Inquiry Search
Rec-ID | Code | Recommendation |
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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 |
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. |
REC327-4347 | 36 - Volunteers | By December 2023, the Rural Fire Service should: develop a strategy to ensure that local brigade volunteers are adequate in numbers and appropriately trained to operate fleet appliances in the RFS Districts where they are required. |
Rec-ID | Code | Recommendation |
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REC322-4246 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the Interagency Protocol for Fire Management be reviewed by all relevant entities, including representatives of the Butchulla people, and be updated as a matter of priority. Entities responsible for the protocol should implement a process for regular review and evaluation of its effectiveness. This review process should be conducted after a major bushfire event, or to reflect any material change to applicable legislation and policy. It should also consider pre-arranged approvals and a range of agreed fiscal protocols between the agencies. |
REC322-4244 | 16 - Training and behaviour | The Inspector-General Emergency Management recommends the Department of Environment and Science review its training framework and minimum mandatory training requirements for Queensland Parks and Wildlife Service Incident Controllers to ensure they are appropriately trained to manage significant events. |
REC322-4252 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services regularly review and evaluate the effectiveness of the Queensland Bushfire Plan with land managers and stakeholders, including disaster management groups. A review should occur in line with any material change to the Queensland State Disaster Management Plan, the Disaster Management Act 2003, the Prevention Preparedness Response and Recovery Guideline, or after major bushfire events, to ensure appropriate alignment and currency. |
REC322-4218 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends this report be returned to the IGEM to monitor, evaluate and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC322-4219 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends should a Queensland Government Action Plan be considered, clarity about the intent of the recommendations be sought from the Inspector-General Emergency Management to assist in informing this process. |
REC322-4220 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science monitor the progress of relevant improvement activities resulting from the K’gari (Fraser Island) Bushfire Review, through their respective lessons management programs. |
REC322-4240 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the next review of the Queensland State Disaster Management Plan examines and provides guidance in respect to the application of Queensland’s disaster management arrangements to support hazard specific events such as bushfire. |
REC322-4229 | 16 - Training and behaviour | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services identifies stakeholders that would benefit from predictive service products. Suitable advice and training should be provided to these stakeholders to assist with using and interpreting the products. |
Rec-ID | Code | Recommendation |
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REC321-4207 | 25 - Inquiry, audit, lessons management and after action review | We recommend that DELWP reviews its target for the number of fuel hazard assessments conducted and ensures that this measure is evidence based, accurately reflects regional performance, and that the department monitors and reports on each region’s performance against it. |
REC321-4208 | 38 - Agency/Department Reporting | We recommend that DEWLP and CFA (in consultation with FRV) develops financial reporting to monitor fuel management costs and estimate future costs. |
REC321-4209 | 38 - Agency/Department Reporting | We recommend that DEWLP and CFA (in consultation with FRV) systemically documents and publicly reports reasons why it does not complete planned burns. |
Rec-ID | Code | Recommendation |
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REC319-4197 | 36 - Volunteers | Relief and recovery capability: The Inspector-General for Emergency Management recommends that Emergency Management Victoria and the entity referred to in Recommendation 13, or otherwise responsible government department develop and resource an ongoing strategy to coordinate spontaneous volunteers that can be activated before, during or after emergencies. |
Rec-ID | Code | Recommendation |
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REC318-4177 | 38 - Agency/Department Reporting | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in conjunction with legislated fuel management organisations – develop a common set of objectives, metrics and reporting requirements for fuel management that form part of a compulsory regime that enables the Victorian Government to report publicly on a holistic fuel management program. The reporting requirements should: |
REC318-4182 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in partnership with agencies engaged in state, regional and incident control centres: |
REC318-4181 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in collaboration with the emergency management sector and as part of the emergency management planning reforms: |
REC318-4178 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in collaboration with the Country Fire Authority and local government – undertake a review of the current residual risk target to ensure that it remains contemporary in terms of its designated percentage value. The review should: |
REC318-4171 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the State review (and where necessary amend) legislation including but not limited to the Country Fire Authority Act 1958, Forest Act 1958 and Local Government Act 2020 to: |
Rec-ID | Code | Recommendation |
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REC317-4102 | 25 - Inquiry, audit, lessons management and after action review | Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments. |
REC317-4074 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should review the content of the Defence Assistance to the Civil Community manual to ensure consistency of language and application with a revised COMDISPLAN. |
REC317-4120 | 16 - Training and behaviour | Australian, state and territory governments should establish a national mechanism for sharing of trained and qualified recovery personnel and best practice during and following natural disasters. |
Rec-ID | Code | Recommendation |
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REC316-4018 | 25 - Inquiry, audit, lessons management and after action review | The five year review of the Emergencies Act examine amendments to better define the rationale for a State of Alert / State of Emergency whilst ensuring that the relevant Minister / Chief Minister still has sufficient discretion to make a declaration based on advice from relevant Government officials and committees. |
REC316-4020 | 16 - Training and behaviour | EPSDD and ESA work together to develop values officer training and accreditation. |
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. |
