Inquiry Search
Rec-ID | Code | Recommendation |
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REC327-4346 | 32 - Doctrine, standards, and reform | By December 2023, the Rural Fire Service should: establish a fleet maintenance framework to ensure regular update of District Service Agreements with local councils. |
REC327-4350 | 32 - Doctrine, standards, and reform | By December 2023, the Rural Fire Service should: develop a fleet enhancement framework and strategy that is informed by an assessment of current fleet capability to respond to fire incidents, and research into the most appropriate technologies and appliances to address emerging and future fire risks across NSW. |
REC327-4345 | 32 - Doctrine, standards, and reform | By December 2023, the Rural Fire Service should: review and improve processes for timely recording of fleet asset movements, locations, and maintenance status. |
Rec-ID | Code | Recommendation |
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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. |
REC315-3867 | 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 |
REC315-3814 | 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. |
REC315-3873 | 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. |
REC315-3854 | 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. |
REC315-3866 | 11 - Evacuation and shelters | That, in order to ensure evacuation arrangements can be scaled up when needed, Resilience NSW: |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3872 | 11 - Evacuation and shelters | That, in order to improve support for people evacuating with animals, the Department of Primary Industries: |
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. |
REC315-3805 | 32 - Doctrine, standards, and reform | That, to strengthen cross-agency accountability and deliver improved bush fire risk management outcomes: |
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. |
REC315-3852 | 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. |
REC315-3859 | 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. |
REC315-3804 | 32 - Doctrine, standards, and reform | That the NSW RFS Commissioner consult with the Fire and Rescue NSW Commissioner and other emergency services to develop a protocol in the event that simultaneous emergency events necessitate the re-allocation of resources while a Section 44 declaration is in place. |
REC315-3870 | 11 - Evacuation and shelters | That, in order to ensure the safety and wellbeing of vulnerable people during an evacuation, Resilience NSW: |
REC315-3844 | 32 - Doctrine, standards, and reform | That, in order to enhance fire fighting strategies in severe conditions, the NSW RFS implements the following in respect to backburning: |
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. |
REC315-3798 | 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. |
REC315-3820 | 32 - Doctrine, standards, and reform | That Government amend the Rural Fires Act 1997 so that all public land management agencies be required to forward complaints received about bush fire hazards to the Commissioner of the NSW RFS. As an interim measure, heads of agencies should commence this practice immediately. |
Rec-ID | Code | Recommendation |
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REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
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REC002-4011 | 32 - Doctrine, standards, and reform | The Commission feel that the 4th clause in the present Act, relating to the spacing of cut-throughs, should be amended to admit of any convenient or safe system of mining being pursued. This is a matter of detail that would be better out of the Act. The Commission would advise that the word should not occur at all, and that, if bratticing be used, or the air by some other satisfactory device be conveyed to the face, scope would be given to Managers to introduce systems of mining adapted to the circumstance of each particular coal-seam, with advantage to all concerned. |
Rec-ID | Code | Recommendation |
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REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1247 | 32 - Doctrine, standards, and reform | The State Government to create a Rural Fire Service to enhance the capability for rural fire management and bushfire risk management at a State, regional and local level. The proposed Rural Fire Service will: · be established as a separate entity from the Department of Fire and Emergency Services or, alternatively, be established as a sub-department of the Department of Fire and Emergency Services; · have an independent budget; · be able to employ staff; · have a leadership structure which, to the greatest degree possible, is regionally based and runs the entity; · be led by a Chief Officer who reports to the responsible Minister on policy and administrative matters; and to the Commissioner for Fire and Emergency Services during operational and emergency response; · have responsibilities and powers relating to bushfire prevention, preparedness and response; and · operate collaboratively with the Department of Fire and Emergency Services, the Department of Parks and Wildlife, Local Government and volunteer Bush Fire Brigades. In creating the Rural Fire Service, the State Government to consider whether back office and corporate support services could be effectively provided by an existing Department, such as the Department of Fire and Emergency Services or the Department of Parks and Wildlife. The State Government to review the creation of the Rural Fire Service two years after its establishment, to assess whether its structure and operations are achieving the intended outcome. |
