Inquiry Search
Rec-ID | Code | Recommendation |
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REC317-4081 | 18 - Access to fire ground | State and territory governments should provide information to the public on the closure and opening of roads. Information should be provided in real-time, or in advance based on predictions, where possible. |
REC317-4105 | 13 - Mapping and data quality | Australian, state and territory governments should agree to: |
REC317-4091 | 11 - Evacuation and shelters | State and territory governments should provide further community education on the function and limitations of different sheltering facilities, including evacuation centres, Neighbourhood Safer Places, places of last resort and natural disaster shelters. This education should be nationally consistent. |
REC317-4060 | 13 - Mapping and data quality | Australian, state and territory governments should create common information platforms and share technologies to enable collaboration in the production, analysis, access, and exchange of information, data and knowledge about climate and disaster risks. |
REC317-4096 | 8 - Communications and warnings | State and territory governments should urgently deliver and implement thevall-hazard Australian Warning System. |
REC317-4080 | 18 - Access to fire ground | State and territory governments should include road closure and opening information on all roads within their borders on public apps. |
REC317-4102 | 25 - Inquiry, audit, lessons management and after action review | Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments. |
REC317-4090 | 11 - Evacuation and shelters | State and territory governments should, as a priority, adopt nationally consistent terminology and functions for the different sheltering facilities, including evacuation centres, Neighbourhood Safer Places, places of last resort and natural disaster shelters. |
REC317-4059 | 13 - Mapping and data quality | Australian, state and territory governments should prioritise the implementation of harmonised data governance and national data standards. |
REC317-4095 | 9 - Community education | State and territory governments should deliver education to ensure that the public understands the new Australian Fire Danger Rating System ratings, the potential danger attached to each rating, and the action that should be taken in response to each rating. |
REC317-4074 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should review the content of the Defence Assistance to the Civil Community manual to ensure consistency of language and application with a revised COMDISPLAN. |
REC317-4100 | 9 - Community education | Australian, state and territory governments should: |
REC317-4089 | 11 - Evacuation and shelters | State and territory governments should ensure that those responsible for evacuation planning periodically review those plans, and update them where appropriate, including in relation to: |
REC317-4112 | 9 - Community education | State and territory governments should: |
REC317-4094 | 8 - Communications and warnings | State and territory governments should expedite the development and implementation of the Australian Fire Danger Rating System. It should ensure that there is national consistency in the visual display of the AFDRS and action to be taken in response to each rating. |
REC317-4068 | 13 - Mapping and data quality | Australian, state and territory governments should establish a national register of fire and emergency services personnel, equipment and aerial assets. |
REC317-4099 | 8 - Communications and warnings | Australian, state and territory governments should continue to explore the feasibility of a national, all-hazard emergency warning app. |
REC317-4088 | 11 - Evacuation and shelters | State and territory governments should ensure that those responsible for evacuation planning periodically review those plans, and update them where appropriate, including in relation to: |
REC317-4109 | 13 - Mapping and data quality | Australian, state and territory governments should develop consistent processes for the classification, recording and sharing of fuel load data. |
REC317-4093 | 11 - Evacuation and shelters | State and territory governments should ensure those responsible for evacuation planning periodically review those plans, and update where appropriate, to provide for coordination between states and territories in cross border areas and to provide cross-border access to evacuation centres. |
REC317-4066 | 2 - Emergency powers | The Australian Government should make provision, in legislation, for a declaration of a state of national emergency. The declaration should include the following components: |
REC317-4098 | 8 - Communications and warnings | The Australian Government should facilitate state and territory governments working together to develop minimum national standards of information to be included in bushfire warnings apps. |
REC317-4084 | 9 - Community education | State and territory governments should continue to deliver, evaluate and improve education and engagement programs aimed at promoting disaster resilience for individuals and communities. |
REC317-4106 | 13 - Mapping and data quality | Australian, state and territory governments should ensure greater consistency and collaboration in the collation, storage, access and provision of data on the distribution and conservation status of Australian flora and fauna. |
