Introduction
Acknowledgement of First Peoples
The Board of Inquiry into the McCrae landslide acknowledges Aboriginal and Torres Strait Islander people as the first peoples and Traditional Owners and custodians of the land and waterways on which we live. We honour and pay our respects to Elders past and present.
Letter of Transmission
Introduction
On 18 March 2025, the Board of Inquiry was established to inquire into, report on, and make recommendations in relation to, amongst other things, the cause of the landslide that occurred on 14 January 2025 in McCrae on the Mornington Peninsula (McCrae Landslide), the adequacy of measures taken to prevent and minimise landslides in McCrae, and measures to be taken for the prevention or mitigation of the risk of similar landslide events occurring again in McCrae.
The McCrae Landslide occurred on the escarpment of 6 and 10–12 View Point Road in McCrae on the morning of 14 January 2025. The landslide has had a profound impact on the McCrae community. It destroyed Kellie and Nicholas (Nick) Moran’s house which once stood at 3 Penny Lane. It has upended the lives of many residents who were evacuated and have since been displaced.
The impact the McCrae Landslide has had on residents extends well beyond property damage. The psychological and emotional toll for members of the McCrae community has been, and continues to be, significant.
The McCrae Landslide was not an isolated landslide event. It was preceded by a smaller landslide nine days earlier, on 5 January 2025, which damaged the back of 3 Penny Lane. Remarkably, a little more than two years earlier, two landslides occurred in quick succession in November 2022, damaging two properties. Those landslides also occurred on the escarpment of 10–12 View Point Road, to the west of the site of the McCrae Landslide.
Given the history of landslides in McCrae, and the impact on the community, it was time to find the answers to the important and unanswered questions being asked by the community.
Within a short time of the Board of Inquiry commencing work, it was ascertained that it would be necessary to engage an expert geotechnical engineer to opine on the cause of the McCrae Landslide because no other expert had yet provided an opinion. Preeminent geotechnical engineer, Darren Paul, was then engaged.
Determining the cause of a landslide is often complex. They can be caused by the interaction of multiple factors – some of which are natural, some of which are anthropogenic (that is, caused by human activity). Complexities reside in disentangling these causal factors and weighing their relative contributions.
Notwithstanding those complexities, a simple point ultimately emerged: the November 2022 landslides, the 5 January 2025 landslide, and the McCrae Landslide share a common causal factor–water.
The Board of Inquiry has found that the McCrae Landslide and the earlier landslide of 5 January 2025 were caused by water that leaked from a burst water main owned by South East Water (SEW). That burst water main was located approximately 450 metres south of 3 Penny Lane, near the corner of Bayview Road and Outlook Road. The burst water main had leaked for several months prior to its repair over New Year's Eve, releasing about 40.3 million litres of water during the period it was undetected – the equivalent of about 16 Olympic-sized swimming pools.
In the months leading up to the McCrae Landslide, residents knew that something was not right. Water from an unknown source was observed on the streets uphill of 3 Penny Lane throughout November and December 2024. The water roared in the stormwater drainage system. It bubbled up through the roads. It pushed up and cracked the bitumen. It created potholes. It flowed down the streets. It saturated and seeped from the nature strips.
Throughout November and December 2024, residents of McCrae raised their concerns about the water with both the Mornington Peninsula Shire Council (Shire) and SEW. The complaints were numerous.
For many weeks, no one knew the source of the water – not the residents, the Shire nor SEW. The water was thought to be related to potential issues with stormwater drainage, road drainage or SEW’s water mains. The Shire and SEW treated the water issues with varying degrees of priority.
While the Shire and SEW took steps in response to those water issues, none were effective in preventing the water from flowing towards the escarpment on which the McCrae Landslide occurred. While each organisation invested resources and time, they operated in siloes, missing valuable opportunities for collaboration and co-ordination.
The Board of Inquiry has sought to understand why the Shire and SEW acted as they did in the lead up to the McCrae Landslide. Some reasons stand out.
First, neither the Shire nor SEW knew at the relevant time that the water surfacing on the streets of McCrae throughout November and December 2024 was caused by the burst water main. The burst was only discovered on 30 December 2024 and repaired in the early hours of New Year’s Day. The burst was not easy to find.
Second, neither appreciated the seriousness of excess water accumulating in an area adjacent to a steep escarpment with high susceptibility to landslides. As a result, they did not respond with the urgency, nor view the situation through the appropriate lens that the situation demanded.