REC291-1244 | 11 - Evacuation and shelters | The Department of Fire and Emergency Services to work with the Department of Planning and Local Governments to adopt a policy which enables Local Governments to identify, register and communicate, ‘Places of Bushfire Last Resort’ in settlements and townsites where the life risk from bushfire is very high or greater. |
REC291-1240 | 14 - Incident Mgt Teams | The Departments of Parks and Wildlife and Fire and Emergency Services to adopt the policy that all bushfire Level 3 Incident Management Teams in the Perth Hills and the South West will be integrated and pre-formed from the start of the 2016/17 fire season with substantial involvement of both the Departments of Parks and Wildlife and Fire and Emergency Services personnel on all teams. |
REC291-1239 | 14 - Incident Mgt Teams | The State Government to establish an arrangement to develop a ‘network’ of Western Australian State Government agency personnel who can be called upon for bushfire and emergency incident management capability within Western Australia. The arrangement will be led by the State Emergency Management Committee and modelled on systems used by the Department of Parks and Wildlife. |
REC291-1238 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee to adopt, across all hazards, the doctrine of: · the primacy of life; · the ‘Strategic Control Priorities’ (as documented by the Department of Fire and Emergency Services); and · community warnings that are timely, tailored and relevant. Agencies will reinforce amongst emergency management personnel the importance of this doctrine through briefings and intent statements. |
Rec-ID | Code | Recommendation |
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REC290-1218 | 7 - Inter-agency communication | Cross-agency resource management system |
REC290-1214 | 14 - Incident Mgt Teams | Flexible pre‐formed multi‐ agency IMTs |
REC290-1211 | 32 - Doctrine, standards, and reform | Review of institutional arrangements in the fire sector |
Rec-ID | Code | Recommendation |
---|---|---|
REC280-1395 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service reassess the protection of pastoral assets during bush fires to ensure that priority for protection is not simply afforded to the homestead, and that land holders are, within reason, able to request which of their own assets are protected. |
REC280-1391 | 32 - Doctrine, standards, and reform | 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. |
REC280-1390 | 32 - Doctrine, standards, and reform | That the NSW Government consider enabling the default position during catastrophic and extreme fire danger periods to be the same as for section 44 fires, so that fire control centres have the same systems and resources ready to deploy should a fire break out. |
REC280-1403 | 32 - Doctrine, standards, and reform | That the Ministry for Police and Emergency Services urgently review its policies for the provision of disaster welfare services to ensure that in the event of a bush fire emergency and the declaration of a fire under section 44 of the Rural Fires Act 1997, adequate funding and services, especially recovery centres and mental health services, are provided for an adequate length of time, with gradual transition to normal service delivery when those services are no longer required. |
REC280-1389 | 32 - Doctrine, standards, and reform | That the NSW Government, as a matter of urgency, amend the Rural Fires Act 1997 to codify the current interim arrangements for command and notification requirements for class 1 and class 2 fires, which clarify that the NSW Rural Fire Service or Fire and Rescue NSW: |
REC280-1397 | 32 - Doctrine, standards, and reform | That the NSW National Parks and Wildlife Service adopt an interim fencing agreement in the immediate aftermath of a fire. This will enable emergency and interim works to commence, but features such as length, fencing components and site of the fence line are not binding. A final fencing agreement would be negotiated no earlier than six months following a major national park fire. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
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. |
Rec-ID | Code | Recommendation |
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REC277-1165 | 32 - Doctrine, standards, and reform | Clarify the role of the ROC and SOC and their reporting relationships: The ROC and SOC have important coordination roles under the State Emergency Management Arrangements to support both the incident and the broader region and state. Clarifying the role of the ROC and SOC, their reporting relationships, and how the command structures of other agencies are integrated, will have three main benefits: the ROC and SOC can perform their functions effectively • no inconsistencies, gaps or duplication in the activities of the IMT, ROC and SOC • transparency of incident management |
REC277-1164 | 14 - Incident Mgt Teams | Establish multi-agency preformed IMTs: An effective IMT for large and complex fire incidents requires the capacity and expertise of multiple agencies. Establishing multi-agency preformed IMTs will have three main benefits: adequate IMT resources can be deployed with ease • strong working relationships will be built between IMT members • common approaches to incident management and fire response can be embedded. |
REC277-1166 | 7 - Inter-agency communication | Develop an integrated inter-agency resource management system: Large and complex fire incidents require resources from multiple agencies. Developing an integrated inter-agency resource management system will have three main benefits: identifying potential resources will be more straightforward • the status and location of resource deployments can be tracked • planning of deployments can take into account all relevant information |