REC316-4042 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC315-3807 | 16 - Training and behaviour | That, in order to expand NSW’s specialist aviation personnel safety and capacity, Government expand simulator capabilities at the NSW RFS Training Academy. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3803 | 16 - Training and behaviour | That Government support training initiatives to increase the capacity of fire authorities to fight the kind of megafires seen in the 2019-20 season. The training initiatives should include: |
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. |
REC315-3840 | 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. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
REC315-3860 | 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. |
REC315-3838 | 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. |
REC315-3859 | 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. |
REC315-3861 | 16 - Training and behaviour | That, in order to expand the pool of trained personnel able to undertake the Public Information Functional Area Coordinator (PIFAC) role, Resilience NSW and the NSW Police Media Unit (PIFAC) develop and deliver a training package for Emergency Management Media Liaison Officers. |
Rec-ID | Code | Recommendation |
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REC314-3267 | 16 - Training and behaviour | Invest in fireground leadership and incident management training for CFS, SES and MFS personnel to improve safety on the fireground. Invest in greater technological interoperability such as AVL, Thermal Imagery, Burnover Protection Systems (BOPS), lightning tracking and appropriate vehicle fleets for bushfire conditions including at the peri-urban interface. |
Rec-ID | Code | Recommendation |
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REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
REC308-2465 | 29 - Operational Health and Safety | Fatigue management strategies and guidance should be improved to ensure sustainable staffing practices are incorporated into disaster management planning. |
REC308-2464 | 16 - Training and behaviour | The provision of system-wide education, guidance and testing to enhance requests for Assistance is strengthened. |
Rec-ID | Code | Recommendation |
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REC307-2445 | 16 - Training and behaviour | All agencies should identify the capacity and appropriate positions for the role of liaison officers, and ensure sufficient numbers are trained. |
REC307-2435 | 16 - Training and behaviour | Building capacity in fire simulation and predictive capabilities, including the capability of people to read and interpret these products through training, should be investigated and considered. |
Rec-ID | Code | Recommendation |
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REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
REC301-2384 | 36 - Volunteers | TFS should pursue the creation of a cadre of volunteer remote area firefighters. In doing so the TFS should not consider itself limited to upskilling of current volunteer brigade members, but should carry out a cost benefit analysis of creating one or more remote area firefighting units based in urban areas, in order to tap into the potential of those members of the urban-based Tasmanian community who may have advanced knowledge and skills relating to navigation and survival in wilderness areas. |
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. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
Rec-ID | Code | Recommendation |
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REC299-1344 | 25 - Inquiry, audit, lessons management and after action review | That a review of the cross‑tenure approach be undertaken to determine its effectiveness and to address issues that arise in fire prevention on private and public land. |
REC299-1343 | 25 - Inquiry, audit, lessons management and after action review | That the Government conduct a review of fire prevention |
REC299-1345 | 36 - Volunteers | That issues of animal welfare be given a higher practical priority in the planned burning process on the ground, including: |
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. |
Rec-ID | Code | Recommendation |
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REC288-1199 | 36 - Volunteers | The Committee finds that on the evidence presented, that volunteer firefighters are at risk of being undervalued and underrated and that the Government should use best endeavours to ensure the full acknowledgement and recognition of these services. |
Rec-ID | Code | Recommendation |
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REC287-1183 | 16 - Training and behaviour | Further conversations take place between TFS and SES to identify what skills and capabilities may be transferable between the agencies, not just in the event of a future fire, but in case of future hazards for which SES is the primary response agency, including food, earthquake and tsunami. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
REC287-1181 | 16 - Training and behaviour | The Tasmanian fire agencies develop a multi-agency position to ensure that training for incident controllers includes training in how the transition from local incident control to Divisional Command is managed. |
REC287-1190 | 16 - Training and behaviour | That a full review be undertaken of the benefts and costs of training a cadre of Tasmanian volunteer firefghters in remote area firefghting, with reference to the experience of jurisdictions interstate that already do so. |
REC287-1189 | 16 - Training and behaviour | That suffcient Tasmanian firefghters are trained in winch operations to sustain a ‘first strike’ capability until they can be reinforced (if necessary) by interstate capability; and that consideration be given to how winch-capable aircraft can be sourced to support this activity at fire incidents. |
REC287-1187 | 16 - Training and behaviour | All Tasmanian fire agency staff who are assigned to aviation-related roles be required to complete the formal nationally recognised training appropriate to that role. Tasmanian fire agencies arrange secondments to larger states for staff who are going to undertake aviation-related roles, to give them practical experience of the role in advance of any major incidents. |
REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
Rec-ID | Code | Recommendation |
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REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1393 | 36 - Volunteers | That the NSW Rural Fire Service formally recognise the Volunteer Fire Fighters Association as a legitimate advocacy organisation representing volunteer bush fire fighters, and duly consult with it on policy and operational matters. |
REC280-1392 | 36 - Volunteers | That the NSW Rural Fire Service, in order to ensure greater respect for volunteer fire fighters’ knowledge and experience in the management of fires: |
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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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. |
REC265-1115 | 16 - Training and behaviour | Training and awareness raising should be conducted to enhance the appreciation and understanding of DFES State and Regional operational personnel, including potential Incident Management Team members, of the nationally adopted Bushfire Alert and Messaging Matrix, in order to ensure that the most appropriate alert levels and associated community messaging are applied during bushfire incidents. |