Third, neither prioritised the management and mitigation of landslide risk in McCrae. The Shire had not shared with SEW information regarding landslide risk in the McCrae area.
In view of all the information before the Board of Inquiry, it became apparent that landslide risk was, and is, largely forgotten. Landslide risk does not feature in the State Emergency Management Plan (SEMP). It does not feature in the Southern Metro Regional Emergency Management Plan, which is applicable to McCrae. It does not feature as a significant risk in the Mornington Peninsula Shire Municipal Emergency Plan. It does not feature in the Shire’s Asset Management Strategy and Stormwater Asset Management Plan. It does not feature in SEW’s reactive processes and procedures for detecting leaks. This must change.
One of the chief lessons the Shire, SEW, and similarly placed organisations, must take away from the work of this Board of Inquiry is that landslide risk cannot be ignored. The consequences can be devastating. Although the McCrae Landslide resulted in no fatalities, one person was seriously injured, and several others narrowly escaped harm.
History should not repeat itself in McCrae. The Shire and SEW must change their approach to managing and mitigating landslide risk in areas of high landslide susceptibility. In determining how to move forward, each organisation must look to the past to understand what has happened, why it happened, and what could have been done differently.
Meaningful progress has been made by both the Shire and SEW in advancing reform. Both organisations are reviewing their current practices and looking for ways to change and incorporate the lessons learnt from the McCrae Landslide. One of the most significant changes is that the Shire is planning a strategic assessment of landslide risk patterns across the full escarpment area and updating its asset management strategies and processes to account for landslide risk. Similarly, SEW has recognised landslide risk in its Strategic Asset Management Plan and is in the process of mapping areas potentially susceptible to landslides to guide its approach to asset management and risk control measures, including decisions regarding asset renewal in those areas.
That said, the path forward will not be without its challenges. The solutions to prevent or mitigate the risk of a further landslide in McCrae will take time and energy to implement.
In order to mitigate the risk of further landslides at the site of the McCrae Landslide, substantial works need to be carried out, involving, for example, the use of engineered rockfill. The cost of such works will not be insignificant, nor will the time required to complete them.
In order to mitigate the risk of further landslides in McCrae generally, several risk reduction measures have been recommended. These include the introduction of an Erosion Management Overlay (EMO) – a planning tool designed to address landslide risk – over parts of McCrae that are known to be highly susceptible to landslides; assessing water infrastructure; improving a range of processes; amending emergency management plans; and educating the community. The recommendations will require sustained effort over several years.
Some reforms will also need to occur on a broader scale, including at state level, so that systemwide improvements can be implemented to address landslide risk.
To recognise those challenges is not to ignore that the residents of McCrae have already endured too much stress and uncertainty. Steps need to be taken promptly so that those who have not returned home as a result of the November 2022 landslides and the McCrae Landslide are able to do so soon and safely. Equally, steps need to be taken so that residents who have since returned to their homes feel safe – that is something they both need and deserve. A mechanism has been recommended to assist all relevant parties to progress the mitigation and remediation works required at the site of the 2022 and 2025 landslides. The hope is that this will result in residents returning home sooner and the Shire and SEW being able to turn their focus to broader landslide risk mitigation activities required in McCrae.
Terms of Reference
Terms of Reference
The Terms of Reference raise a number of questions. Those questions and the Board of Inquiry’s answers are:
Q: What was the cause of the McCrae Landslide?
A: Water from a burst water main owned by SEW and located near the corner of Bayview Road and Outlook Road.
Q: Were actions or decisions taken before the McCrae Landslide to prevent or mitigate landslides? If so, were they adequate?
A: Yes, limited actions were taken.
In particular, at some point between 2012 and 2019, the Shire adopted an informal practice of imposing additional planning requirements on properties that were mapped by geotechnical experts as falling within high landslide susceptibility areas. The practice was intended to protect areas prone to landslide, by minimising land disturbance and inappropriate development. This measure, however, was not an adequate substitute for imposing an EMO over those areas.
Q: Were actions, decisions or omissions made that may have contributed to causing the McCrae Landslide?
A: Yes.
Two omissions stand out.
SEW’s delay in locating the burst water main may have contributed to the McCrae Landslide.
The burst water main was located nearly five months after it first started leaking, two months after residents first noticed water rushing along and surfacing on streets uphill of Penny Lane, and six days before the 5 January 2025 landslide.