Rec-ID | Code | Recommendation |
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REC265-1110 | 32 - Doctrine, standards, and reform | Whenever a Bush Fires Act 1954 section 13 transfer of control is invoked, the Incident level of an event should also be reviewed and any changes documented. |
REC265-1109 | 14 - Incident Mgt Teams | Future appointments to the role of Incident Controller should be limited to one for the entire duration of the incident, with nominated Deputy Incident Controllers to assist or ‘take charge’ in the Incident Controller’s absence. This measure will provide for a single point of responsibility and control for the incident and assist with any subsequent review or enquiry. If it is not possible to implement this proposal for liability reasons, the number of Incident Controllers should nevertheless be reduced to the minimum. |
REC265-1107 | 32 - Doctrine, standards, and reform | Standard Operating Procedure 1 (Mobilisation Zone 2, Perth Hills area) should be reviewed to ensure that appropriate escalation triggers and levels of operational readiness are in place for future periods when severe fire weather conditions are forecast. |
REC265-1124 | 32 - Doctrine, standards, and reform | EMP 4.4 and Westplan – Recovery Coordination should be amended to: clarify the wording around handing over control of the incident from the Controlling Agency to local government and the transition from response to recovery; include principles and criteria that will assist the Controlling Agency and local government to determine the best time to effect a hand over of control of the incident; make explicit the roles and responsibilities of the parties involved in the handover of control of the incident; specify the information required in the needs and impact assessments provided to local government by the Controlling Agency so that local government is given sufficient information to take control of incidents; clarify the roles, responsibilities and the title of the State Recovery Controller and ensure that the appropriate wording is reflected in Westplans and State Emergency Management Policies; Hazard Management Agencies, combat and support agencies and local governments need to fully inform themselves of the role of the State Recovery Controller and implement a more effective approach to communicating |
REC265-1102 | 25 - Inquiry, audit, lessons management and after action review | SEMC Secretariat Community Emergency Management Officers should work with the Shire to document the Shire of Mundaring’s learnings from the Parkerville Stoneville Mt Helena fire with a view to sharing this with other local authorities particularly those facing similar situations in order to extend the range of tools available to assist local governments to understand their roles and responsibilities in future emergencies. |
REC265-1114 | 32 - Doctrine, standards, and reform | Procedures should be reviewed to address the risks associated with response aircraft all working from one forward operating base, including the need for a designated fire protection unit to be available in the event of an aircraftrelated fire or other emergency incident |
REC265-1100 | 32 - Doctrine, standards, and reform | The forthcoming review by SEMC of SEMP 4.4 Recovery Coordination and Westplan – Recovery Coordination and SEMP 4.1 Incident Management should include consideration of: |
REC265-1113 | 32 - Doctrine, standards, and reform | The role of the Ground Controller should be reaffirmed in operational doctrine and reinforced in Incident Management Team training. During incidents involving aircraft the appointment of a Ground Controller should be confirmed by the Incident Controller |
Rec-ID | Code | Recommendation |
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REC261-1506 | 32 - Doctrine, standards, and reform | That the NSW Government, as a matter of urgency, amend the Rural Fires Act 1997 to codify the current interim arrangements for command and notification requirements for class 1 and class 2 fires, which clarify that the NSW Rural Fire Service or Fire and Rescue NSW: |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1516 | 32 - Doctrine, standards, and reform | That the NSW National Parks and Wildlife Service remove from its boundary fencing policy and standard contract the condition that requires adjoining land owners to maintain a fence that has been damaged by trees falling from national park land. |
REC261-1512 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service reassess the protection of pastoral assets during bush fires to ensure that priority for protection is not simply afforded to the homestead, and that land holders are, within reason, able to request which of their own assets are protected. |
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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REC260-1053 | 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. |
REC260-1066 | 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. |
REC260-1052 | 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. |
REC260-1065 | 32 - Doctrine, standards, and reform | That the National Parks and Wildlife Service review its procedures for monitoring Class 1 fires occurring in ‘severe’ or worse fire conditions that cannot be reconnoitred at ground level adequately due to terrain or dangerous conditions, and consider including aerial surveillance (if reasonably practicable) as a standard procedure in such circumstances. |
REC260-1064 | 32 - Doctrine, standards, and reform | That the National Parks and Wildlife Service review its protocols for control of Class 1 fires under its control to ensure that incident controllers managing fires in ‘severe’ or worse fire conditions receive as much incident management planning support as is reasonably practicable in the circumstances. |