REC265-1103 | 16 - Training and behaviour | DFES should review its training courses and Standard Operating Procedures to satisfy itself that all incident management personnel have the required level of understanding of WA emergency management arrangements, including those that relate to the roles of the Incident Management Team and Incident Support Group and the declaration of incident levels. |
Rec-ID | Code | Recommendation |
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REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
Rec-ID | Code | Recommendation |
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REC261-1510 | 36 - Volunteers | That the NSW Rural Fire Service formally recognise the Volunteer Fire Fighters Association as a legitimate advocacy organisation representing volunteer bush fire fighters, and duly consult with it on policy and operational matters. |
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 |
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REC260-1062 | 16 - Training and behaviour | That the National Parks and Wildlife Service consider incorporating “worst-case scenario” training, as proposed in Mr Conway’s report, in its suite of fire-fighting protocols, exercises and training packages for senior incident controllers and other senior managers. |
REC260-1057 | 16 - Training and behaviour | That the Rural Fire Service and National Parks and Wildlife Service introduce training, exercises or information packages, or other suitable forms of professional development, for operational fire fighters and analysts concerning the potential effects of atmospheric instability and vorticity-driven lateral spread on fire behaviours in severe-catastrophic fire danger conditions. |
REC260-1068 | 16 - Training and behaviour | That the National Park and Wildlife Service review its fire weather training regime and consider adopting or adapting the fire weather training courses introduced in Victoria following the 2009 bushfire disaster. |
Rec-ID | Code | Recommendation |
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REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
Rec-ID | Code | Recommendation |
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REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1540 | 16 - Training and behaviour | Commanding Officer Defence Explosive Ordnance Training School, assisted by Joint Logistics Command Regional Explosive Ordnance Serices staff, conduct explosive ordnance accounting training for all instructional staff as a matter of priority and that such training be conducted for Defence Explosive Ordnance Training School staff on an annual basis. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
REC257-1536 | 16 - Training and behaviour | The Australian defence Force Explosive Ordnance Disposal course be reviewed by Manager Joint Training - Air Force, to ensure the assessments meet the learning outcomes specificed in the relevant Training Management Package. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
Rec-ID | Code | Recommendation |
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REC254-1581 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
REC254-1583 | 16 - Training and behaviour | 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 |
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REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0925 | 16 - Training and behaviour | That training and development of personnel to establish a suitable state of readiness, be included in the recommended review by Tasmania Police of its approach to emergency management. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0924 | 16 - Training and behaviour | That an exercise program — to establish and maintain an acceptable state of readiness for agencies and organisations required to be involved in emergency operations — be developed and implemented. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0868 | 16 - Training and behaviour | That Tasmania Fire Service, Forestry Tasmania, and Parks and Wildlife Service have a process for ensuring fire strategy and tactics are appropriate and remain focussed. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0936 | 16 - Training and behaviour | That the State Fire Management Committee note the decline in machinery and skilled operators from the forestry industry in the private sector and determines how this reduction in fire management capability can be addressed. |
Rec-ID | Code | Recommendation |
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REC246-0788 | 25 - Inquiry, audit, lessons management and after action review | TFS seek to address the following outstanding items from the recommendations of the Victorian Bushfires Royal Commission. § 45 out of 53 Community Bushfire Response Plans for “at risk” communities have been finalized. The remaining eight should be completed as a priority action. § That TFS progress the development of Community Bushfire Mitigation Plans for the 53 at risk communities, possibly as an action for reactivated Fire Management Area Committees. § TFS, together with other ESOs and local government, should develop a common comprehensive approach to the option of planned evacuation from dangerous or potentially dangerous areas to safer areas and eventual return. § TFS should include factors for consideration for evacuation during a bushfire into their training doctrine for Incident Controllers. § The IAP Template and its application be reinforced as an important operational requirement for IMT’s during the 2013-14 pre-season briefing program. 10 § That TFS review their use of IRMS to ascertain if either its full potential is not being realized through a lack of operator training or it is in fact not providing the required functionality and there is a need to research an improved resource management system which enhances interoperability. § The TFS Publication: Guidelines for Development in Bushfire Prone Areas of Tasmania http://www.fire.tas.gov.au/userfiles/stuartp/file/Publications/BushDeve… s2012.pdf requires an update to reflect the provisions of Planning Directive #5 Bushfire-Prone Areas Code. |
Rec-ID | Code | Recommendation |
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REC241-0984 | 16 - Training and behaviour | That Rural Fire Service Queensland work with the State Emergency Service, Surf Life Saving Queensland and other volunteer organisations to develop training programs which can be recognised by all organisations (E.G. chainsaw training, Four-wheel drive training) |
REC241-1030 | 25 - Inquiry, audit, lessons management and after action review | That Rural Fire Brigades only be required to conduct an audit of finances if the Brigades income exceeds $5,000 for a financial year. RFSQ District offices should investigate options for savings on the costs of auditing Brigades in their district through either an in-house or external provider. Legal Status of Brigades |
REC241-0976 | 16 - Training and behaviour | That Rural Fire Service Queensland recognise training and experience in rural fire Brigades as equal to experience gained in other rural fire services when considering candidates for employment. |
REC241-1022 | 29 - Operational Health and Safety | That Rural Fire Service Queensland in consultation with the Rural Fire Brigades Association Queensland will undertake a full review of the medical and health protocols to support the new Volunteer organisation. |
REC241-1017 | 36 - Volunteers | That each District office establish and maintain a register of suitably qualified Australasian Inter-service Incident Management System trained volunteers who are prepared to undertake the management of operations and provide these to the District Fire Management Group. |
