Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC326-4341 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures regular monitoring is in place as part of funding deeds. |
REC326-4342 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures staff declare conflicts of interest prior to the commencement of a grants stream, and that these conflicts of interest are recorded and managed. |
REC326-4343 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures a communications plan is in place, including the communication of guidelines to potential applicants. |
REC326-4344 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: establishes and follows guidelines that align with relevant good practice guidance including accountabilities, key assessment steps and clear assessment criteria. |
REC326-4340 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: documents all key decisions and approvals in line with record keeping obligations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC321-4213 | 3 - Biodiversity | We recommend that DELWP improves the effectiveness, consistency and transparency of its environmental and cultural values checks by: - finalising its review of operational values checking processes and committing to an implementation plan - clarifying and formalising principles and procedures, making them publicly available where possible - improving capability and capacity among staff responsible for carrying out values checks, for example through training - developing a long-term program of work and investment to improve the quality, consistency and comprehensiveness of underlying datasets - increasing alignment in regard to values checks between agencies carrying out fuel management. |
REC321-4207 | 25 - Inquiry, audit, lessons management and after action review | We recommend that DELWP reviews its target for the number of fuel hazard assessments conducted and ensures that this measure is evidence based, accurately reflects regional performance, and that the department monitors and reports on each region’s performance against it. |
REC321-4214 | 1 - Land-use and building regs | We recommend that DELWP determines which elements of different regional planning approaches are the most effective and implements these across the state. |
REC321-4208 | 38 - Agency/Department Reporting | We recommend that DEWLP and CFA (in consultation with FRV) develops financial reporting to monitor fuel management costs and estimate future costs. |
REC321-4215 | 1 - Land-use and building regs | We recommend that DELWP develops more holistic bushfire-management planning that focuses on the best mix of risk treatments rather than planned burning alone. |
REC321-4209 | 38 - Agency/Department Reporting | We recommend that DEWLP and CFA (in consultation with FRV) systemically documents and publicly reports reasons why it does not complete planned burns. |
REC321-4210 | 3 - Biodiversity | We recommend that CFA (in consultation with FRV) improves its values checks by providing ongoing state-wide support to regional vegetation management officers and leveraging any relevant systems or capabilities from DELWP to conduct values checks through guidance, training and ongoing funding. |
REC321-4203 | 9 - Community education | We recommend that DELWP provides advice to government, in consultation with Country Fire Authority, Fire Rescue Victoria and councils, on options to improve owner and occupier awareness of and accountability for bushfire management overlay planning controls (see Section 4.3). |
REC321-4211 | 1 - Land-use and building regs | We recommend that CFA (in consultation with FRV) improves planning on private land to ensure risk assessments and plans are conducted consistently across public and private land to address state-wide bushfire risk based on where and how they can most effectively reduce risk. |
REC321-4206 | 3 - Biodiversity | We recommend that DELWP conducts more effective ecosystem resilience monitoring by: - setting a target for regions on the quantity of ecosystem resilience monitoring assessments that they should complete annually - setting an outcomes-level target that defines desirable values for key ecosystem resilience metrics - reporting publicly against all of the metrics in its Measuring Ecosystem Resilience in Strategic Bushfire Management Planning policy in its fuel management reports. |
Rec-ID | Code | Recommendation |
---|---|---|
REC316-4042 | 25 - Inquiry, audit, lessons management and after action review | ACT Government undertake a detailed legislative review to ensure that information regarding vulnerable community members can be appropriately accessed, provided and used during an emergency event. |
REC316-4018 | 25 - Inquiry, audit, lessons management and after action review | The five year review of the Emergencies Act examine amendments to better define the rationale for a State of Alert / State of Emergency whilst ensuring that the relevant Minister / Chief Minister still has sufficient discretion to make a declaration based on advice from relevant Government officials and committees. |
REC316-4041 | 9 - Community education | The ESA Community Education and Engagement program be adapted to include an expanded role for RFS volunteers and include a wider set of stakeholders who are more vulnerable to the impact of bushfire. A plan would require wider involvement across stakeholder organisations such as Directorates who have existing relationships with vulnerable groups. |