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. |
REC260-1056 | 32 - Doctrine, standards, and reform | That the Rural Fire Service and National Parks and Wildlife Service consider adopting the approach to fire classification suggested by Mr Conway that “classification and resourcing of the fire ground response and incident management capability should reflect the potential of the fire rather than observed fire behaviour. |
REC260-1069 | 32 - Doctrine, standards, and reform | That NPWS conduct a review of its hazard reduction policies to ensure all assets within and on the boundary of the Park are clearly identified and an adequate policy or management plan exists for the protection of all assets, including a procedure pursuant to which progress in meeting hazard reduction targets is regularly and comprehensively assessed. |
Rec-ID | Code | Recommendation |
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REC254-1585 | 14 - Incident Mgt Teams | DFES and Local Government Bushfire Brigades ensure that only those with the required AIIMS competence have the authority to manage Level 1 incidents, noting they may not be Fire Control Officers. |
REC254-1584 | 32 - Doctrine, standards, and reform | DFES or DEC (depending on land tenure) is mandated to take over control of emergency incidents from Local Government once they have been declared Level 2 incidents. WESTPLAN BUSHFIRE and legislation to be amended accordingly. |
REC254-1580 | 32 - Doctrine, standards, and reform | Critical operational procedures such as ‘Red Flag Warnings’, on a common fireground need to be consistent across DFES, DEC and Local Government. In particular, the operational procedure of Red Flag Warnings needs to be adopted by all WA fire agencies. |
REC254-1588 | 32 - Doctrine, standards, and reform | WA fire agencies adopt a common set of standing orders, operational procedures, training and competencies for rural firefighting that are produced in hard copy, leading to integrated multi-agency training, IMTs, Regional and State coordination/control centres. |
REC254-1587 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
Rec-ID | Code | Recommendation |
---|---|---|
REC226-0570 | 14 - Incident Mgt Teams | Logistics and resource officers in IMTs need to collaborate and establish full awareness and control over the available resources. |
REC226-0577 | 7 - Inter-agency communication | A system of vehicle tracking should be fitted to all fire appliances and linked to the common operating picture. Good communications planning is essential for good command and control. |
REC226-0555 | 14 - Incident Mgt Teams | The state should identify the number of fully trained, experienced and accredited Level 3 Incident Controllers required to be available at any time and establish a process for identification of suitable personnel, ongoing training and accreditation. |
REC226-0586 | 14 - Incident Mgt Teams | At Level 3, the available fire management expertise should be applied overwhelmingly to the fire management aspects of emergency management, possibly in incident control, and certainly in situations planning and operations roles. |
REC226-0563 | 14 - Incident Mgt Teams | Procedures to relocate IMTs need to be established in doctrine and exercised to ensure continuity of control. |
REC226-0569 | 32 - Doctrine, standards, and reform | Section 13 arrangements need to be clarified across key agencies. |
REC226-0575 | 14 - Incident Mgt Teams | In multi-agency responses the culture, training and equipment characteristics of each of the agencies should be considered in their employment. |
REC226-0554 | 14 - Incident Mgt Teams | For incidents of this complexity, effective control in the critical phase (first 24-36 hours of the fire) requires an appropriately resourced IMT. |
REC226-0585 | 14 - Incident Mgt Teams | DEC’s fire management expertise should be augmented by multi-agency IMTs that incorporate the expertise of other agencies and in fast developing situations the appropriate decisions will need to be made early. |
REC226-0562 | 14 - Incident Mgt Teams | Opportunities be sought to utilise local government representatives in other areas of the IMT particularly in public information or other community related functions. |
REC226-0567 | 14 - Incident Mgt Teams | IMTs need to establish early and effective liaison with Local Governments. |
REC226-0574 | 14 - Incident Mgt Teams | Clear direction to divisional and sector commanders and a common communications platform enables maximum return to be gained from the application of tactical resources and this rests on good incident action planning, and good command and control. |
REC226-0552 | 7 - Inter-agency communication | Communications planning for geographic regions with recognised black spots and specific communications challenges should be prepared in advance of an emergency in order to support the IMT Communications Planning Officer |
REC226-0584 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command and not through agency chains of command |
REC226-0558 | 14 - Incident Mgt Teams | Predetermined locations for Level 3 IMTs should be reviewed and adequately resourced with necessary communications and IT capacity. |
REC226-0566 | 14 - Incident Mgt Teams | Incident Controllers should be supported by a planning function that combines experienced weather forecasters, fire behaviour experts and local knowledge. |
REC226-0573 | 14 - Incident Mgt Teams | Strategic direction seeks to identify and resource those areas of tactical action that offer the greatest advantage. |
REC226-0551 | 14 - Incident Mgt Teams | As presently implemented, the AIIMS planning role is under-developed and provides insufficient support to the Incident Controller. |
REC226-0580 | 32 - Doctrine, standards, and reform | The role of district and local emergency management committees should be reviewed to ensure they are appropriately engaged in the active management of emergencies across the PPR R continuum |
REC226-0557 | 14 - Incident Mgt Teams | An intensive exercise/training program should be developed and maintained across agencies to identify and establish a pool of current Incident Controllers who are capable of managing a Level 3 incident. |
REC226-0592 | 11 - Evacuation and shelters | Decisions on evacuations need to be made early enough for people to be fully informed, prepared and to move to a place of greater safety. Failure to conduct good planning can create situations where loss of life can occur |
REC226-0565 | 14 - Incident Mgt Teams | Contingency planning is a critical function in the early stages of an escalating incident, and should provide the foundation of an IAP. |
REC226-0572 | 14 - Incident Mgt Teams | Contingency planning before the fire may have supported the IMT in recognising and seizing strategic opportunities earlier. |
REC226-0550 | 14 - Incident Mgt Teams | Greater investment in training on specific functions within the AIIMS structure will improve the support provided to the Incident Controller. |
REC226-0579 | 32 - Doctrine, standards, and reform | Legislative change may be needed to enable FES A to better manage fire- fighting resources across the state. |
REC226-0556 | 14 - Incident Mgt Teams | Within the AIIMS IMT doctrine the roles of the Incident Controller and Deputy Incident Controllers should be defined and well-practiced. |
REC226-0587 | 14 - Incident Mgt Teams | To be effective, multi-agency IMTs will need to be exercised regularly and supported by sound and comprehensive doctrine. |
REC226-0564 | 14 - Incident Mgt Teams | The expected scenario, with a view to the worst-case scenario should provide the basis for an IAP. |
Rec-ID | Code | Recommendation |
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REC225-0540 | 25 - Inquiry, audit, lessons management and after action review | : In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
REC225-0531 | 32 - Doctrine, standards, and reform | Critical operational procedures such as ‘Red Flag Warnings’, on a common fireground need to be consistent across DFES, DEC and Local Government. In particular, the operational procedure of Red Flag Warnings needs to be adopted by all WA fire agencies. |
REC225-0539 | 32 - Doctrine, standards, and reform | WA fire agencies adopt a common set of standing orders, operational procedures, training and competencies for rural firefighting that are produced in hard copy, leading to integrated multi-agency training, IMTs, Regional and State coordination/control centres. |
REC225-0538 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC225-0537 | 7 - Inter-agency communication | Future coordination/support/control of integrated emergency management across all agencies in Albany needs to be merged and located in a single joint facility. This issue needs to be reviewed statewide. |
REC225-0536 | 32 - Doctrine, standards, and reform | DFES and Local Government Bushfire Brigades ensure that only those with the required AIIMS competence have the authority to manage Level 1 incidents, noting they may not be Fire Control Officers. |
REC225-0534 | 32 - Doctrine, standards, and reform | Once Recommendation 1 has been actioned, all agencies give greater priority to the promulgation of Red Flag warnings in order to enhance situational awareness on the fireground. |
Rec-ID | Code | Recommendation |
---|---|---|
REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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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. |
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
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 |
---|---|---|
REC203-0294 | 14 - Incident Mgt Teams | Opportunities should be sought to embed other local government representatives in other areas of the IMT particularly in public information. |
REC203-0307 | 11 - Evacuation and shelters | When people are being moved away from their homes it’s important that they move to a place of greater safety and that their movement is relatively assured. |
REC203-0300 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command, and not through agency chain of command. |
REC203-0297 | 32 - Doctrine, standards, and reform | The role of district and local emergency management committees should be reviewed to ensure they are appropriately engaged in the active management of emergencies across the PPR R continuum |
REC203-0296 | 32 - Doctrine, standards, and reform | Legislative change may be needed to enable FES A to manage fire-fighting resources across the state. |
Rec-ID | Code | Recommendation |
---|---|---|
REC202-0502 | 32 - Doctrine, standards, and reform | The Minister for Environment bring to Parliament by June 2012 amendments to the Conservation and Land Management Act 1984 that reflect the use by the Department of Environment and Conservation of prescribed burns for both biodiversity conservation and community protection purposes. |
REC202-0499 | 32 - Doctrine, standards, and reform | The Minister for Emergency Services institute a thorough review by December 2012, including a comparison to other jurisdictions, of the risk analysis processes used by FESA, the Police and DEC to prepare them to protect the State from bushfires and other natural disasters. |
REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