REC241-0983 | 16 - Training and behaviour | That the current Primary Producer Brigade manual be withdrawn and a working group comprising Rural Fire Service Queensland staff, Rural Fire Brigade Association of Queensland representatives and Primary Producer Brigade volunteers and as a priority produce a new, simpler and less bureaucratic booklet. |
REC241-0974 | 16 - Training and behaviour | That all employees of Rural Fire Service Queensland MUST demonstrate a background in, knowledge or experience of land management and volunteering. |
REC241-1015 | 29 - Operational Health and Safety | That the First Officer or Brigade Officer retain the ability to seek assistance from any person whose services are available at the fire. Any person appointed to provide this assistance should be protected under relevant Workplace Health and Safety and Workcover legislation. |
REC241-0978 | 36 - Volunteers | That in recognition of their commitment to the community volunteers employed by the State Government should be released to assist as volunteers for up to five (5) days per year in appropriately identified emergency operations. |
REC241-0982 | 16 - Training and behaviour | That the requirement for Primary Producer Brigade members to undertake a Firefighter Minimum Skills course be removed and replaced with a ‘Primary Producer Brigade Induction’ course. |
REC241-1041 | 16 - Training and behaviour | That, as with Recommendation 23 related to Rural Fire employees, all State Emergency Service employees should have a recorded history of volunteering. |
REC241-0969 | 16 - Training and behaviour | That a mobile training program be established for areas with identified above average fire risk to train in fire behaviour and Australasian Inter-Service Incident Management System principles across land tenures. |
REC241-0965 | 29 - Operational Health and Safety | That the number of Bushfire Safety Officer positions be, over time, increased so that one BSO operates out of each District office. |
REC241-0955 | 36 - Volunteers | That corporate support, such as administration and finance, to volunteer services be shared to enable a closer working relationship between the services. |
REC241-0981 | 16 - Training and behaviour | That Rural Fire Service Queensland utilise external Registered Training Organisations for the training of volunteers and other stakeholders. |
REC241-1018 | 16 - Training and behaviour | That members of Primary Producer and Rural Classified Brigades will only require a Criminal History Check if they become an office bearer of that Brigade. |
REC241-0956 | 16 - Training and behaviour | That, wherever possible, combined training take place between volunteers across a wide range of volunteer organisations. |
REC241-0980 | 16 - Training and behaviour | That Rural Fire Service Queensland to have its own training support coordinators who, in conjunction with external Registered Training Organisations, co-ordinate the training curriculum throughout Queensland. |
REC241-0985 | 16 - Training and behaviour | That the Department of Community Safety review Rural Fire Service Queensland and other volunteer organisation records and consider options to simplify recognition of training records and competencies, criminal history checks, equipment capacities and other background information for volunteers who belong to more than one volunteer organisation. |
REC241-0977 | 16 - Training and behaviour | That all volunteer training conducted by the Rural Fire Service Queensland will be relevant to employment levels within the Rural Fire Service Queensland. |
REC241-1040 | 36 - Volunteers | That RFSQ review local SAP function and delegation to enable effective and timely support for volunteers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
Rec-ID | Code | Recommendation |
---|---|---|
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
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. |
REC228-1620 | 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: |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC225-0532 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
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. |
REC223-0518 | 16 - Training and behaviour | The Department of Environment and Conservation explore human resourcing models that: · make succession planning a priority; · look at options for the attraction and retention of staff; and · review how the salary levels of staff matches the decision making required in major activities such as prescribed burns. |
Rec-ID | Code | Recommendation |
---|---|---|
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
Rec-ID | Code | Recommendation |
---|---|---|
REC209-1652 | 16 - Training and behaviour | Increase the capacity and capability of the Alice Springs Regional Committee. |
REC209-1650 | 16 - Training and behaviour | Secondment of expertise in fire management planning and fire control from other jurisdictions, in a training capacity, be investigated in preparation for the 2012 fire season. |
REC209-1648 | 16 - Training and behaviour | Recruitment strategies, be developed, including “growing their own”, that result in the appointment and retention of skilled people to the vacant Bushfires NT positions. The vacant senior position in Alice Springs should be immediately advertised as a permanent position at the appropriate level to attract skilled applicants. |
REC209-1641 | 16 - Training and behaviour | Knowledge and skills in AIIMS and WebEOC and incident management are further developed through regular scenario planning and incident management simulation exercise. |
REC209-1643 | 25 - Inquiry, audit, lessons management and after action review | An evaluation be conducted into the integration of the appropriate elements of the South Australian Country Fire Service “Crimson” networking system into Bushfires NT ICT. |
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 |
---|---|---|
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
REC204-1912 | 38 - Agency/Department Reporting | The Board of Tourism WA should take action to ensure that it reviews the quality of Board papers that are submitted to it by the executive of Tourism WA. |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC202-0494 | 16 - Training and behaviour | The Minister for Emergency Services introduce by the 2012-13 bushfire season psychological testing of all FESA career staff and bushfire and rescue volunteers. |
REC202-0509 | 36 - Volunteers | The Minister for Emergency Services and the Minister for Environment develop by December 2012 a Volunteer Charter that recognises the important work undertaken by the State’s volunteer bushfire and emergency services personnel. |
REC202-0508 | 36 - Volunteers | The Minister for Emergency Services and the Minister for Local Government review and report to Parliament by May 2012 on ways in which the State’s volunteer firefighters and rescue workers can be more effectively managed and valued. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0257 | 29 - Operational Health and Safety | FESA needs to place greater priority on the appointment of Safety Advisors to Level 3 incidents as is reflected in WESTPLAN Bushfire. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC200-0390 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: measuring and mapping fuel loads maintaining fuel load databases drawing up prescriptions for, and overseeing controlled burns building effective working relationships with all relevant stakeholders. |
