exercise, essential items, medical care, work or education if it can't be done from home. A maximum of two people (outside of a household) in any gathering was allowed. Other states enacted similar restrictions but Victoria was slightly different, most notably there were bans on:

  • Golf (considered exercise in other states under social distancing practises);

  • Fishing (yes, five people on a pier spaced out is very dangerous to the fish);

  • Partners, that's right! You couldn't see your partner unless you lived together. Known as the "bonking ban" (was overturned)

  • April 2nd: An abattoir, Cedar Meats had a worker test positive to COVID, it was understood the worker was never on site, but fellow employees stated that they were occasionally.

  • April 29th: Cedar Meats now have a cluster. The report is that they failed to report the positive test rates for about a week. Although it was also reported that Cedar Meats was a major campaign donor to the Andrew's government. Regardless the departments hadn't continued to monitor despite a possible red-flag a month earlier.

  • May 8th: The Prime Minister, State Premiers and Chief Ministers agreed to a "Re-opening Plan" it meant that some business could reopen, gatherings of five people in the home and 10 outdoors. Many states had already enacted many of this before the unified agreement. The idea of the national plan was to get everyone on the same page.

  • That Same Day: After the national announcement, Victorian Premier Daniel Andrews stated that Victoria won't consider reopening just yet, maybe next week. Media did question as to why it wouldn't happen considering Victoria had done well with suppression and announcing the change would mean families could do something for Mother's Day.

  • May 10th - Mothers Day: Victoria is the only state that forbids people from seeing their mother's on Mother's Day. Although many breached this or said to mum "hey let's be creative and meet up at Bunnings or the Supermarket." Despite the good suppression numbers at the time Andrews instead decided to dangle the carrot and continue the mantra that "we can't risk lives".

  • May 11th: Andrews announced from May 13th Victorians can have gatherings of five people in the house and 10 outside. Many questioned how in the space of 24hrs a complete 180 had been made with this decision and why couldn't it have been done on Friday/Saturday and possibly have allowed families to get together the day before.

  • May 24th: It was announced that from June 1st Victoria would be moving to effectively a highbred of Steps One and Two in the National Reopening plan. Other states were effectively planning to be full-on into Step Two by June but Victoria was still going to play it safe.

  • June 1st: The new rules are meant;

  • 20 people for inside and outdoor gatherings;

  • Restaurants, Cafes and Bars were permitted to open if they had proven they had a COVID safe plan in place;

  • Yes, Golf and Fishing made its return;

  • Also to open were zoos, outdoor amusement parks, libraries, youth centres and community facilities;

  • Beauty and personal care services like nail salons, spas and tattoo parlours would also reopen

During the whole time, Victorian's also faced the harshes penalties in the country. Included was $1600 on the spot fines for breaching COVID rules. It was so strict that a mother and daughter received $1600 fines each for doing a driving lesson together, it was overturned but only after a media outcry. Police were permitted to do spot checks. If they showed up at your house, and someone was proven not to reside there, everyone was fined. A family that, albeit stupidly, held their son's birthday party had 18 people around. Close to $30,000 worth of fines were handed out to the attendees. Neighbours all over were encouraged to call and dob in neighbours as well.


The leadership of Andrews during this whole time was "you must do what we say and don't question it" meaning he got dubbed "Dictator Dan." The rules showed no common sense or leeway and no explanation as to why the data of this state was different compared to other states. If anyone dared question Andrews then the mantra frequently was "it's not worth a life!"

Victorians finally saw a light at the end of the tunnel on June 1st. They could get out again and do many of the things they used to, with precautions. Other states were well into Step Two re-openings in the first week of June but Victorian's weren't fussed. After two months there were signs we were out of this. Victoria had done well. Lockdowns were harsh, penalties the strictest and even with dragging its feet with the reopening people were happy. They were getting back to normality.


This was highlighted on June 14th, when it was stated that from the 21st the state would move in line with Step 2 of the National Reopening Plan. But within a week that was cancelled due to "concerning increases in cases" and from "an unknown source". By the first week of July, suburbs were considered "hot spots", public housing estates were locked down and it wasn't long before Victoria had its border shut to every other state. Melbourne's metropolitan area was locked down to Stage three again (but golf and fishing were allowed this time?) later Melbourne went to Stage Four meaning, well, house-arrest. You must stay in your home, are only allowed out for one hour a day to shop for essentials or exercise and you must be by yourself. Also, you can't go more than 5kms from your place of residence. Cases hitting up to nearly 800+ a day were recorded. People have also died.