REC202-0505 | 7 - Inter-agency communication | The Minister for Emergency Services makes it a priority that the annual budgets of FESA and WA Police are sufficient to bring forward the completion dates of the current radio projects now underway. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0253 | 14 - Incident Mgt Teams | Review the command function of the MROC for Level 3 incidents when the SOC is activated. |
REC201-0252 | 7 - Inter-agency communication | FESA must actively manage the transition to WAERN and provide alternative means for regional crews to communicate when in areas where WAERN is not operated. |
REC201-0259 | 11 - Evacuation and shelters | FESA seek legal and policing advice regarding the policy to leave residents who chose not to evacuate in a declared ‗dangerous area‘ after a bushfire. |
REC201-0251 | 14 - Incident Mgt Teams | All responding crews and the incident command appointments should adopt a ‘Size Up‘ reporting format. |
REC201-0258 | 14 - Incident Mgt Teams | FESA should review the size of the existing pre-formed IMT to include additional Information and Planning officers and increased resourcing of scribes and management support for all Level 3 incidents. |
REC201-0248 | 14 - Incident Mgt Teams | To provide Level 3 IC‘s (and FESA) with a level of confidence and to maintain currency across the pool of accredited IC‘s, regular exercising of IC‘s and Level 3 IMT‘s is required. |
REC201-0255 | 14 - Incident Mgt Teams | FESA and DEC need to appoint accredited Level 3 IC‘s based on experience, competency and currency. |
REC201-0254 | 14 - Incident Mgt Teams | FESA should continue to develop with DEC and Local Government a number of rostered pre-formed IMT‘s available throughout the fire season, regardless of predicted weather. |
Rec-ID | Code | Recommendation |
---|---|---|
REC200-0341 | 32 - Doctrine, standards, and reform | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-1702 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-0372 | 7 - Inter-agency communication | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-1713 | 7 - Inter-agency communication | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
REC200-0391 | 14 - Incident Mgt Teams | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. This should include provision for a formal review of the performance of individual Level 3 Incident Controllers after every incident. |
REC200-0339 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia establish an inter-agency working group to continue the development of the new single emergency services Act. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0366 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-1709 | 32 - Doctrine, standards, and reform | The Western Australian Police and the Fire and Emergency Services Authority jointly examine the Traffic Management System developed in response to the 2009 Victorian bushfires and seek its adaptation to use in WA with additional attention to the access and egress by bona fide residents to areas that are evacuated. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1696 | 32 - Doctrine, standards, and reform | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-0363 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-1706 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-0382 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-1721 | 32 - Doctrine, standards, and reform | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
REC200-0362 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-1704 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority review its use of the Australian Interagency Incident Management System to ensure that the most appropriate resources (including aerial resources) are used to respond to an incident. If resources are rejected during an incident either through the decision making process or other grounds, the reason for the decision should be documented. |
REC200-0380 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: give clear and explicit direction about when and how an incident should be declared clearly articulate the actions to be taken clearly define accountabilities provide detailed criteria for elevating issues and engaging other agencies. |
REC200-1720 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-1703 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-0374 | 11 - Evacuation and shelters | Hazard Management Agencies overseeing the response to incidents on the urban fringe select evacuation centres that are well within the urban environment and unlikely to be impacted by the incident. |
REC200-1714 | 11 - Evacuation and shelters | Hazard Management Agencies overseeing the response to incidents on the urban fringe select evacuation centres that are well within the urban environment and unlikely to be impacted by the incident. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0111 | 14 - Incident Mgt Teams | Conducting a pre-fire season exercise for each Pre-Formed Incident Management Team could be used to “re-accrediting” each team on an annual basis. |
REC183-0107 | 32 - Doctrine, standards, and reform | The DEC Fire Management Policy should be reviewed and updated. |
REC183-0112 | 14 - Incident Mgt Teams | DEC’s incident management capability could be enhanced by: – Appointing a Deputy Incident Controller for every Level 3 IMT. – Establishing a fast response “short” IMT capability for each Level 3 IMT. – Establish clear triggers to initiate sending in a “short” IMT to a fire. – Including FESA officers in pre-formed Level 3 IMT’s. – Establishing additional pre-formed Level 3 IMT’s with FESA. – Where appropriate, appointing a local Bush Fire Brigade officer as Deputy Operations Officer. |