REC317-4092 | 11 - Evacuation and shelters | State and territory governments should ensure those responsible for evacuation planning periodically review these plans, and update them where appropriate, to account for the existence and standard of any evacuation centres and safer places (however described) in the community, including: |
REC317-4065 | 13 - Mapping and data quality | Australian, state and territory governments should continue to develop a greater capacity to collect and share standardised and comprehensive natural disaster impact data. |
REC317-4097 | 9 - Community education | State and territory governments should ensure that the implementation of the Australian Warning System is accompanied by a carefully developed national education campaign that considers the needs of all Australians. |
Rec-ID | Code | Recommendation |
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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. |
REC315-3872 | 11 - Evacuation and shelters | That, in order to improve support for people evacuating with animals, the Department of Primary Industries: |
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. |
REC315-3799 | 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. |
REC315-3864 | 9 - Community education | That, in order to ensure people can access clear information on cross-border fires, the NSW RFS: |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3832 | 8 - Communications and warnings | That, in order to improve the provision of evidence-based public health messaging about air quality during bush fire events, Government develop a public education campaign and supporting systems before the next bush fire season. This should include: |
REC315-3871 | 11 - Evacuation and shelters | That, in order to ensure equitable access to evacuation centres and associated support services for people in border communities, Resilience NSW ensure cross-border access arrangements are reflected in evacuation centre management guidelines. |
REC315-3855 | 7 - Inter-agency communication | That, in order to ensure all agencies have a clear understanding of cross-border communication channels during bush fires, all MoUs between state or territory agencies include an agreed protocol about how agencies will communicate across borders and that these are reflected in Incident Action Plans. |
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. |
REC315-3863 | 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. |
REC315-3811 | 8 - Communications and warnings | That in order to provide greater consistency in public information and warnings, especially in border areas: |
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: |
REC315-3870 | 11 - Evacuation and shelters | That, in order to ensure the safety and wellbeing of vulnerable people during an evacuation, Resilience NSW: |
REC315-3854 | 7 - Inter-agency communication | That, in order to ensure emergency response agencies can communicate across state and territory borders, the Commonwealth Government allocate 10 + 10 MHz as a dedicated spectrum for Public Safety Mobile Broadband (PSMB) at no cost to states and territories. |
REC315-3862 | 8 - Communications and warnings | That, in order to improve information flows and increase public awareness of ABC emergency broadcasts, Government: |
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. |
REC315-3867 | 11 - Evacuation and shelters | That, in order to ensure evacuation centres are fit-for-purpose, Resilience NSW work with Local Emergency Management Committees (LEMCs) to: a) update the guidelines for LEMCs identifying evacuation centres to require a risk assessment of potential locations, which should include identifying alternate sources of power for use by evacuation centres and recording these appropriately |
REC315-3819 | 13 - Mapping and data quality | That, as part of the spatial technology acceleration program, Government support deployment of remote sensing and picture processing technologies to monitor and audit how well Asset Protection Zones and defendable space are being maintained, especially around towns. |
REC315-3853 | 7 - Inter-agency communication | That, in order to ensure the State Emergency Operations Centre (SEOC) can maintain communications during emergencies, the Government provide the SEOC with independent Public Safety Network functionality. |
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. |
REC315-3801 | 13 - Mapping and data quality | That, in order to improve capability to detect ignitions and monitor accurately all fire edge intensity and progression automatically across the State in near real time, Government establish a spatial technology acceleration program to maximise the information available from the various remote sensing technologies currently in use and to plan for inclusion of new remote sensing systems that can sense precisely and rapidly through heavy smoke, cloud, fog and dust. This will require work within the State and with partners nationally and internationally. |
REC315-3866 | 11 - Evacuation and shelters | That, in order to ensure evacuation arrangements can be scaled up when needed, Resilience NSW: |
REC315-3814 | 11 - Evacuation and shelters | That the NSW RFS identifies remote bush fire prone areas that do not already have an indoor Neighbourhood Safer Place (NSP) and upgrades the relevant NSW RFS Stations to meet NSP guidelines. These stations would require adequate Asset Protection Zones and active/passive protection systems to provide short-term protection. |