The Board of Inquiry is, however, unable to determine whether delay contributed to the McCrae Landslide given that this was not the subject of expert evidence. Of course, had the leak been identified and repaired very shortly after it began, the McCrae Landslide would not have occurred. However, the evidence does not establish the critical threshold or timing at which intervention would have averted the event.
Further, that the Shire and SEW did not take steps after the 5 January 2025 landslide to try to intercept the subsurface water flow upslope of the landslide site, and direct it away from the site, may have contributed to the McCrae Landslide.
The Board of Inquiry is, however, unable to make a positive finding on this matter as the experts were unable to opine whether taking such steps would have sufficiently lessened the likelihood of the McCrae Landslide occurring.
Q: Were risk assessments undertaken to determine the likelihood and severity of landslides in McCrae before the McCrae Landslide? If so, were they adequate?
A: Yes.
Significantly, in 2012, the Shire received a geotechnical report which classified the McCrae escarpment in the vicinity of 10–12 View Point Road, as well as other areas in the Mornington Peninsula, as exhibiting high landslide susceptibility.
The assessment in and of itself was adequate as a guide to expected landslide susceptibility. What was inadequate was the Shire’s use of the assessment. The Shire did not commence updating its EMO schedules to incorporate areas identified in the report as having high landslide susceptibility.
Q: Were there any barriers to the implementation of measures to prevent or mitigate landslides in McCrae that existed before the McCrae Landslide occurred?
A: Yes.
There are regulatory barriers. Notably, there are limitations on the ability of current statewide planning policy and tools to manage landslide risk. Further, the regulatory framework relevant to how local councils and landowners manage landslide risk on private land is limited.
Q: What is the regulatory framework in relation to the prevention and management of landslides in Victoria?
A: The regulatory framework is fragmented. Various statutes directly or indirectly support the prevention and management of landslides, including the Planning and Environment Act 1987 (Vic), Building Act 1993 (Vic), Building Regulations 2018 (Vic), and the Emergency Management Act 2013 (Vic).
Q: What measures could be taken for the prevention or mitigation of the risk of a similar landslide event to the McCrae Landslide occurring in the future in McCrae?
A: A range of measures are available, and they need to be implemented by multiple organisations and agencies. The measures include imposing an EMO on parts of McCrae that are known to be at high risk of a landslide; managing water infrastructure; improving processes and procedures; developing comprehensive plans for responding to landslide events; and educating the community.
The structure of this Report
The structure of this Report
The Board of Inquiry’s Report comprises eight chapters:
a. Chapter 1: The Process of the Board of Inquiry outlines the establishment of the Board of Inquiry, sets out the manner in which it carried out its work, and acknowledges those who provided invaluable support to it.
b. Chapter 2: Overview of McCrae describes key features of the suburb of McCrae including its geology and topography.
c. Chapter 3: What happened in McCrae? places the McCrae Landslide in context by recounting historical landslide events in McCrae, before describing the circumstances leading up to and following the November 2022 landslides, the 5 January 2025 landslide, and ultimately, the McCrae Landslide.
d. Chapter 4: What caused the landslides? describes the factors that caused the November 2022 landslides, the 5 January 2025 landslide, and ultimately, the McCrae Landslide.
e. Chapter 5: Mitigation measures describes the various proposals for mitigating the risk of further landslides at the site of the McCrae Landslide as well as the broader McCrae area.
f. Chapter 6: Conduct of the Mornington Peninsula Shire Council and South East Water assesses the conduct of the Shire and SEW in the lead up to the McCrae Landslide. It includes the Board of Inquiry’s recommendations for those organisations to manage and mitigate landslide risk in the future in light of key learnings from the McCrae Landslide.
g. Chapter 7: Lessons we could have learnt from other landslides describes recurring issues identified in the context of significant historical landslides in Victoria, Australia and elsewhere. It highlights lessons learnt and opportunities for reform to reduce landslide risk.
h. Chapter 8: Improving landslide management describes the regulatory framework in relation to the prevention and management of landslides in Victoria and recommends improvements.
i. The Report’s Appendices bring together a range of documents designed to assist and inform readers.