REC183-0115 | 32 - Doctrine, standards, and reform | The Hazard Management Agency for bushfire has not been defined. Defining the HMA for bushfire should be addressed. |
REC183-0108 | 32 - Doctrine, standards, and reform | DEC should consider publishing a new reference document that describes policy, doctrine and key systems of work of the fire management system. This document would be a “brief case” or “back pack” reference and would be reviewed annually and issued to all senior staff and fire management personnel. |
REC183-0113 | 14 - Incident Mgt Teams | A summary Incident Action Plan could allow the Incident Controller to more quickly appreciate the situation and articulate a plan early in an incident. |
REC183-0114 | 14 - Incident Mgt Teams | Higher level DEC guidance to Level 3 Incident Controllers could be improved by introducing a more explicit and robust process of questioning, engagement, monitoring and oversight of Level 3 Incident Controllers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0123 | 32 - Doctrine, standards, and reform | FESA implements measures that will ensure unity and clarity of command. |
REC182-0131 | 14 - Incident Mgt Teams | FESA establishes a dedicated intelligence function in Incident Management Teams for major bushfires and ensure this function is appropriately supported with threat based tools and systems. |
Rec-ID | Code | Recommendation |
---|---|---|
REC173-0102 | 32 - Doctrine, standards, and reform | That further amendments be made to the Bush Fires Act 1954 be drafted to provide fire response agencies with the necessary authorisation and statutory protection to respond to a fire on private property, or land that Local Government, Department of Environment and Conservation (DEC) or FESA is responsible for, until such time as the responsible agency is able to attend and take control. The amendments to be drafted, in conjunction with the urgent progression of critical amendments as recommended by the Community Development and Justice Standing Committee. |
REC173-0100 | 32 - Doctrine, standards, and reform | The prioritising of the critical amendments to the Bush Fires Act 1954 recommended by the Community Development and Justice Standing Committee that relate to fire management, ie: a. Fire and Emergency Services Authority (FESA)‘s ability to assume control of a fire in specific circumstances b. Amendments to the definition of property c. Providing FESA with the authority to declare a total fire ban |
Rec-ID | Code | Recommendation |
---|---|---|
REC172-0001 | 32 - Doctrine, standards, and reform | The Emergency Management Regulations 2006 be urgently amended to determine a HMA(s) for bushfire. |
REC172-0006 | 14 - Incident Mgt Teams | Prior to the bushfire season, potential IMG members, many of whom are members of the Local Emergency Management Committee (LEMC) should be made aware of, and possibly exercise, their role as an IMG member. |
REC172-0018 | 32 - Doctrine, standards, and reform | The Interagency Guidelines need to be amended to reflect what is operationally possible with regard to risk management rather than what is required to achieve an absence of risk. |
REC172-0043 | 7 - Inter-agency communication | There needs to be a system that allows laptop computers brought to an incident to be configured at the start of the season and allow them to be easily activated to the correct configuration when they arrive at the incident. |
REC172-0005 | 14 - Incident Mgt Teams | Potential IMG membership should be identified in local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA. |
REC172-0010 | 14 - Incident Mgt Teams | The responsibilities and obligations for an OAM and OAMG (when established) needs to clarified and codified in Westplan Bushfire with regard to • Provision of information to participating organisations about the progress and potential of an incident; • Dealing with information disseminated to the public; and • Sourcing, coordinating and prioritising resources required by incidents within the Operations Area. There is lack of clarity in current arrangements concerning the role of the agency undertaking control operations e.g. DEC or a local govt and the transfer of these responsibilities to an OAMG when established. |
REC172-0042 | 7 - Inter-agency communication | Portable, reliable mobile repeaters are required to provide radio communications into areas not covered by existing repeater networks. These repeaters need the capacity to be linked. |
REC172-0004 | 14 - Incident Mgt Teams | A formal IMG meeting should be convened as early as possible at initiating incidents with potential. At the very least early advice to potential IMG members should be made that a meeting is likely to be convened. The initial IMG should include all IMG representatives to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0009 | 14 - Incident Mgt Teams | When an OAMG is established, a formal declaration of its establishment needs to be transmitted to all organisation/agencies involved. The declaration should clearly establish the reporting arrangements for Incident Controllers to the OAM as described in Westplan Bushfire. |
REC172-0035 | 14 - Incident Mgt Teams | At Level 3 incidents the Information Services Unit should be adequately resourced with information technology and at least 6 persons, all of whom are very experienced and capable in dealing with the information demands of a Level 3 incident. |
REC172-0003 | 32 - Doctrine, standards, and reform | All incidents where the HMA delegates the authority to manage suppression operations to another agency on its behalf, should be achieved via a written delegation setting out the scope, limitations and duration of the delegation. |
REC172-0008 | 14 - Incident Mgt Teams | Potential OAMG membership should be identified in DEMC protocols and local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA.] |
