ACT Emergency Services Agency commissioner Georgeina Whelan and Emergency Services Minister Mick Gentleman must take responsibility for a culture of blame shifting and fear that a snap review has found is crippling the ESA.
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According to the review's report the agency, which is responsible for ambulance, fire, search and rescue and roadside rescue services in the territory, needs to undergo profound changes in order to replace "a culture of blame and fear" with one of "trust and collaboration".
Report author Professor Tony Walker said many stakeholders "described an at times chaotic environment with a culture of blame" and that "there is a consistently reported lack of trust among the executives which is impacting the agency".
It is of particular concern that Professor Walker found the ESA's first responders do a good job despite a divided and bickering executive leadership team that made their task harder than it has to be.
Noting the impact of COVID and the "Black Summer", he said "[the] ESA has been operating at a high tempo for a number of years. This is increasing workforce fatigue and challenging traditional planning cycles".
This, considering first responders put their lives and wellbeing on the line for the community everyday, is just not good enough.
The United Firefighters Union, which has been critical of the ESA's management for many years, has a point when it says Mr Gentleman is not the right person to implement the review's recommendations.
Given he has been the Emergency Services Minister for almost seven years there is an argument that if, as the review found, the ESA is suffering from a lack of leadership and direction Mr Gentleman is part of the problem, not the solution.
He is, after all, the responsible minister and, as such, appears to have erred by coming out in support of the ESA commissioner and its leadership team on June 8.
Given that in its response to the review Justice and Community Safety has accepted all 18 of Professor Walker's recommendations, Mr Gentleman's assertion that "I have every confidence in the ESA and the ESA commissioner" was clearly premature.
And it is impossible to overlook the fact the review must be seen as a damning indictment of the day-to-day leadership of the ESA by Commissioner Whelan.
Commissioner Whelan, a former army brigadier, joined the ESA as the chief officer of the State Emergency Service in late October 2017. She was appointed to the top job in August 2019 and has held that position ever since.
Her tenure has not been without controversy and incident.
In 2020 she wrote a strong letter to the chair of the ACT Bushfire Council, Dr Sarah Ryan, saying she had lost confidence in the body which she accused of undermining the ESA in the aftermath of the 2019-2020 fire season. The council had expressed concerns about "persistent shortcomings" in the ACT's level of bush fire preparedness for the 2020-21 fire season.
More recently she has been rounded on by the members of the ambulance service, who publicly declared they had no confidence in her leadership.
ESA has also faced questions over how and why Defence was brought in to help during the Black Summer fires, given an army helicopter started the blaze that destroyed much of Namadgi National Park.
Given the damning nature of the review's findings, and JAC's acceptance of its recommendations, it is difficult to see how the management culture within the ESA can be overhauled without a significant shakeup of the existing leadership structure.
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