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. |
REC200-0361 | 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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1731 | 16 - Training and behaviour | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. |
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. |
REC200-1730 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: |
REC200-1705 | 29 - Operational Health and Safety | The Fire and Emergency Services Authority (FESA) review its program to decommission vehicles and ensure that when such vehicles are offered during an incident that FESA staff adhere to FESA‟s own policy of „Use of Private Vehicles in Fires‟ |
Rec-ID | Code | Recommendation |
---|---|---|
REC198-2904 | 16 - Training and behaviour | The CFA, in collaboration with the other agencies develop a case study of the response to and recovery from the TriTech fire as a training and development opportunity. |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1755 | 16 - Training and behaviour | The CFA examine options to enable sufficient training materials to be available to ensure effective training delivery. As part of this examination, the CFA explore the feasibility of utilising the TAFE system. |
REC197-1742 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop initiatives and strategies that will maximise the involvement of young people as volunteers and their retention as volunteers. |
REC197-1763 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review the process for RCC and RPL with the view to making that process transparent, efficient and fair. |
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
REC197-1754 | 16 - Training and behaviour | The CFA proceed with the update of facilities and infrastructure at Fiskville to enable its better utilisation by volunteers and employees for training. Where necessary, the Government support this update when determining CFA funding. |
REC197-1740 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop and introduce an arrangement whereby a volunteer can transfer from one brigade to another and still remain a member of the CFA, without the need to resign. |
REC197-1762 | 16 - Training and behaviour | The CFA provide greater opportunities for leadership training for volunteers at all levels but particularly at the brigade level. The CFA, as far as practicable, endeavour to ensure that persons appointed to positions of leadership have the necessary capability. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1768 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby more volunteers are qualified to participate in Incident Management Teams. |
REC197-1753 | 16 - Training and behaviour | The CFA continue the Mobile Training Infrastructure Project and the Fixed Training Infrastructure Project. Where necessary, the Government support these initiatives in determining CFA funding. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1739 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop a systemic exit strategy, which ensures that relevant information is captured consistently across all brigades. |
REC197-1761 | 16 - Training and behaviour | The CFA continue the development of key principles in relation to training, in consultation with volunteers and paid personnel. In the development of those principles, account should be taken of matters raised by volunteers to this Inquiry and the comments that I have made about training delivery. Account should also be taken of principles contained in any statement of Vision, Mission and Values adopted by the CFA. |
REC197-1747 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review its arrangements with respect to First Aid training and maintenance of currency of qualifications, with a view to the delivery of such training and maintenance best meeting brigade needs. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
REC197-1735 | 36 - Volunteers | A. The CFA continue to explore and develop initiatives with modern information and communication technologies to maximise the benefits that they may bring to volunteer involvement in the CFA. |
REC197-1757 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, examine options to enable the engagement of an adequate instructor strength to serve the training needs of volunteers. Those options should include making more use of volunteers as instructors. |
REC197-1770 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, review the arrangements for the reimbursement of volunteer expenses. This review could be done in conjunction with the review of possible reimbursement of employers of CFA volunteers as recommended in Recommendation 5. |
REC197-1765 | 16 - Training and behaviour | The CFA continue the development of Vector Command Training and its availability and utilisation by volunteers. The feasibility of this training being provided online be explored by the CFA as part of the consideration of the use of the NBN. |
REC197-1751 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to training budgets and, in particular, with respect to what relates to volunteer training and what relates to career staff training. |
REC197-1734 | 36 - Volunteers | A. Consideration be given to the VFBV being funded directly by Government rather than by the CFA. |
REC197-1756 | 16 - Training and behaviour | CFA develop an individual training pathway for operational volunteers to enable volunteers to be able to better identify their career and training options and pursue a pathway that meets their expectation. |
REC197-1745 | 36 - Volunteers | The CFA revisit with the UFU the arrangements relating to Community Education Firefighters/Fire Officers and the use of volunteers in this role. |
REC197-1764 | 16 - Training and behaviour | A. The CFA, in consultation with volunteers, employees, the VFBV and the UFU, examine the feasibility of utilising the TAFE system for training delivery. |
REC197-1750 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to the identification and meeting of training demand, and plans to meet such demand. |
Rec-ID | Code | Recommendation |
---|---|---|
REC196-0233 | 16 - Training and behaviour | Further train Incident Controllers in the management of the Information Section and its roles. |
REC196-0232 | 16 - Training and behaviour | Increase the regularity of training for ICC Information Section staff and encourage pre-season drilling and trials in the use of OSOM and Emergency Alert particularly under critical capacity conditions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC195-0326 | 16 - Training and behaviour | The Fire Services recognise the specialised role of Information Sections and enhance training and resources accordingly. |
REC195-0314 | 16 - Training and behaviour | The Fire Services enhance and increase joint training and exercise programs at all levels of command and control, including the State Control Centre. (These programs need to enable volunteer participation.) |
REC195-0310 | 16 - Training and behaviour | The Fire Services Commissioner ensures that there is a comprehensive understanding of the State Command and Control Arrangements for Bushfires in Victoria across the Fire Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC193-0220 | 16 - Training and behaviour | The State Fire Management Council work with local government councils to improve the availability of relevant professional development. |