REC316-4017 | 15 - Inter-service cooperation | The working group (Rec 1) should include relevant stakeholders deciding collectively what the declaration might mean for such things as sub and supporting plans and the relevant community messages and calls to action. |
REC316-4038 | 25 - Inquiry, audit, lessons management and after action review | The CCIP be reviewed in conjunction with the review of the Emergency Plan and the two synchronised. A workable approach to delivering operational emergency communications and strategic WhoG communications is developed with simple and clear reporting arrangements. |
REC316-4014 | 25 - Inquiry, audit, lessons management and after action review | That Justice and Community Safety Directorate (JACS) lead a working group from across relevant organisations to undertake the five year review of the Emergencies Act in conjunction with a wholistic review of the Emergency Plan and relevant sub-plans; and recommendations from this review, to the extent they are accepted by Government. Bringing together a small Taskforce of staff from across government for a set period would assist the working group in delivering the work needed to address these and other recommendations. |
REC316-4034 | 15 - Inter-service cooperation | Efforts be increased to build trust, confidence and a common operating picture across PCS and RFS and seek mechanisms that identifies RFS and PCS as equitable partners in delivery of fire management across the territory. |
REC316-4045 | 42 - Culture and Heritage | WHoG desktop exercise should be conducted to test and support relocation and evacuation planning. |
REC316-4033 | 25 - Inquiry, audit, lessons management and after action review | The BFC Terms of Reference be reviewed to ensure they are contemporary and reflect learnings from this and recent bushfire seasons. |
REC316-4043 | 15 - Inter-service cooperation | NDIA be engaged in regard to information sharing in emergencies as part of the above actions. |
REC316-4019 | 15 - Inter-service cooperation | In collaboration with other jurisdictions the ACT share the learnings for this bushfire event and work to officially embedded values officers and RRATs as key elements of bushfire response. |
Rec-ID | Code | Recommendation |
---|---|---|
REC315-3833 | 3 - Biodiversity | That Government invest in long-term ecosystem and land management monitoring, modelling, forecasting, research and evaluation, and harness citizen science in this effort. This will include, among other things: |
REC315-3806 | 15 - Inter-service cooperation | That the NSW RFS work with AFAC to analyse the impact of changing fire seasons on inter- jurisdictional resource sharing agreements, both domestic and international, and determine any flow-on effects for NSW fire fighting personnel capacity. |
REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3822 | 42 - Culture and Heritage | That Government adopt the principle that cultural burning is one component of a broader practice of traditional Aboriginal land management and is an important cultural practice, not simply another technique of hazard reduction burning. |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3830 | 39 - Disaster Risk Management | That as a matter of urgency, in order to accelerate and finalise a State-wide strategic fire trail network, the NSW RFS Commissioner and Bush Fire Coordinating Committee (BFCC): |
REC315-3799 | 9 - Community education | That at the start of each fire season, based on advice from the Bush Fire Coordinating Committee, Government provide a public statement with an evaluation of the likely fire season risk and the effectiveness of the planning and preparation for the upcoming season. This should be based on sophisticated monitoring of the key risk factors and signals for an extreme fire season. It should form the basis for clear public communication about these risks on a regional basis and the actions that Government proposes in preparation. |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3813 | 35 - Business and Industry in relation to industry | That, in order to ensure tourism businesses are prepared for natural disasters including bush fires, Resilience NSW work with NSW RFS and Destination NSW to develop bush fire preparedness support for tourism businesses, based on research into existing models. Over time, this support could be expanded to include other natural hazards. |
REC315-3869 | 42 - Culture and Heritage | That, in order to ensure Aboriginal people can access appropriate support during evacuation, Resilience NSW work with Local Emergency Management Committees and Aboriginal Affairs to ensure: |
REC315-3828 | 9 - Community education | That, in order to improve bush fire planning and protection of road infrastructure and to ensure communities, freight movers and fire fighting agencies have appropriate access and egress in a bush fire event, Government, working with local government as needed: |
REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3850 | 3 - Biodiversity | That Government develop and implement a policy on injured wildlife response, rescue and rehabilitation including: |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3864 | 9 - Community education | That, in order to ensure people can access clear information on cross-border fires, the NSW RFS: |
REC315-3825 | 39 - Disaster Risk Management | That Government, acknowledging that a strategic approach to planning for bush fire will take time, and in order to protect, prepare and build resilience into existing communities better, should immediately: |