Where did it all go wrong? As I said, it's a perfect Swiss Cheese model. I believe it started as early as April. So let's look at the Swiss Cheese model when it comes to this catastrophe.


Hole 1 - Differences in rules to other states:

Golf was the biggest epidemy of the illogical decisions of the government. Sam Newman an ex-Aussie Rules footballer, media personality and avid golfer prooved that Andrews was not logical in any of his decision making. Newman protested outside State Parliament house. Media brushed him off as seeking attention. Yes, Newman is an attention seeker, but when you listen to what he said, he had logic in his argument. Why was golf banned when it had always been the most "socially distance activity" and why could you drive across the border and play 18 holes but couldn't in Victoria? What were the reasons?


Hole 2 - The tone and mantra coming from officials:


The tone was always "you must do this or you will kill someone". When it came to Newman's protest Andrews' response was "I don't pay attention to Sam, I want to play golf, but I don't need to play golf! It is not worth a life!" but as Newman said on the radio "that's not entirely a logical response." Newman wanted some logic in the decision making, adding "if Victoria allowed golf but if you were over 65 you can't play, well that makes sense if you're over 65 you are most at risk. Instead, we just got told, do as I say or you will kill someone, that's not logic, that's drama." There definitely would be a degree of logic if that was the case, but the tone from the government was not that, it was to address the people as if they were children. You better do what "Daddy Dan" says or you will kill someone! You can only talk like that to adults for so long before the message is lost.

Hole 3 - Drunk with power:

The "bonking ban" showed that government departments were probably overstepping the mark. The mother and daughter being fined for being together in a car to learn how to drive was illegal? It showed Victoria was becoming more a dictatorship in that everyone must follow the rules or else. Police in other states were instructing people to move from park benches or stop sunbathing on the beach and go home, but they weren't fined on the spot as harshly like Victorians. Dictator Dan was now the narrative.


Hole 4 - Cedar Meats:


After a positive test of a staff member at this abattoir, there was no follow up by the health department or agencies to continue monitoring the place and thus put the emphasis on the company to do it themselves. The reason given was that the staff member had never been on-site, but other staff members reported that they were at times. At the end of April, this was the biggest cluster in the state and threatened to derail everything. Blame was placed at the company for not reporting to the Health Department for at least a week. However, a red-flag was raised at the start of April and there was no follow-up or monitoring? Instead, the honour system was in place at a food handling facility during a pandemic? Police were fining people left, right and centre but a food processing plant was assumed to be "ok" with no follow-up? Combine it with the fact that they are a political donor to the Government and it starts to smell of a "cover-up". What adds to this belief is when a school was instantly closed after a teacher had tested positive for COVID. This teacher was actually conducting classes from home and had never been on the school's property, yet it was closed instantly? So you close a school at the drop of a hat but don't monitor or close an abattoir, who happens to also be one of your donors?


Hole 5 - Mother's Day:


Other states were lifting restrictions in the week leading up to Mother's Day. The Federal Government and all States and Territories agreeing to a Reopening plan, Andrews, despite agreeing to the plan, still didn't open up in time for Mother's Day. Instead, all weekend it was told to Victorians reopening is "not worth a life" including on Mother's Day itself the mantra was "you are putting mum at risk!". Yet, just the day after it was decided to reopen? If decisions had been made earlier, many families could've gotten together in small groups for Mother's Day. Now, we all love our mothers, but if it's only on one day a year you go see her and tell her that, well, I think you should reassess your priorities. However, the decision appeared to be delayed on purpose. Why was it not possible to assess the moves on Friday and by Saturday night make an announcement? The scare-mongering tactic was used all weekend but by now it was beginning to wear thin and contributed to the belief of Hole 3 - Drunk with Power.