REC193-0219 | 16 - Training and behaviour | The Tasmania Fire Service, the Department of Primary Industries, Parks, Water and Environment and Forestry Tasmania continue to encourage the relevant national bodies to further implement the COAG 2004 recommendation, namely: ... that the Australasian Fire Authorities Council and Emergency Management Australia — in partnership with state and territory agencies and other education and research institutions — coordinate a national program of professional development focused on bushfire mitigation and management. Under the program, partners would deliver nationally coordinated professional development services to all jurisdictions. |
REC193-0218 | 16 - Training and behaviour | The Tasmania Fire Service, the Department of Primary Industries, Parks, Water and Environment and Forestry Tasmania pursue funding from the Commonwealth (Department of Education, Employment and Workplace Relations), in line with COAG Recommendation 11.2, namely that the states and territories and the Australian National Training Authority provide additional funding, as necessary, to registered training organisations to support the development and delivery of learning and training resources to all firefighters. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0110 | 16 - Training and behaviour | DEC should emphasise the principle of foresight by adopting an appreciation and decision making process and training staff in that process. |
REC183-0122 | 16 - Training and behaviour | A staff recognition and reward framework for service to fire management should be considered for DEC fire staff. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
Rec-ID | Code | Recommendation |
---|---|---|
REC181-0174 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures for investigating safety incidents and ‘near-misses’ to ensure that all dangerous incidents, including back-burns, are fully investigated and that all relevant people are consulted and informed of the results. |
REC181-0175 | 16 - Training and behaviour | The Country Fire Authority and the Department of Sustainability and Environment require without exception that all relevant staff be trained in the need for Incident Controller approval to be obtained before a back-burn is lit. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
REC181-0176 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment adopt the title ‘safety officer’ (as opposed to ‘safety adviser’) and require without exception that a safety officer be appointed to every level 3 incident management team. |
REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
Rec-ID | Code | Recommendation |
---|---|---|
REC176-0146 | 16 - Training and behaviour | The Commonwealth organise the co-operation of state land management and fire agencies to provide the practical training aspect of the curriculum as part of a national bushfire accreditation course. |
REC176-0145 | 16 - Training and behaviour | The Commonwealth assist the states with bushfire training for land managers and volunteers by co-ordinating curriculum development and delivery of a national bushfire accreditation course, to be delivered by the relevant state agencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC172-0041 | 16 - Training and behaviour | Media liaison personnel are needed to ‘ride’ shotgun’ on media personnel to facilitate them getting their stories without imposing on the effectiveness of operations. |
REC172-0030 | 29 - Operational Health and Safety | A strategically located Staging Area serviced with check in/out personnel should be considered as early as possible at incidents involving an extended attack. |
REC172-0031 | 16 - Training and behaviour | Pre-season refresher training to include an emphasis on check in/out procedures |
REC172-0023 | 16 - Training and behaviour | Pre-season multi- agency refresher training for Ground Controllers should be undertaken each year. |
Rec-ID | Code | Recommendation |
---|---|---|
REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3002 | 16 - Training and behaviour | That the Tasmania Fire Service provide additional training in the use of thermal camera imaging: |
REC166-3001 | 16 - Training and behaviour | That the Tasmania Fire Service provide further training in respect to sprinkler systems, namely: |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
Rec-ID | Code | Recommendation |
---|---|---|
REC156-3495 | 16 - Training and behaviour | The Department of Primary Industries should work through the appropriate Ministerial Councils to seek alignment of competency standards for line workers across jurisdictions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC155-3478 | 38 - Agency/Department Reporting | That all information pertaining to current and planned prescribed burns be published more prominently on the Department of Sustainability and Environment’s website, with a single prominent link to this material on the website homepage. |
REC155-3477 | 38 - Agency/Department Reporting | That the details of any variation or amendment of a Fire Operations Plan, including: the carrying forward or postponement of burns within the three-year period covered by a Fire Operations Plan; the carry over, removal or rescheduling of burns between past, present and future Fire Operations Plans; and the alteration of burn boundaries (including alterations of less than 25 per cent); should appear on the Department of Sustainability and Environment’s website at the time of the change and be included in the Fire Operations Plan for the following year. |
REC155-3476 | 38 - Agency/Department Reporting | That finalised Fire Operations Plans be made publicly available in their entirety (with the exception of any private information) on the Department of Sustainability and Environment’s website and in hard-copy, and that this requirement be clearly stated in future Codes of Practice. This should include the “district burns list”, or its future equivalents, and a map which shows the corresponding burns for each Fire District. Each map should be provided in a format which can be downloaded directly from the Department’s website without the need for further data manipulation by the user. An identical hardcopy version of the map for each Fire District should be also be available to members of the public on request and free of charge. |
REC155-3466 | 25 - Inquiry, audit, lessons management and after action review | A comprehensive review of the effectiveness of the increased prescribed burning target in meeting ecological and bushfire suppression needs should be conducted every three years. |
REC155-3468 | 38 - Agency/Department Reporting | That the Department of Sustainability and Environment, Department of Primary Industries, Parks Victoria & VicForests separately cost, and report, annual expenditure on fuel reduction burning, ecological burning and regeneration burning in their Annual Reports. |
REC155-3467 | 38 - Agency/Department Reporting | The Department of Sustainability and Environment should report its performance against the increased prescribed burning target in its annual report, which should also include the following details: |
Rec-ID | Code | Recommendation |
---|---|---|
REC153-1798 | 16 - Training and behaviour | That the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public. |
