Inquiry Search
Rec-ID | Code | Recommendation |
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REC327-4349 | 38 - Agency/Department Reporting | By December 2023, the Rural Fire Service should: develop performance measures to assess the performance and capabilities of the fleet in each RFS District by recording and publicly reporting on: fire response times and fire response outcomes; and, completions of fire hazard reduction works. |
REC327-4348 | 38 - Agency/Department Reporting | By December 2023, the Rural Fire Service should: report annually on fleet allocations to RFS Districts, and identify the ways in which fleet resources align with district-level fire risks |
Rec-ID | Code | Recommendation |
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REC316-4014 | 25 - Inquiry, audit, lessons management and after action review | That Justice and Community Safety Directorate (JACS) lead a working group from across relevant organisations to undertake the five year review of the Emergencies Act in conjunction with a wholistic review of the Emergency Plan and relevant sub-plans; and recommendations from this review, to the extent they are accepted by Government. Bringing together a small Taskforce of staff from across government for a set period would assist the working group in delivering the work needed to address these and other recommendations. |
REC316-4046 | 33 - Relief and recovery | Emergency Plan and Recovery sub-plans should be amended to better define recovery mechanisms and responsibilities, including hand over points to recovery authorities and community engagement for the delivery of long term recovery mechanisms. |
REC316-4042 | 25 - Inquiry, audit, lessons management and after action review | ACT Government undertake a detailed legislative review to ensure that information regarding vulnerable community members can be appropriately accessed, provided and used during an emergency event. |
REC316-4038 | 25 - Inquiry, audit, lessons management and after action review | The CCIP be reviewed in conjunction with the review of the Emergency Plan and the two synchronised. A workable approach to delivering operational emergency communications and strategic WhoG communications is developed with simple and clear reporting arrangements. |
REC316-4033 | 25 - Inquiry, audit, lessons management and after action review | The BFC Terms of Reference be reviewed to ensure they are contemporary and reflect learnings from this and recent bushfire seasons. |
REC316-4018 | 25 - Inquiry, audit, lessons management and after action review | The five year review of the Emergencies Act examine amendments to better define the rationale for a State of Alert / State of Emergency whilst ensuring that the relevant Minister / Chief Minister still has sufficient discretion to make a declaration based on advice from relevant Government officials and committees. |
Rec-ID | Code | Recommendation |
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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. |
REC315-3859 | 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. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
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. |
REC315-3801 | 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. |
REC315-3840 | 29 - Operational Health and Safety | That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters. |
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. |
REC315-3800 | 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: |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
REC315-3868 | 33 - Relief and recovery | That, in order to ensure people only need to tell their story once to access government agency support following an emergency, Resilience NSW and Service NSW jointly design an inclusive, person-centred approach to information collection at evacuation centres. This should be supported by an opt-in scheme enabling personal information to be shared between NSW government agencies, local councils and non-governmental organisations administering support services for disaster-affected people. |
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. |
REC315-3838 | 29 - Operational Health and Safety | That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members. |
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. |
Rec-ID | Code | Recommendation |
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REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
Rec-ID | Code | Recommendation |
---|---|---|
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: |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC261-1520 | 33 - Relief and recovery | 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. |
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. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC260-1049 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC259-1046 | 33 - Relief and recovery | That prior to the commencement of any major clean-up, firm policy be established and made known to the extent to which material removal will be the responsibility of the home owner, the Council or the State led recovery effort. |
REC259-1043 | 33 - Relief and recovery | That a single victim registration form be designed, which captures all relevant details required for use by any support agency both in the Response Phase at Evacuation centres and during the Recovery Phase. That such documents when completed form part of a wider database which can be accessed by all relevant agencies |
Rec-ID | Code | Recommendation |
---|---|---|
REC228-1615 | 38 - Agency/Department Reporting | The Territory and Municipal Services Directorate, as part of its Bushfire Operations Plan monitoring and reporting, should assess and publicly report on cumulative progress against broader outcomes identified in the Regional Fire Management Plans and the Strategic Bushfire Management Plan. |
REC228-1614 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the ACT Bushfire Council, should conduct a review of the ACT Bushfire Council against its recently developed terms of reference (July 2013) within two years. |
REC228-1609 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency should undertake audits to meet the requirements in the Strategic Bushfire Management Plan for the preparation, sharing and publication of annual progress reports. Annual progress reports should be made available to the ACT Bushfire Council. |
REC228-1620 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the Territory and Municipal Services Directorate, should review the Farm FireWise Program, including: |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
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. |
REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
Rec-ID | Code | Recommendation |
---|---|---|
REC126-1960 | 13 - Mapping and data quality | That an appropriate geographic information systems capability be maintained to enable the production of fire-specific maps as the need arises and that personnel from the Emergency Services Agency and other agencies be trained in the operation of map production systems, so that 9maps can be modified to include fire-specific information as required |
REC126-1959 | 13 - Mapping and data quality | That the Emergency Services Agency introduce a program with land management agencies in the ACT to ensure that maps of all public and private land in the ACT are subjected to regular review and amendment as required. Maps of a scale sufficient to facilitate fire management operations should be available in printed form and maintained on an electronic database capable of modification to add relevant features during a firefighting operation |
REC126-1952 | 25 - Inquiry, audit, lessons management and after action review | That regular periodic reviews be undertaken of changes made to the operational and management arrangements for dealing with wildfires and other emergencies in the ACT, to ensure that those arrangements continue to comply with the Australian Inter-Agency Incident Management System Incident Control System |
REC126-1947 | 25 - Inquiry, audit, lessons management and after action review | That the ACT Government commission a review of coroners’ jurisdiction in order to determine whether that jurisdiction ought to be limited or expanded and, if so, to what extend |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |
REC126-2010 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the extent to which the recommendations in the McLeod report have been implemented in order to ensure implementation of those not yet implemented |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
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. |
REC121-3753 | 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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
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. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
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. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
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. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
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. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |