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BCAM FIRE WATCH / INVESTIGATION ARCHIVE

West Terrace, Bankstown

Bankstown, New South Wales, Australia · 6 September 2012 · Coronial findings and recommendations published

A fire that originated on an apartment balcony trapped two residents. The NSW coroner examined missing sprinklers, post-occupation alterations, fire safety statements and unresolved orders. The coroner could not determine the ignition cause on the balance of probabilities.

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Findings and evidence status

Fire origin and limits

The coroner found that the fire originated on the balcony of Unit 53, but could not establish its cause on the balance of probabilities. Connie Zhang died after falling while trying to escape.

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Unresolved building safety record

The findings document unapproved alterations, an annual fire safety statement considered probably inaccurate, and fire safety orders and engineering questions that were not substantively resolved before the fire.

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Sprinkler protection

The building had no sprinkler system. The coroner recommended that the Australian Building Codes Board consider sprinklers in all new Class 2 and 3 buildings.

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FROM INVESTIGATION TO PRACTICE

One case. Three lines of sight.

Questions for current buildings, inferred from this case. Check local requirements and the building’s actual condition.

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01 / DESIGN

Engineer

Reconcile the approved fire strategy with the occupied building. Which alterations, sprinkler assumptions, hydrant and smoke-control questions need a fresh assessment, and who has signed off each answer?

02 / FIELD

Fire protection contractor

Compare the annual fire safety statement and service evidence with the equipment and configuration on site. Flag discrepancies and keep defects open until the work and verification are recorded.

03 / RESPONSE

Brigade

What current information identifies access, firefighting water, smoke-control limitations and unresolved orders before a response? Record any operational discrepancy for the building team to investigate.

BCAM / SHARED BUILDING RECORD

What has to connect

Approved plans and later alterations; fire safety statements; system test results; orders; engineering responses; accountable owner and verified close-out date.

Changes and response

2015 coronial recommendation

The coroner asked the ABCB to consider a wider sprinkler requirement, along with clarifying “substantially enclosed” and “direct egress”. A recommendation did not itself amend the NCC.

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2019 NCC provision, narrower in scope

NCC 2019 introduced sprinkler requirements for new Class 2 and 3 residential buildings with four or more storeys and an effective height of 25 metres or less. This is narrower than the coroner’s all-new-buildings proposal; applicability to any building depends on its approval and jurisdiction.

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Reviewed 28 September 2026. Legal and inquiry status can change; use the linked authority for the latest position.