REC153-1792 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the duties and responsibilities attaching to that position insofar as they apply to an ongoing fire incident, and in particular to recognise the need to conduct a risk assessment in relation to an incident and the need to scrutinise, evaluate and validate the strategies and Incident Action Plans of Incident Management Teams. |
REC153-1797 | 16 - Training and behaviour | That the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public. |
REC153-1796 | 16 - Training and behaviour | That the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in risk assessment. |
REC153-1795 | 16 - Training and behaviour | That the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in risk assessment. |
REC153-1794 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of all Incident Management Team members, in particular but not limited to the Incident Controller and Planning Officer, of the need to conduct a full risk assessment that not only addresses operational risk, but the risk posed to the general public by an existing incident and at all times to consider and identify the ‘worst case scenario’ outcome. |
REC153-1793 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the need to deliver to the Deputy State Coordinator timely, accurate and relevant information pertaining to an ongoing fire incident. |
Rec-ID | Code | Recommendation |
---|---|---|
REC150-3127 | 16 - Training and behaviour | QFRS improve the capacity to address the brigade training gap by continuing to encourage and facilitate the accreditation of volunteer trainers within brigades where appropriate. |
REC150-3126 | 16 - Training and behaviour | QFRS continue to support area training staff in the development and implementation of brigade training programs and calendars. |
REC150-3122 | 29 - Operational Health and Safety | QFRS implement a system to monitor the condition and safety of brigade buildings and equipment. |
REC150-3125 | 38 - Agency/Department Reporting | QFRS introduce a system to collate and analyse performance information for use in management reporting and to support effective decision making processes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC136-3523 | 38 - Agency/Department Reporting | This Report should be considered for publication so that the insights, data, conclusions and recommendations are available within Queensland and other jurisdictions to assist with disaster management issues in the future. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC126-1980 | 16 - Training and behaviour | That public land management agencies ensure that their senior personnel have appropriate experience in fire management and are provided with adequate resources and suitable experienced and trained staff to effectively implement fire management programs |
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 |
REC126-1969 | 16 - Training and behaviour | That a review be conducted of the adequacy of training and the numbers of firefighters experienced in performing effective, safe large-scale back-burning operations |
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 |
REC126-1968 | 16 - Training and behaviour | That land managers ensure their staff are properly trained in the effective use of large bulldozers at wildfires and that staff are available to be assigned to supervise bulldozer operations |
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 |
REC126-1957 | 16 - Training and behaviour | That the Emergency Services Agency review the level of understanding among firefighting personnel of the latest information available nationally and internationally about wildfire behaviour and suppression and provide additional training if warranted |
REC126-1955 | 16 - Training and behaviour | That training of all personnel involved with emergency services be under constant review |
REC126-1983 | 16 - Training and behaviour | That the Australian Federal Police and the Emergency Services Agency ensure that personnel in their respective organisations are fully briefed on the agreed policy on evacuations |
Rec-ID | Code | Recommendation |
---|---|---|
REC124-3890 | 16 - Training and behaviour | Update education and training programs relating to prescribed burning to reflect revised organisational priorities including year round (365 day) fire management program: |
Rec-ID | Code | Recommendation |
---|---|---|
REC122-3791 | 16 - Training and behaviour | The Committee recommends that training be provided to landholders to enable them to assist with prescribed burns. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3764 | 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. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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: |
REC121-3759 | 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: |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3691 | 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. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
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”. |
REC121-3722 | 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. |
REC121-3753 | 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. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
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. |
REC121-3711 | 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. |
REC121-3755 | 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. |
REC121-3776 | 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. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3712 | 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. |
REC121-3726 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3680 | 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. |
REC121-3749 | 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”. |
REC121-3774 | 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: |
REC121-3765 | 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. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
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. |
REC121-3733 | 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. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
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. |
REC121-3729 | 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. |
REC121-3758 | 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. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3905 | 16 - Training and behaviour | Firefighting organisations should: address their key training and development issues |
Rec-ID | Code | Recommendation |
---|---|---|
REC104-2333 | 25 - Inquiry, audit, lessons management and after action review | That in doing so, this Review must consult with the agencies mentioned above, and others such as VICSES and the Departments of Human Services and Primary Industries. |
REC104-2195 | 38 - Agency/Department Reporting | That the creation of buffers by chaining and then burning swaths of mallee be explicitly monitored for: |
REC104-2328 | 36 - Volunteers | That CFA, VICSES and other volunteer-based emergency service organisations develop proposals in support of the strategies for sustainable volunteerism, and that the State Government advocate these initiatives to the Federal Government. |
REC104-2281 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA work cooperatively to review the management and application of bulldozers in fire suppression operations to ensure that they are used effectively, appropriately and are adequately supervised. |
REC104-2260 | 16 - Training and behaviour | That VICSES, with the support of the CFA, includes basic fire safety training as one of the competencies for the VICSES Volunteers. |