REC315-3852 | 7 - Inter-agency communication | That, in order to improve fireground communications between NSW agencies and interstate personnel: a) Government ensure all NSW fire authority personnel and vehicles can access and utilise the Public Safety Network (PSN). This should include access to NSW RFS Private Mobile Radio networks where PSN coverage is not yet available. |
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. |
REC315-3859 | 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. |
REC315-3800 | 13 - Mapping and data quality | That the NSW Government, along with other Australian governments, ask AFAC to establish a national bush fire database. This database would enable: |
REC315-3865 | 8 - Communications and warnings | That the NSW RFS include the following priorities in the Fires Near Me improvements roadmap: |
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. |
Rec-ID | Code | Recommendation |
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REC302-2394 | 15 - Inter-service cooperation | Take immediate steps to eliminate fire boundaries for call and dispatch purposes to create an agnostic approach to the threat of fires from both a departmental and organisational perspective |
REC302-2393 | 15 - Inter-service cooperation | In recognising the success of the work of both the volunteer based Rural Fire Service and the full time Fire and Rescue NSW (FRNSW) members in joint operations – both agencies should be represented at major briefings or press conferences to reinforce successful integrated collaborative efforts rather than individual agency achievements |
REC302-2404 | 8 - Communications and warnings | Review the effectiveness of emergency public information arrangements, and give consideration to embedding an ABC Manager (not a journalist) into the RFS headquarters during emergencies to broadcast warnings to the community that can be pooled to commercial media outlets |
REC302-2400 | 15 - Inter-service cooperation | Until a single call centre is developed, continue deployments of a senior RFS officer to Fire and Rescue NSW ComCen on a 24/7 day basis. This arrangement should determine the quickest most suitable resource and who is ‘in charge’ of an incident |
REC302-2396 | 15 - Inter-service cooperation | The Commissioners of Fire and Rescue NSW (FRNSW) and the RFS issue an instruction to FRNSW ComCen that while AVL capability is being made available to the RFS vehicle fleet, no offers of assistance by one agency to the other in combatting a fire is rejected or delayed if what is being offered is appropriate |
Rec-ID | Code | Recommendation |
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REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
Rec-ID | Code | Recommendation |
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REC280-1380 | 13 - Mapping and data quality | That the NSW Rural Fire Service investigate mechanisms to enhance the predictability of megafires and how this information is communicated easily to the public. |
REC280-1379 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1497 | 8 - Communications and warnings | That the NSW Rural Fire Service investigate mechanisms to enhance the predictability of megafires and how this information is communicated easily to the public. |
REC261-1496 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
REC261-1509 | 34 - Local knowledge | That the NSW Rural Fire Service, in order to ensure greater respect for volunteer fire fighters’ knowledge and experience in the management of fires: |
REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
Rec-ID | Code | Recommendation |
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REC260-1051 | 8 - Communications and warnings | That the Rural Fire Service consider redrafting the disclaimer in its fire predictions to make abundantly clear where the potential errors or omissions may affect the prediction and how to detect them if they are there (for example, by comparing them with linescans) and what other factors (such as VLS) may affect the predictions and in what way. |
REC260-1059 | 8 - Communications and warnings | That the Rural Fire Service and National Parks and Wildlife Service consider amending their protocols for upgrading advices to higher levels to emphasise the significance and urgency of raising warning levels as soon as the potential dangers of fire to lives or property materially increase. |
REC260-1050 | 13 - Mapping and data quality | Alternatively, I recommend that the RFS consider developing such capacity to deploy weather balloons itself, in conjunction with mobile weather stations, for this purpose. |
REC260-1055 | 34 - Local knowledge | That the Rural Fire Service together with other land managers develop a program whereby local stakeholders come together regularly (every 2 months during non-fire season and monthly during the fire season) to share intelligence and to consider hazard and incident management measures for implementation. |
REC260-1067 | 15 - Inter-service cooperation | That as part of the adoption of such a posture in ‘severe’ or worse fire conditions, the National Parks and Wildlife Service consider alerting, at an early stage, all relevant persons and organisations, such as shire councils, heavy plant operators, the local RFS captains, Fire & Rescue NSW and other emergency services, that it is doing so, and that their assistance may be required at short notice. |
REC260-1049 | 13 - Mapping and data quality | That the Rural Fire Service consider proposing an arrangement with the Bureau of Meteorology to deploy weather balloons specifically for the purpose of assessing atmospheric instability during periods of severe to catastrophic fire danger in locations most likely to be severely affected, for example, areas in which a very high C-Haines index reading is registered and local fires have been identified. |
REC260-1054 | 2 - Emergency powers | That the Rural Fire Service consider extending pre-emptive section 44 to whole of Castlereagh RFS/Warrumbungle Shire area. |
REC260-1066 | 14 - Incident Mgt Teams | That during periods of ‘severe’ or worse fire conditions, that the National Parks and Wildlife Service consider adopting a posture of pre-emptive planning and deployment of incident management teams in national parks similar to the manner in which the Rural Fire Service does. |
REC260-1053 | 14 - Incident Mgt Teams | That in Class 3 fire-fighting operations, the Rural Fire Service consider including a fire behaviour analyst in the incident management team if feasible. |
REC260-1061 | 18 - Access to fire ground | That the National Parks and Wildlife Service, in consultation with the relevant local Council(s), devise a policy that enables the John Renshaw Parkway to be closed at either end of the Warrumbungle National Park during a bush fire in such a way that its closure would not impede access by emergency services vehicles into the park. |
REC260-1052 | 14 - Incident Mgt Teams | That the Rural Fire Service consider amending its fire prediction reports to include a checklist of significant factors that have not been able to be considered in the prediction model and a warning to be alert for them and seek intelligence on them from fire ground managers. |
REC260-1060 | 7 - Inter-agency communication | That the Rural Fire Service and National Parks and Wildlife Service review the procedures for requesting aerial support in ‘severe’ or worse fire conditions to ensure that delays in providing it are reduced to the minimum time possible. |
Rec-ID | Code | Recommendation |
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REC259-1044 | 9 - Community education | That where, in the future a similar process for land clearing is adopted, the rationale and process is better explained and widely promulgated. |
REC259-1048 | 8 - Communications and warnings | That State and Local Government agencies maximise communication to the residents owning bushfire prone properties to be aware of their level of exposure by having access to the BAL relevant to their property. |
REC259-1045 | 9 - Community education | That recovery policy incorporates the need for regular public meetings which give access to officials and representatives of agencies, as required |
Rec-ID | Code | Recommendation |
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REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
Rec-ID | Code | Recommendation |
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REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1545 | 15 - Inter-service cooperation | Range Control Officer Marrangaroo Training Area liase with the local Rural Fire Service units to develop a map indicating the areas of the range likely to contain unexploded ordnance. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
REC257-1555 | 14 - Incident Mgt Teams | The lines of responsibility be made clearer and some individual, perhaps the Regional Environmental Officer, or agency be given overarching responsibility to ensure recommended works related to bushfire mitigation on Defence Estate are carried out in accordance with the Bushfire Management Plan which the Manual for Fire Protection Engineering directs be prepared. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1547 | 15 - Inter-service cooperation | The Marrangaroo Training Area Regional Environmental Officer confer with the local Rural Fire Service at least annually and determine a hazard reduction regime capable of implementation. It is furter recommended all ranges be reviewed in relation to the same issue, that is, that personnel involved in the management of each range under Defence control be directed to confer with local firefighting authorities on at least an annual basis to assess hazard reduction responses to be pursued for that range in subsequent years. |
Rec-ID | Code | Recommendation |
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REC236-2783 | 2 - Emergency powers | The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
Rec-ID | Code | Recommendation |
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REC232-2828 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. |
REC232-2827 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: |
REC232-2823 | 8 - Communications and warnings | The Australian Government, in consultation with consumers and other relevant federal, state and territory agencies, develop a national communication strategy for consumers to be used in the event of an infectious disease outbreak. |
REC232-2819 | 9 - Community education | The Australian Government, coordinated by the Department of Health and Ageing and in consultation with the wider Australian community, develop a national public awareness campaign to better inform and engage the travelling public about infectious disease issues. This campaign should cover the risks associated with travelling overseas, preventative measures that can be undertaken to minimise these risks, and screening measures used at the border to prevent the importation of infectious disease. |
REC232-2815 | 25 - Inquiry, audit, lessons management and after action review | The Department of Health and Ageing review the existing evidence base to evaluate the cost-effectiveness of its policy to use heat scanners at ports of entry as a measure to mitigate the risk of infectious disease importation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC176-0143 | 8 - Communications and warnings | The Commonwealth Government work with the states and their agencies to ensure consistent terminology is used when communicating with the public. |
Rec-ID | Code | Recommendation |
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REC163-1939 | 2 - Emergency powers | That the Rural Fires Act 1997 be amended to provide to designated Fire Investigation Officers of the Rural Fire Service the power to enter any land upon which a bushfire has occurred for the purposes of investigation for a period of up to 24 hours after a fire has been declared out. |
Rec-ID | Code | Recommendation |
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REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
Rec-ID | Code | Recommendation |
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REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3629 | 8 - Communications and warnings | We recommend that NSW Health continue with its good work and continue to improve communication mechanisms with those, such as GPs, likely to be affected in major infectious disease outbreaks. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3615 | 9 - Community education | That the Department of Primary Industries should continue to raise awareness among producers of OJD risks and the operation of Sheep Health Statements. |
REC128-3613 | 9 - Community education | That the Department of Primary Industries and Rural Lands Protection Boards employ outreach activities to alert these small producers to their responsibilities and improve their awareness of animal and plant pests and diseases. |
REC128-3600 | 34 - Local knowledge | The Department of Primary Industries continue to consult local community about emergency planning and sites for disposal to retain confidence in the event of a genuine emergency. |
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3765 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
Rec-ID | Code | Recommendation |
---|---|---|
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
REC098-2165 | 7 - Inter-agency communication | The Committee recommends that Emergency Management Australia and the Australian Communications Authority work with state and territory bush fire authorities to ensure that that district communication plans |
REC098-2153 | 7 - Inter-agency communication | The Committee recommends that the state and territory bushfire agencies ensure that, on a district basis, communications are addressed within the district operations plans and that the plans are capable of easy adoption to incident action plans. |
REC098-2164 | 7 - Inter-agency communication | The Committee recommends that: |
REC098-2162 | 13 - Mapping and data quality | The Committee recommends that the 1:100,000 national mapping program be accelerated to achieve an average life of no greater than 10 years with priority given to those areas most susceptible to national disasters. |
REC098-2181 | 11 - Evacuation and shelters | The Committee recommends that the Australasian Fire Authorities Council’s suggested evacuation protocol be adopted by all of the Australian States and Territories. |
REC098-2161 | 13 - Mapping and data quality | The Committee recommends that Emergency Management Australia be required to participate in the development and delivery of spatial information systems as part of a national approach to emergency planning and management data. The first priority in policy development and of systems should be related to bushfire hazards. |
REC098-2174 | 9 - Community education | The Committee recommends that the Insurance Council of Australia coordinates a public education campaign aimed at illustrating the importance of asset protection and how this can be achieved (that is, insurance products). |
REC098-2160 | 13 - Mapping and data quality | The Committee recommends that Geoscience Australia take responsibility, in conjunction with Emergency Management Australia, for developing a national spatial data policy to coordinate the development of data systems, the collection of data and the sharing of data between all the emergency response agencies across Australia, and that both agencies participate in the development and delivery of spatial information |
REC098-2168 | 2 - Emergency powers | The Committee recommends that the Commonwealth investigate, and where necessary, require the urgent enhancement of the provision of emergency power and telecommunications services for the purpose of |
Rec-ID | Code | Recommendation |
---|---|---|
REC013_3977 | 8 - Communications and warnings | To arrange with settlers who live on hills or have a clear view, and are connected by telephone, to act as " look-outs ", and to communicate with the brigade in the case of fire. |