REC315-3842 | 24 - Govt responsibility | That, in order to prioritise early suppression and keep fires small: |
REC315-3810 | 24 - Govt responsibility | That, to ensure updated resource-sharing arrangements are in place, the NSW and Victorian Governments progress and finalise a multi-agency Memorandum of Understanding before the 2020-21 fire season commences. |
REC315-3863 | 15 - Inter-service cooperation | That, in order to provide real-time information on evacuation doorknocking during emergency events, Government explore a shared data gateway for NSW agencies based on the NSW State Emergency Service Collector app and a common mapping and analytics platform. |
REC315-3824 | 1 - Land-use and building regs | That Government commit to shifting to a strategic approach to planning for bush fire, and develop a new NSW Bush Fire Policy similar to the NSW Flood Prone Land Policy in order to accommodate changing climate conditions and the increasing likelihood of catastrophic bush fire conditions; to build greater resilience into both existing and future communities; and to decrease costs associated with recovery and rebuilding. |
REC315-3835 | 15 - Inter-service cooperation | That, in order to ensure the safety of local landholders on firegrounds, the NSW RFS emphasises the importance of local landholders using protective clothing while fire fighting as part of the RFS’ ‘Farm Fire Unit Integration’ priority for 2020-21. |
REC315-3808 | 22 - Role of local Gvt | That, in order to strengthen the capability of local councils in future emergency events: |
REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
REC315-3823 | 42 - Culture and Heritage | That, in order to increase the respectful, collaborative and effective use of Aboriginal land management practices in planning and preparing for bush fire, Government commit to pursuing greater application of Aboriginal land management, including cultural burning, through a program to be coordinated by Aboriginal Affairs and Department of Planning, Industry and Environment working in partnership with Aboriginal communities. This should be accompanied by a program of evaluation alongside the scaled-up application of these techniques. |
Rec-ID | Code | Recommendation |
---|---|---|
REC288-1197 | 9 - Community education | The Committee finds that on the evidence presented, the State Fire Commission introduces key performance indicators reporting in relation to its work in community engagement to measure its success in program delivery and community engagement. |
REC288-1196 | 9 - Community education | The Committee finds that on the evidence presented, that the State Fire Commission should assess whether community engagement programs of the State Fire Services and State Emergency should be centralised. |
Rec-ID | Code | Recommendation |
---|---|---|
REC270-1147 | 9 - Community education | improves engagement with communities to prepare for and respond to bushfires by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC246-0788 | 25 - Inquiry, audit, lessons management and after action review | TFS seek to address the following outstanding items from the recommendations of the Victorian Bushfires Royal Commission. § 45 out of 53 Community Bushfire Response Plans for “at risk” communities have been finalized. The remaining eight should be completed as a priority action. § That TFS progress the development of Community Bushfire Mitigation Plans for the 53 at risk communities, possibly as an action for reactivated Fire Management Area Committees. § TFS, together with other ESOs and local government, should develop a common comprehensive approach to the option of planned evacuation from dangerous or potentially dangerous areas to safer areas and eventual return. § TFS should include factors for consideration for evacuation during a bushfire into their training doctrine for Incident Controllers. § The IAP Template and its application be reinforced as an important operational requirement for IMT’s during the 2013-14 pre-season briefing program. 10 § That TFS review their use of IRMS to ascertain if either its full potential is not being realized through a lack of operator training or it is in fact not providing the required functionality and there is a need to research an improved resource management system which enhances interoperability. § The TFS Publication: Guidelines for Development in Bushfire Prone Areas of Tasmania http://www.fire.tas.gov.au/userfiles/stuartp/file/Publications/BushDeve… s2012.pdf requires an update to reflect the provisions of Planning Directive #5 Bushfire-Prone Areas Code. |
REC246-0787 | 9 - Community education | TFS make their community education and safety material available to the culturally and linguistically diverse (CALD) communities in Tasmania. |
Rec-ID | Code | Recommendation |
---|---|---|
REC241-1004 | 15 - Inter-service cooperation | That a memorandum of understanding be developed between RFSQ and other organisations with fire fighting capacity at state level, to establish operational procedures when these organisations may be required for a joint response roles. Specifically, the intent will be: Vegetation Fire in a Rural Area: The Rural Fire Brigade in that area (boundary) is in charge and is the first Brigade called by Firecom. Structural Fire in a Rural Area: Firecom calls the Urban Brigade first and they control the incident. Local Rural Fire Brigade must also be notified by Firecom at the same time. Vegetation Fire in an Urban Levy Area: Firecom call the local Urban Brigade first and they control the incident. At their discretion they may call Rural Fire Brigades for assistance. Structural Fire in an Urban Levy Area: Firecom call the local Urban Brigade first and they control the incident. |