Recommendations
Recommendations
| The Board of Inquiry recommends a Victorian Government Minister appoint an experienced mediator to engage in a structured process with the Shire, SEW, affected landowners and any other necessary parties, with a view to reaching agreement in relation to appropriate landslide mitigation and remediation works at and around the site of the McCrae Landslide. |
| The Board of Inquiry recommends the Shire and SEW appoint or engage a suitably experienced individual to lead and oversee their participation in the mediation process (Recommendation 1), with a view to bringing a fresh and pragmatic perspective to the issues. |
| The Board of Inquiry recommends the Shire and SEW obtain expert advice about the use of trench stops and carrier pipes in parts of McCrae to mitigate the risk of landslides, including the use of such measures in more remote locations where water leaks may be less readily detected. |
| The Board of Inquiry recommends the Shire and SEW thoroughly assess their water infrastructure in McCrae to identify any need for repair or replacement works to mitigate landslide risk. SEW should also adopt this measure in relation to its sewer system. |
| The Board of Inquiry recommends the Chief Executive Officer of the Shire review and improve the approach that has been and is being taken by the Shire’s McCrae Landslide Incident Group, with the assistance of a suitably experienced external independent consultant. |
| The Board of Inquiry recommends the Shire progress the work that is currently underway to amend the existing EMO schedules, or add a new schedule, to the Mornington Peninsula Planning Scheme, which has the effect of applying an EMO to at least those areas of the Shire that are highly susceptible to landslides. The Shire should take advice from a geotechnical engineer as to the appropriate scope of the schedule(s). |
The Board of Inquiry recommends the Shire review and improve its processes for responding to landslide incidents with a view to including, amongst other things: a. protocols for timely information sharing with relevant entities, agencies and individuals; and b. mechanisms for urgent steps to be taken to mitigate the risk of a subsequent landslide, such as contacting the VicSES when there is a threat of a subsequent landslide, and using equipment on Shire or private land (with permission) to try to divert hazardous water flow. |
| The Board of Inquiry recommends the Shire review and improve its processes for responding to incidents of water upwelling in and around areas highly susceptible to landslides. |
The Board of Inquiry recommends the Shire progress the work that is planned or currently underway to assess and mitigate landslide risk in McCrae, including undertaking a strategic assessment of landslide risk patterns across the full escarpment area and updating its asset management strategies and processes to account for landslide risk. To the extent not already incorporated, the project should include: a. obtaining external expert advice about any necessary modifications to the Shire’s stormwater system in McCrae; b. obtaining external expert advice about the presence and management of excess water around 6 and 10–12 View Point Road and Penny Lane, McCrae; and c. consideration of the additional mitigation matters identified in section 9.3 of the PSM Landslide Risk Assessment dated 28 May 2025. |
| The Board of Inquiry recommends the new Managing Director of SEW review and improve the approach that has been and is being taken by SEW's McCrae Strategy Group, with the assistance of a suitably experienced external independent consultant. |
| The Board of Inquiry recommends SEW progress its work on calibrating its alarms in areas susceptible to landslides to drive effective and timely leak investigations. |
| The Board of Inquiry recommends SEW progress its work on developing flow balancing algorithms required for real-time flow balancing, with the objective of enhancing its ability to detect potential water leaks in a timely manner, especially in areas susceptible to landslides. |
The Board of Inquiry recommends SEW clearly document its leak detection processes and procedures to: a. outline training requirements to ensure employees and contractors apply procedures consistently; b. set out the systematic steps that employees and contractors must take when investigating unknown sources of water; c. provide guidance on the interpretation of field test results; d. require employees and contractors, in more complex cases, to assess whether the unknown water may be originating from a SEW asset located uphill or at a more distant location; e. set out roles, responsibilities, and escalation pathways for decision-making; and f. include provisions for periodic review and updating of the processes and procedures to account for any lessons learnt, new technology, or changes in risk profile. |
| The Board of Inquiry recommends SEW review its leak detection practices and processes to ensure they are appropriately adapted to address the heightened risk of excess water accumulating or surfacing in areas susceptible to landslides. |
| The Board of Inquiry recommends SEW ensure that on-site electrical conductivity readings outside mains water range are not taken as conclusive evidence that leaking water has not originated from its assets. Appropriate processes and procedures should be developed to account for the possibility that the water may have travelled through the ground and changed in its chemical composition. |
| The Board of Inquiry recommends SEW progress its work to develop systems and processes capable of identifying the potential relationship between clusters of complaints in relation to potential water leaks, particularly in areas that are susceptible to landslides. |
The Board of Inquiry recommends the Victoria State Emergency Service (the VicSES) progress the development of a landslide sub-plan to the SEMP. In this context, it is also recommended the Emergency Management Commissioner consider consequential amendments to the SEMP, including making water corporations and local councils participating agencies for landslide mitigation activities, such activities should include the: a. identification of landslide risk; b. development of operational and maintenance plans and processes for water assets; and c. sharing of information between water corporations and local councils to assist in the identification of landslide risk and the management of water assets. |
| The Board of Inquiry recommends Emergency Management Victoria, the VicSES, and the Inspector-General for Emergency Management update existing training and education programs to incorporate and reflect the development of the landslide sub-plan and any related amendments made to the SEMP. |
| The Board of Inquiry recommends Victorian regional and municipal emergency management planning committees, including the Southern Metropolitan and Mornington Peninsula Committees, review their emergency management plans to ensure that landslide risk management is appropriately addressed. This includes reviewing and updating previous risk assessments, and where landslide risk is identified, water corporations should be represented on the committee. |
The Board of Inquiry recommends the Victorian Government develop and implement a project that addresses data gaps on landslide risk. As part of the project, the Victorian Government should explore options for how landslide risk data can be shared and made broadly accessible, including by those living in areas with landslide risk for use in mitigating and managing the risk. Consideration should be given to all options, including: a. the creation of an online data resource; b. engaging with Geoscience Australia to explore opportunities, such as a partnership, aimed at resuming online data collection of Victorian landslides which was ceased in 2018; c. the provision of technical or financial assistance to local government authorities where necessary; and d. statewide mapping of landslide susceptibility, in coordination with relevant government departments. |
| The Board of Inquiry recommends the Shire arrange appropriate training and develop guidelines for relevant staff about local landslide risk, mitigation and management. |
| The Board of Inquiry recommends the Shire arrange appropriate community information events to educate residents, business owners and service providers about local landslide risk, mitigation and management in order to support them in identifying and reducing risks on their land. |
| The Board of Inquiry recommends the Victorian Government, local councils and relevant stakeholders work together to identify pathways for early identification of landslide risk and ensure escalation processes and procedures are well understood. This is a matter which may be most appropriately addressed as part of the development of the landslide sub-plan to the SEMP. |
| The Board of Inquiry recommends municipal emergency management planning committees review their procedures to ensure that, following landslide incidents there is appropriate debriefing which includes actively considering opportunities to improve mitigation, planning and preparedness measures. |
| The Board of Inquiry recommends the Victorian Government consider how insights from the Victorian Coastal Monitoring Program could be applied to landslides and explore options to expand or build on the program, including by monitoring areas identified as being highly susceptible to landslides. |
The Board of Inquiry recommends the Victorian Government review and strengthen the management of landslide risk within the land use planning system to ensure Victorians can have confidence that areas at risk of landslide are subject to proportionate, timely and consistent planning controls. Consideration should be given to: a. developing consistent principles for the application of planning overlays, including threshold requirements such as slope gradient; b. identifying consistent tolerable levels of residual risk to the community; c. the appropriateness of continuing to combine landslide risk and coastal erosion within a single overlay; d. building internal geotechnical engineering expertise in the Department of Transport and Planning to support appropriate technical review and applications to amend planning schemes; e. providing technical and financial support when appropriate to municipal councils to support the identification of landslide risk for the purpose of planning scheme amendments; f. developing planning practice notes and guidance; g. incorporating the Australian guidelines for landslide developed by the Australian Geomechanics Society; h. providing planning authorities with best practice guidance on how to consider cross-cutting hazards such as bushfire and landslide; and i. requiring more frequent reviews of hazard-related planning controls such as overlays, to ensure they reflect changing environmental impacts. |
| The Board of Inquiry recommends the Shire urgently implement an interim EMO schedule that applies, at a minimum, to the land that was identified as highly susceptible to landslides in the 2012 mapping obtained by the Shire. The Shire should promptly obtain advice from geotechnical engineers about the appropriateness of including a wider area on an interim basis. |
| The Board of Inquiry recommends the Victorian Minister for Planning ensure that the Shire’s application for an interim EMO schedule (Recommendation 27) proceeds expeditiously, including by constituting herself to act as the planning authority if deemed appropriate and necessary to achieve this outcome. |
| The Board of Inquiry recommends the Victorian Government develop guidance materials clarifying the roles and responsibilities of local councils, municipal building surveyors and residents in respect of landslide mitigation works following landslides and more generally. |
| The Board of Inquiry recommends the Victorian Government consider the current regulatory environment for how local government and private landowners manage risks on and from private land susceptible to landslides, both to the wider community and the environment. |