Hole 6 - Black Lives Matter Protest:

10,000 people attended this protest because at the start of the week they had effectively been given a green light. The Andrews government and the Police Minister announced that attendees would not be fined because it was "dangerous to crowd control that many people and keep the peace". It was then added "please don't go, but if you feel you must, please social distance" the equivalent of your mother saying "look if you're going out, please take a coat". Compare this to the Prime Minister, who acknowledged the right to protest but if you go to this protest you were showing "great disrespect." Highlighting the facts that by going meant you were not recognising the fact that we found a way to celebrated ANZAC day without mass-gatherings and more importantly, hundreds of families and their friends couldn't even attend a love ones funeral and give them a proper send-off. It spoke to the populous as a leader should and he implied to find a different way to conduct this protest. In New South Wales, the state government attempted to get a court order to block the protest, which was successful but got overturned on appeal the next day. Regardless, the police in that state ensured that the protesters didn't remain stagnant for long times, in essence forcing a march and stating that it could only go for a two-hour window, which was upheld quite well on both sides. In Victoria, we had the city gridlocked with protesters and the police were instructed to not do a thing. The Victorian Government fined the organisers a week later due to an outcry. Problem solved? Nope, three people received a $1600 fine each, that was all. The state government should've attempted a court-order or say to the organisers that if it went ahead they would face a $50,000 fine. At least it would demonstrate that you were doing every humanely possible to stop this mass-gathering. It didn't and it leads to Hole 7.


Hole 7 - One rule for some, one rule for others:

This is the hole that destroyed the credibility of the Andrews' Government. Unlike the other states, Victoria hadn't taken a hardline with the protesters and had effectively given a green-light to it. Despite having a state under lockdown for nearly two months, dishing out the most and harshes fines of any state, refusing to answer questions, provide logic in the decision making, a possible cover-up with a cluster, the same mantra that we were all children and if we went out we would kill someone, however, all this didn't apply to the protesters. Victorians everywhere went "no more" after this. Former Federal Parliamentary Speaker Bronwyn Bishop did say very early in the piece that when it came to Victoria's lockdown laws that going down such a strict and punishable path with the same mantra every day meant that it wouldn't take long for "civil disobedience to occur." It happened because after the protests more people went out. Just the day after a group of police was instructed to even close a pier of fisherman because it was "dangerous due to social distancing" yet the day before 10,000 were in the city with no social distancing. Although people started going out more after this weekend the majority were sensible, still followed the rules but started returning to restaurants, cafes and bars. They went and saw friends and family, they started returning as close as possible to their lives even under the rules. For the minority of idiots, the protest symbolised either a) the emergency is over OR b) the whole thing was a scam. Regardless, as I say the majority of people did the right thing but more people were out.

Hole 8 - It's all your fault!:


Two weeks after allowing the protests to go-ahead the lifting of restrictions was cancelled and the blame was labelled squarely by Andrews at "Families" for not following the rules. We saw a return to the naughty child mantra, it was exactly like Andrews saying "I gave you freedoms and you took advantage. This is your fault!" Now yes, following the protests people did start going out again. But they were still doing the right thing. It didn't stop the fact that the blame was labelled solely at families who got together though. We soon learnt this was not the case.


Hole 9 - Contact Tracing, Testing, Literature, Quarantine and Exercise:


As cases started to go up, it was apparent that the state's health department responsible for contact tracing couldn't keep up and was behind the eightball. It couldn't handle the task. The resources simply weren't in place despite some time to prepare. Flattening the curve wasn't just about Hospitals but getting facilities ready for a mass pandemic. Those being tested for COVID would also be waiting up to nine days for results and literature was even being distributed at some testing sites that after a test you only had to stay at home and self-isolate if you had symptoms. Those with the virus were still going out for supplies etc. instead of being forced to stay at home and be traced at all times. The "honour system" and the threat of a spot check was seen good enough by authorities when these people were actually infected? The real pièce de résistance though was when the Chief Health Officer stated that it was entirely legal under the State's Human Rights Charter for people with COVID to leave their homes if they were exercising. The wheels really were starting to spin-off now.

Hole 10 - Hotel Quarantine:


Well, the spike in cases was due to the infection coming from the very thing that was meant to protect us. No doubt, this is the biggest public disaster in Australian political history. I will be posting more on this bungle soon, as this is already a long post. I digress, Victoria's woes were happening in the background in as early as April (told you). Only two days after the cancellation of restrictions was meant to be easing it broke that the State's Hotel Quarantine programme was a massive failure and in fact, was not quarantining the virus at all. Quarantine was run by private security firms, effectively nightclub bouncers who were hired via WhatsApp and Gumtree to manage it. These guards had no training in the use of Personal Protection Equipment or Biosecurity procedures. The health department also had very little staff in the hotels to oversee it. The Age Newspaper even reported on June 23rd that "Multiple federal government sources have confirmed concerns about the lack of expert medical personnel advising hotel workers, who have the task of delivering food and escorting guests without appropriate personal protective equipment. The hotel staff had no training in the use of PPE and would wear the same mask and gloves for hours, while no medical waste bins were provided in the initial weeks of hotel quarantine.” Unlike other states that got their State Health Department, Police (as too Private Security) and the Military to run it and turned their hotels into Fort Knox, Victoria was entirely a private enterprise to probably the lowest bidder and to meet "inclusion quotas" of diverse companies. Victoria's three quarantine hotels might have appeared to be like Fort Knox in appearance, but inside it was nowhere near the expectations you would except for a biosecurity hazard. Those who were quarantined in the hotels also weren't tested for COVID at any time during their stays either. On July 2nd it was reported that hotel staff were sleeping with guests, allowing guests to go around the corner to convenience stores, sharing cigarette lighters with fellow staff and guests, allowing family members and other guests to visit each other in other rooms to play games. Security staff were also seen to be shaking hands with each other and guests. The main source of infections was now spreading into the community. Combine that with more people getting out due to Hole 7 and the fact that these security guards were also going to second jobs like Uber and Taxi driving, the seeds of the disaster had been planted.

So when people ask how could a state that had the harshes lockdowns, the slowest to reopen and also declare a state of disaster at the start still find itself in this position? You can now answer "Swiss Cheese". It wasn't just one clear cut problem, it's due to massive failings in multiple government departments, no accountability and poor leadership. Victoria is a state that was in trouble well before COVID-19 and this has resulted in a high price being paid and the fault is solely at the Andrews Government. The people of Victoria did the right thing and even put up with being treated like children because "Daddy Dan" apparently knew best. Yet his government couldn't handle the basics.

So how has he gotten away with this?

Well when he has spent the last six years in government with no accountability, has full control of the lower house so even with cross-bench support a "no confidence" motion will never get up it has made him believe he was invincible and that the state would follow him to the ends of the Earth. Well, despite, a Twitter following wanting to "give Dan a hug" and saying they "stand with Dan" the tide is turning and I firmly believe that if COVID has done anything positive it has exposed this poorly run government that is lead by Andrews. In this post, we haven't even gotten on to the pre-COVID budget, belt and road, corruption, smashing the Country Fire Authority into a thousand pieces, red-shirts and branch staking. I understand that you are human and that these decisions will be taking its toll on you. But it's your decisions and those of your Ministers that have put us here and like a fish, it rots from the head. You have lead the state into a disaster that was man-made by not being prepared and trying to protect yourself only.

Now calling for you to resign is not productive right now, but how can we continue to trust you and your government to get us out of this? This should now be outsourced to Federal or Independent Authorities, the same authorities you have claimed to support in the COVID crisis then immediately abandon to go your own way. How can Victorians trust you to get them out of this when the same person/s who put us there are still making the decisions? How can we trust you too when you refuse to answer basic questions? When people do ask questions they get hounded by yourself and the Twitter-verse for simply asking for accountability. It is not just political point-scoring or evil NewsCorp actions against you. It's demanding accountability and all governments in a democracy are accountable. Before this, the 'Ruby Princess' was the biggest failure in Australian political history when it came to COVID-19, but unlike yourself, an inquiry went ahead with all guns blazing and the report was released last week and their State's Health Minister is probably not going to survive the next week.


The bell is tolling for thee, Daniel Andrews. Just because you stand in front of a press pack for 90 minutes each day and talk doesn't mean you are doing the right thing, but some people seem to buy this act. Well, I don't and never did even before COVID! I will congratulate you though as it's very impressive that you can stand on your feet and say nothing for 90 minutes. Stop hiding behind your so-called "inquiry" into the Quarantine programme and order it to continue, there is no reason why it can't go ahead even under the new lockdowns. The sitting of Parliament too. It leads to mistrust that perhaps you do have something to hide and are afraid of accountability. The people have a right to answers now, even basic ones. We are here because of your government's inept attitudes and arrogance. You might feel you have the Twitter following on your side, but once they realise that their favourite coffee shop will never be reopening because the owner has gone under, I hope they will finally wake up from their keyboards and phones to finally see your faults and realise the disaster of handling this pandemic is entirely at your government's feet.


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