REC241-1001 | 24 - Govt responsibility | That the extent of forest and plantation fuel load fire risk in South East Queensland requires a designated government resources fire team to manage this risk and proactively conduct fuel mitigation burning; and provide a wildfire response to government land. |
REC241-0999 | 28 - Personal responsibility | That on all land where fuel load creates a fire risk, the owner shall be responsible for the construction and maintenance of effective firebreaks. Failure to provide effective and accessible firebreaks will result in the cost of firebreak construction to control a wildfire on this land being debited to the land owner |
REC241-0979 | 24 - Govt responsibility | That the Queensland Government liaise with the Federal Government with a view to securing incentives for employers that recognise loss of income and employee time for emergency operations. |
REC241-0954 | 24 - Govt responsibility | That a Ministerial Advisory Council be established to inform the Minister of matters relating to Rural Fire Service and SES volunteers. |
REC241-1030 | 25 - Inquiry, audit, lessons management and after action review | That Rural Fire Brigades only be required to conduct an audit of finances if the Brigades income exceeds $5,000 for a financial year. RFSQ District offices should investigate options for savings on the costs of auditing Brigades in their district through either an in-house or external provider. Legal Status of Brigades |
Rec-ID | Code | Recommendation |
---|---|---|
REC228-1609 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency should undertake audits to meet the requirements in the Strategic Bushfire Management Plan for the preparation, sharing and publication of annual progress reports. Annual progress reports should be made available to the ACT Bushfire Council. |
REC228-1619 | 1 - Land-use and building regs | The Territory and Municipal Services Directorate, in consultation with the Emergency Services Agency, should improve its management of Land Management Agreements, with respect to rural leaseholders’ fire management responsibilities, by: |
REC228-1605 | 24 - Govt responsibility | The Justice and Community Safety Directorate should continue to review its strategic and accountability indicators and the Territory and Municipal Services Directorate should commence a review of its strategic and accountability indicators. The directorates should consult to develop complementary measures which better assess their bushfire management activities. |
REC228-1618 | 24 - Govt responsibility | The Emergency Services Agency, the Environment and Sustainable Development Directorate and the Territory and Municipal Services Directorate should strengthen across-Government delivery of major projects in the Strategic Bushfire Management Plan and Regional Fire Management Plans by collectively: |
REC228-1615 | 38 - Agency/Department Reporting | The Territory and Municipal Services Directorate, as part of its Bushfire Operations Plan monitoring and reporting, should assess and publicly report on cumulative progress against broader outcomes identified in the Regional Fire Management Plans and the Strategic Bushfire Management Plan. |
REC228-1623 | 15 - Inter-service cooperation | The Emergency Services Agency and the Territory and Municipal Services Directorate should develop and routinely review a strategic bushfire capability for the ACT. The contribution of ACT Fire and Rescue (including the Community Fire Units) and the ACT Rural Fire Service (including Parks Brigade) should be explicitly stated. |
REC228-1614 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the ACT Bushfire Council, should conduct a review of the ACT Bushfire Council against its recently developed terms of reference (July 2013) within two years. |
REC228-1622 | 15 - Inter-service cooperation | The Emergency Services Agency and the Territory and Municipal Services Directorate should continue to improve working arrangements between the ACT Rural Fire Service Parks Brigade and the ACT Rural Fire Service headquarters, by: |
REC228-1610 | 24 - Govt responsibility | The Emergency Services Agency should annually review fire management zones and the Territory and Municipal Services Directorate should subsequently update the Regional Fire Management Plans. |
REC228-1620 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the Territory and Municipal Services Directorate, should review the Farm FireWise Program, including: |
Rec-ID | Code | Recommendation |
---|---|---|
REC193-0226 | 22 - Role of local Gvt | Local government councils should: strongly encourage owners to make improvements to construction or increase buffers in order to meet minimum safety standards implement programs to audit impacted properties and issue abatement notices where necessary monitor and maintain their reserves to ensure that adequate buffers to neighbouring buildings exist. |
REC193-0225 | 22 - Role of local Gvt | Local government councils should move promptly to: adopt the Tasmania Fire Service Guidelines for Development in Bushfire Prone Areas of Tasmania give effect to the Department of Primary Industries, Parks, Water and Environment Neighbouring Developments and Fire Management Policy. |