REC172-0002 | 32 - Doctrine, standards, and reform | The Emergency Management Act 2005 is amended to provide a mechanism for one HMA to transfer responsibility to another HMA and ensure that both HMA’s are provided the powers and protection necessary under that Act. |
REC172-0007 | 14 - Incident Mgt Teams | A formal OAMG meeting should be convened as early as possible for incidents with the potential to be Level 3 incidents. At the very least early advice to potential OAMG members should be made on days that exhibit extreme fire weather and other high ignition risk factors that a meeting is likely to be convened. The initial OAMG should include all OAMG representatives identified by LEMAC and DEMAC for each area to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0021 | 32 - Doctrine, standards, and reform | Unassigned resources arriving at incidents should be encouraged to make themselves known and to undertake alternate duties. |
Rec-ID | Code | Recommendation |
---|---|---|
REC171-0067 | 14 - Incident Mgt Teams | That to the extent it has not already done so, DEC take action to ensure that in future cases relevant weather forecast information, particularly information as to significant wind changes, is promptly transmitted through the Incident Management Team and made available to persons with field operation responsibility. |
REC171-0070 | 32 - Doctrine, standards, and reform | That a review be conducted of DEC’s ability to manage major fires and consideration be given to increased direct involvement by FESA in fire management role in the case of major fires on reserves or on unallocated Crown lands. |
REC171-0068 | 32 - Doctrine, standards, and reform | That if the Bushfires Amendment Bill 2009 is to be enacted, procedures be put in place which would ensure that in the event of an escalating fire, FESA would receive sufficient information to make an informed judgment as to whether or not to take control of all operations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3621 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and establish a time table to finalise all emergency and contingency plans. |
REC129-3632 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and develop distinct surge capacity plans within each Area Health Service to manage emergency staffing needs, isolation facilities, intensive care units, assisted ventilation services, hospital beds and medical supplies. |
REC129-3631 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop plans to respond to the surge in demand for diagnostic tests and for laboratory personnel. |
REC129-3630 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop systems to bring all the information relevant to the surge in demand for health resources together in real time. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC128-3618 | 32 - Doctrine, standards, and reform | That the Department of Primary Industries should complete a review of the Memorandum of Understanding and ensure the roles of the Department and Rural Lands Protection Boards are more clearly identified outlined for effective delivery of animal health programs. |
REC128-3610 | 32 - Doctrine, standards, and reform | That the Minister for Primary Industries consider amending the Stock Diseases Act 1923 to ban the supply of waste swill to pig owners by food retailing businesses such as bakeries, restaurants and supermarkets. |
REC128-3599 | 32 - Doctrine, standards, and reform | In order to improve the response to animal health emergencies, that the Department of Primary Industries prioritise the finalisation of Memoranda of Understanding with the four jurisdictions bordering New South Wales. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
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. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
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. |
REC121-3691 | 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. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
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. |
REC121-3652 | 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. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
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. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
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. |
REC121-3757 | 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. |
REC121-3676 | 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. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
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. |
REC121-3693 | 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. |
REC121-3753 | 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. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
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. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
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. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3903 | 32 - Doctrine, standards, and reform | Government should: establish emergency management legislation which clarifies State and local government responsibilities, and which rectifies the deficiencies in the State’s bushfire Emergency Management Plan, Westplan Wildfire. |
REC113-3902 | 14 - Incident Mgt Teams | Government should: establish a State-wide command structure across volunteer Bush Fire Brigades for fighting major bushfires, to more effectively manage the coordination of personnel and resources |
Rec-ID | Code | Recommendation |
---|---|---|
REC013_3979 | 32 - Doctrine, standards, and reform | That burning off by "occupiers" on any lands be regulated by permit or by regulation. |