The farmer who employed three farm workers who perished in the November 2015 bushfires, testified about his final moments with them.
Scaddan farmer and volunteer firefighter David Campbell gave his account of November 17, 2015 on day four of the coronial inquest into the deaths of Kim 'Freddy' Curnow, Tom Butcher, Anna Sushchova-Winther and Julia Kohrs-Lichte.
Tom, Anna and Julia worked for Mr Campbell, while Freddy was a neighbouring farmer.
"Tom was with us for over 12 months... he was fast becoming a local," he said.
Mr Campbell told Coroner Sarah Linton that his family and their staff were "on alert" throughout the morning of the 17th.
He said he returned to his farm about 2:45pm and told his wife they needed to prepare to defend their property.
Mr Butcher was anxious about his horse, Cougar, and told his boss he wanted to leave with the horse.
"I told him if he wanted to go, he needed to do it as quickly as he could," Mr Campbell said.
Mr Butcher loaded the horse, helped the Campbells prepare and left with Ms Sushchova-Winther and Ms Kohrs-Lichte.
Mr Campbell said about 4:30pm the fire front passed their house. While the front did not hit his farm, he said they were "right on the edge of the fire line" and were forced to fight off the blaze until 7pm.
"It was two hours of hell," he said.
About 9:30pm Mr Campbell was driving when he was stopped by his sister Jennifer, who told them they had found the four bodies.
"I heard Jen on the two-way asking if everybody was accounted for, and she asked if people had left," he said.
"I told her Tom had left the farm, with the girls. Then I just heard I should come to Grigg Road."
Mr Butcher's car was found on its side, and all three workers had died.
"Obviously your family were devastated when you heard about Tom and the girls?" Coroner Linton asked Mr Campbell.
"Absolutely," he said.
The coroner asked Mr Campbell if there was anything he would like to bring her attention to, in crafting her recommendations.
Mr Campbell hoped lessons would not only be learnt, but acted upon.
"There's been investigations in the past and so many of the same things keep coming up and they've not been addressed," he said.
On day four the inquest heard that a breakdown in communication networks meant a lone emergency services worker who stumbled into the path of a deadly bushfire was forced to coordinate an evacuation of over 100 people.
Former DFES superintendent Trevor Tasker appeared as a witness.
Mr Tasker said he was aware fires were burning in the district when he was called down from his Kalgoorlie post to a state bushfire risk workshop in Esperance.
He was due to take the place of Gavin Warnes, the Esperance district DFES officer, who had been pulled in to start coordinating the response to two more serious fires in Merivale and Cascades.
Mr Tasker said he was driving near the salt lakes towards Norseman when he saw a fire burning on November 17.
There was smoke across the highway and Mr Tasker, with more than 30 years of emergency training, said he recognised the tell-tale signs of a raging bushfire.
He got out of his car and stood on the bonnet to see if he could spot the fire - but strong winds pushed him off.
"I wanted to get to the end of where the smoke was," he said. "I moved my car a number of times and ... blocked the road."
People continued to try and use the highway despite Mr Tasker's vehicle blocking the road, and he said he believed he turned dozens of cars away and towards Salmon Gums throughout the afternoon.
He called the fire in to the Kalgoorlie office and requested resources to help fight it, along with the local government and WA Police. He told them the road needed to be formally closed in the opposite direction.
"All that time I was just hoping someone had shut the north side," he said.
Eventually the fire jumped the highway and began to drop off about 3.30pm, and Mr Tasker was able to continue on to Esperance.
About 5pm, he hit the roadblock set up by volunteer firefighters near Grass Patch Road, near Scaddan. He was told about the massive Cascades fire that had torn through the area and was threatening to break containment lines.
It was at this point Mr Tasker realised those who had taken refuge at Salmon Gums were marooned by the two fires - with one burning near Norseman and another burning Cascades, the evacuation point was firmly in the middle.
At this news, he immediately began driving to check on the evacuees.
The Salmon Gums townsite was engulfed in ash and smoke, and embers were carried up main roads.
More than 100 locals were waiting on the town oval for further instructions, with some elderly evacuees covering their noses and mouths with handkerchiefs.
"Several things are going through my mind at this time and the locals were giving me options," he said.
"One said we should put them into a paddock ... or in the grain silo. But I thought of some awful things that could happen there.
"I looked at alternative places ... nothing was suitable in my mind."
The full significance of the situation slowly hit Mr Tasker, as he realised he was the only senior DFES officer on the ground and communications with his superiors had broken down, essentially leaving him alone with upwards of 100 people as smoke, embers and fire closed in.
"I knew I had to shift people. I had no other option," he said.
He called his DFES manager Gary Gifford about the plan, who then told him to clear it with personnel in Albany, but Mr Tasker's phone signal dropped out.
Before he could get formal permission to begin, other emergency service workers agreed to help Mr Tasker.
"I don't know where my mind was," he said. "It was in another sphere. I wasn't thinking about anything other than the safety of these people. If I'd left them, then 90 per cent of people would have survived.
"But I could guarantee some wouldn't."
Mr Tasker organised people into vehicles, and made them form a line on the highway.
He sent a lead DFES vehicle up ahead, and a Main Roads repair vehicle at the rear. Volunteer firefighters were stationed on either side of the convoy to protect them as they passed through the fireground.
One by one, Mr Tasker spoke to each driver as they passed him.
"I told them windows up, air vents closed and they weren't to stop for anything. Not anything," he said.
Slowly but surely, the convoy made its way towards Norseman through the fireground.
When the last car pulled in, Mr Tasker said it wasn't without anxiety - volunteer firefighters had not come in as expected.
At a community meeting on November 18, he found out they had been called to fight the Cascades fire as it continued to grow and he finally heard about the full scale of the bushfires.
'Grossly insufficient': $25,000 a year for mitigation works
The inquest also heard from Parks and Wildlife manager Greg Mair and Esperance district manager Robert Blok, who both agreed the $25,000 annual budget allocated to them to carry out mitigation works on the nearly six million hectares of unallocated crown land was "grossly insufficient".
Mr Mair said a review into the model currently in use - which dictates parks and wildlife is responsible for the crown land's management but local governments are responsible for bushfire response - was overdue.
"It's outdated, it's confusing and the expectation on volunteer firefighters and local governments is, in my opinion, unreasonable," he said.
Mr Blok said a business case had previously proven a budget of at least $350,000 towards annual bushfire mitigation was more appropriate.
Police response 'rude', 'took too long'
On both day three and four of the inquest, witnesses spoke about the delay in police arriving to the scene where the four bodies had been located.
On day three, farmer and firefighter David Vandenberghe said it took three-and-a-half hours for police to arrive.
He said when they did he was "gobsmacked" at how "rude" a sergeant was and said volunteer firefighters were "treated like criminals".
On day four, Mr Campbell's sister Jennifer Campbell and Gibson brigade captain Blake Halford echoed some of the sentiments Mr Vandenberghe expressed towards the delayed police response.
Mr Halford said police "took too long to arrive", while Ms Campbell said she "felt very let down".
"When help finally did arrive, it was not a happy situation," she said.
Counsel assisting the coroner Sergeant Lyle Housiaux said he had spoken to the Esperance Police officer-in-charge, who was not in Esperance in 2015.
Sgt Housiaux said police would make inquiries as to what occurred and why.
Coroner Linton agreed police needed to look into what happened.
"It's not a name and shame exercise, but police should be aware of the distress it caused," she said.