REC193-0222 | 22 - Role of local Gvt | The Local Government Association of Tasmania advocate, coordinate and support local councils’ input of bushfire risk assets data into the Bushfire Risk Assessment Model. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3461 | 24 - Govt responsibility | DPI should develop an Memorandum of Understanding (MOU) with the Department of Human Services that capitalises on and strengthens the current good working relationship to support joint forward planning and risk management and mitigates against relationship failure in the event of leadership change. The MOU should clarify: |
Rec-ID | Code | Recommendation |
---|---|---|
REC150-3125 | 38 - Agency/Department Reporting | QFRS introduce a system to collate and analyse performance information for use in management reporting and to support effective decision making processes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC139-3551 | 39 - Disaster Risk Management | The SA Country Fire Service to analyse the Coroner’s Report into the Wangary Bushfire 2005, and consider the relevant recommendations from this report in the implementation of the Ministerial Bushfire Management Review recommendations. |
REC139-3549 | 39 - Disaster Risk Management | The SA Country Fire Service investigates the establishment of a Minister’s Bushfire Risk Management Reward Scheme. |
REC139-3546 | 22 - Role of local Gvt | Local Government to be maintained as an important component of bushfire management in South Australia because of the link with the community. |
Rec-ID | Code | Recommendation |
---|---|---|
REC134-3520 | 21 - Role of Commonwealth Government | To improve the management of the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing incorporate into its governance framework: |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3622 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases. |
REC129-3620 | 35 - Business and Industry in relation to industry | We recommend that NSW Health continue with its good work and conclude agreements with private health providers specifying roles, and expectations in the case of an infectious disease pandemic. |
REC129-3626 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making. |
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3904 | 39 - Disaster Risk Management | FESA should: in addition to its current initiatives, develop and implement structured programs (with clearly identified objectives, target groups and time lines for achievement) aimed at: |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3918 | 35 - Business and Industry in relation to industry | That DPI effectively communicates to all sectors of the industry their responsibilities to report new threats, and how to report them. |
REC112-3929 | 35 - Business and Industry in relation to industry | That DPI develops a comprehensive strategy for communicating to industry their rights and responsibilities in relation to threats, incursions, outbreaks and post-outbreak; and also for communicating internally. |
REC112-3913 | 35 - Business and Industry in relation to industry | That DPI works with industry to develop a training module on the certification and verification system for inclusion in industry quality assurance programs. |
REC112-3928 | 3 - Biodiversity | That DPI formalises agreements within the Regional Services and Agriculture Division to ensure that plant health information is included in extension programs. |
REC112-3912 | 25 - Inquiry, audit, lessons management and after action review | That DPI, as part of the development of the Victorian plant biosecurity strategy, undertake a strategic review of its plant health planning framework so that: • corporate and business unit plans at all levels of the department align to each other and to government policy so that staff have a coherent frame of reference to guide their work • performance indicators are developed, used, reported against and evaluated regularly • all plans (including service agreements with other parts of DPI) are communicated to staff and implemented in their day-to-day activities and responsibilities. |
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |
REC112-3911 | 3 - Biodiversity | That DPI develops a consistent process to identify, assess and prioritise potential plant pest and disease threats, and aligns it with prioritisation processes used at the national level by Plant Health Australia. |
REC112-3920 | 15 - Inter-service cooperation | That better use be made of Primary Industries Research Victoria's (PIRVIC) facilities by strengthening links with relevant groups of expertise, such as the Forest Science Centre. |
REC112-3933 | 15 - Inter-service cooperation | That DPI formalises agreements between divisions and groups that allow staff to be involved in incursion responses and reflects this requirement in individual duty statements. |
REC112-3907 | 25 - Inquiry, audit, lessons management and after action review | That Department of Primary Industries (DPI), in partnership with the Department of Sustainability and Environment, reviews all legislation relating to plant biosecurity with a view to streamlining the legislative framework. |
REC112-3919 | 25 - Inquiry, audit, lessons management and after action review | That the model for state funding be reviewed to ensure that DPI can confidently build and maintain a core level of diagnostic expertise and research capability. |
REC112-3932 | 25 - Inquiry, audit, lessons management and after action review | That DPI conducts and documents debriefs after all incursions, and adopts any improvements that are identified through debriefs. |