REC104-2332 | 25 - Inquiry, audit, lessons management and after action review | That the Review of emergency operations centres by the Departments of Premier and Cabinet and Treasury and Finance and the Office of the Emergency Services Commissioner: |
REC104-2194 | 38 - Agency/Department Reporting | That the success of current buffers in terms of assisting suppression operations be continually reviewed, evaluated and documented. |
REC104-2277 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review methods of gathering and processing fire information to ensure all methods are pursued to greatest effect. |
REC104-2259 | 16 - Training and behaviour | That the MFESB continue to give priority to appropriate bushfire training for its firefighters. |
REC104-2293 | 25 - Inquiry, audit, lessons management and after action review | That aviation contractors be required to submit a copy of their annual independent regulatory compliance audit prepared for Civil Aviation Safety Authority to the State Aircraft Unit. |
REC104-2327 | 16 - Training and behaviour | That all fire agencies include a formal mentoring scheme as part of their workforce development programs; and that consideration be given to the use of suitably competent and experienced individuals (such as retired staff), to act as coaches or mentors with inexperienced Incident Controllers. |
REC104-2193 | 38 - Agency/Department Reporting | That if ‘link’ burns continue to be used, then on-site weather sequences and fuel conditions marking successful (‘within explicit prescription’) and unsuccessful burns be documented. |
REC104-2290 | 38 - Agency/Department Reporting | That instances where demand for air support outstrips the supply of State Fleet Aircraft available are recorded. |
REC104-2228 | 25 - Inquiry, audit, lessons management and after action review | That the Government identifies an appropriate body, or bodies, to undertake the audit of the Municipal Fire Management Plans. |
REC104-2249 | 16 - Training and behaviour | That DSE and CFA ensure that: |
REC104-2270 | 29 - Operational Health and Safety | That DSE and CFA continue to stress firefighter safety as their highest priority for incident managers and fire ground supervisors |
REC104-2292 | 25 - Inquiry, audit, lessons management and after action review | That a systematic performance audit of State Aircraft Fleet contractors be conducted jointly by agency and SAU personnel. |
REC104-2294 | 16 - Training and behaviour | That training and competency programs for Incident Controllers should include aircraft firefighting capability training. |
REC104-2289 | 38 - Agency/Department Reporting | That the joint agencies introduce a system of performance measures for reporting the effectiveness of aircraft in firefighting operations. |
REC104-2197 | 25 - Inquiry, audit, lessons management and after action review | That a review of the fuel management zones be implemented with a view to reducing the number of zones so as to focus clearly on (i) asset protection (especially at the Public/Private land interface), and (ii) ecological burns. |
REC104-2235 | 16 - Training and behaviour | That DSE and CFA review selection and training programs for Incident Controllers and Incident Management Team members to ensure that they include all necessary competencies in recognition that technical skills are only one component of the required attributes. |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2264 | 16 - Training and behaviour | That CFA and DSE provide media training to all Level 2 and Level 3 Incident Controllers. |
REC104-2200 | 38 - Agency/Department Reporting | That DSE: |
REC104-2282 | 25 - Inquiry, audit, lessons management and after action review | That quality control or performance assessments are routinely completed post fire season, to ensure that contractors who have not performed to an agreed standard are not re-engaged for the consequential rehabilitation works. |
REC104-2263 | 16 - Training and behaviour | That the person appointed by DSE or CFA as Incident Controller for any incident should have formal qualifications and accreditation in the Incident Control System, be fully aware of the Victorian emergency management arrangements and have access to local fire prevention and response planning, including the Municipal Fire Management Plan |
Rec-ID | Code | Recommendation |
---|---|---|
REC098-2173 | 36 - Volunteers | The Committee suggests that registered volunteer fire fighters be exempt from paying Fire Levy tax to help offset some of the expense they incur during active duty. The exemption could be for a period of 12 months |
REC098-2156 | 36 - Volunteers | The Committee recommends that: |
REC098-2186 | 38 - Agency/Department Reporting | The Committee recommends that the Department of Transport and Regional Services review its record keeping practices to show the type of emergency for which assistance is provided through the Natural Disaster |
REC098-2151 | 29 - Operational Health and Safety | The Committee recommends that the Commonwealth Attorney-General engage the Commonwealth, states and territories in a review of occupational health and safety legislation as it affects the proper and effective functioning of bush fire services. |
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3246 | 38 - Agency/Department Reporting | The Committee recommends that performance monitoring standards be established, reviewed and maintained through a common reporting system by the Minister for Police and Emergency Services. |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
Rec-ID | Code | Recommendation |
---|---|---|
REC019-4158 | 16 - Training and behaviour | That needs in the direction of a fire emergency service be met as far as practicable by the Bush Fires Board in its training programme and in the tactical organisation of existing brigades for use as reserves in districts other than their own. |
REC019-4144 | 16 - Training and behaviour | No opportunity be lost of encouraging the formation of bush fire brigades and the maintenance of enthusiasm and that the Bush Fires Board assist the brigades in any way possible to obtain adequate training and equipment. |
Rec-ID | Code | Recommendation |
---|---|---|
REC016_3948 | 16 - Training and behaviour | It is recommended that workers and volunteers generally be instructed in accordance with a pre-arranged plan, as to what they should do in future times of emergency. Since the fighting of fires is for the greater part a matter of voluntary action, some estimate could perhaps be made, after investigation, of the numbers of men in each department who would be willing to volunteer. It would be necessary that each department should become a component part of an over-riding scheme and that it and its members should be fully instructed in the matter of whistle or siren warnings, places of assembly, reception of messages from the director of proceedings, use of equipment, and the various details which would necessarily be parts of an effective scheme. The training need not be onerous. If given once or twice at the beginning of possible danger periods, it would make for some degree of order and efficiency instead of a probable state of confusion. |
REC016_3945 | 16 - Training and behaviour | It is recommended that a large proportion of men employed in and about the open-cut be systematically trained in the use of equipment and in the tactical disposition of it. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |