Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC317-4072 | 32 - Doctrine, standards, and reform | The Australian Government should consider whether employment protections under the Fair Work Act 2009 (Cth) are sufficient to ensure that fire and emergency services volunteers will not be discriminated against, disadvantaged or dismissed for reasons associated with their volunteer service during natural disasters. |
REC317-4064 | 32 - Doctrine, standards, and reform | Australian, state and territory governments should work together to develop consistent data standards to measure disaster impact. |
REC317-4055 | 32 - Doctrine, standards, and reform | The Australian Government should revise the COMDISPLAN thresholds to provide that a request for Australian Government assistance, including Defence assistance, is able to be made by a state or territory government when: |
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. |
REC317-4076 | 12 - EM agency and authority | Australian, state and territory governments should develop an Australian-based and registered national aerial firefighting capability, to be tasked according to greatest national need. This capability should include: |
Rec-ID | Code | Recommendation |
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REC278-1225 | 32 - Doctrine, standards, and reform | The committee recommends that the Australian and Tasmanian Governments: • develop options to increase co-operation to ensure that the Tasmanian Wilderness World Heritage Area is protected and conserved in line with Australia's obligations under the World Heritage Convention; and • work together to ensure strong provisions to protect the Tasmanian Wilderness World Heritage Area from bushfire risks are included in the Tasmanian Wilderness World Heritage Area Management Plan. |
Rec-ID | Code | Recommendation |
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REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
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. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
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. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
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. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
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. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
Rec-ID | Code | Recommendation |
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REC257-1543 | 32 - Doctrine, standards, and reform | Range Standing Orders be amended to include a direction that no Defence vehicle is to leave the administration area of Marrangaroo Training Area during a bushfire, except to leave Marrangaroo Training Area itself through the main gate, unless it is a properly equipped bushfire fighitng vehicle havig at least four wheel drive capabiliy and self-protection equipment. |
REC257-1551 | 32 - Doctrine, standards, and reform | The use of Internal and External ranges at MTA for patrolling activities be prohibited. |
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. |
REC257-1550 | 32 - Doctrine, standards, and reform | Defence engage with both the Bureau of Meteorology and the Rural Fire Service to determine a more suitable index system. In the interim, Range Standing Orders be amended so that live-firing on the ranges on Marrangaroo Training Area not be permitted where the Forest Fire Danger Index for either the Central Ranges District or Greater Sydney Region is 12, it being the threshold for HIGH Fire Danger Rating or above. put another way, and in a practical sense, Range Standing Orders should, as an interim measure, require the Officer in Charge Practice and the Range Control Officer to consider the Forest Fire Danger Index for both Central Ranges District AND Greater Sydney Region on the day of any given serial. If either index is as 12 or above, live-firing should not be permitted. Any indication in Range Standing Orders or elsewhere that live-firing is permitted on Marrangaroo Training Area when the Fire Danger rating is HIGH should be rescinded. |
REC257-1555 | 14 - Incident Mgt Teams | The lines of responsibility be made clearer and some individual, perhaps the Regional Environmental Officer, or agency be given overarching responsibility to ensure recommended works related to bushfire mitigation on Defence Estate are carried out in accordance with the Bushfire Management Plan which the Manual for Fire Protection Engineering directs be prepared. |
REC257-1538 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School amend relevant instructions, both generally and specifically, so as to ensure that explosive ordnance used in training serials is logged in real time, in accordance with extant doctrine. |
REC257-1549 | 32 - Doctrine, standards, and reform | Marrangaroo Training Area Range Standing Orders should be reviewed to impose a requirement that the Officer in Charge of any live-firing practice ascertain and consider current weather parameters, temperature, humidity, wind strength and direction, registered at Mt Boyce immediately prior to any demolition serial. The setting of those parameters and their limits should be decided in consulation with the Bureau of Meteorology and Rural Fire Service and inserted into Range Standing Orders. |
REC257-1554 | 32 - Doctrine, standards, and reform | All documents be reviewed to remove ambiguity and perceived inconsistencies. Marrangaroo Training Area Range Standing Orders be subject to further examination, with particular consideration of the bushfire mitigation strategies referred to in the Bushfire Management Plan 2011-2014 before amendments to Chapter 10 are made. the basis upon which Range Standing Orders might fix a cut-off point for live-firing exercises should depend on continued bushfire strategies. Range Standing orders and Marrangaroo Training Area Bushfire Management Plan be reviewed annually. if hazard reduction has not occurred or the fire trails degraded, Range Standing Orders should take into account of heightened risk. |
REC257-1537 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School review and enforce Standard Operating Procedures to ensure that appropriate explosive ordnance accounting and handling practices, in accordance with Defence doctrine, are adhered to during all training activities. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1553 | 32 - Doctrine, standards, and reform | On matters relating directly to safety or risk, or when live-firing may occur, where there is ambiguity or apparent inconsistency, the most conservative or restrctive order should be followed until formal clarification has been provided. |
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. |
REC257-1552 | 32 - Doctrine, standards, and reform | Authority be given to the regional Environmental Officer to close a range or impose live-firing restriction in addition to any set out in Range Standing Orders if circumstances so warrant. |
Rec-ID | Code | Recommendation |
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REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
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. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
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. |
REC236-2793 | 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. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
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. |
REC236-2792 | 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. |
REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
Rec-ID | Code | Recommendation |
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REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
Rec-ID | Code | Recommendation |
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REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
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. |
Rec-ID | Code | Recommendation |
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REC098-2154 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth seek to ensure that the Council of Australian Governments seek the adoption by all states and territories of multi-agency protocols and agreements for fire |
REC098-2187 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth require state and territory governments to have in place comprehensive bush fire management plans as a pre-requisite for accessing funding from the National Heritage Trust and like programs. |
REC098-2135 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth seeks to ensure that the Council of Australian Governments implements to a minimum national standard adequate access to all public lands including wilderness areas of national parks. |
REC098-2152 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth, through the Council of Australian Governments and the Australasian Fire Authorities Council, initiate an overhaul of the incident management systems used |
REC098-2170 | 32 - Doctrine, standards, and reform | The Committee recommends that Emergency Management Australia request the Australasian Fire Authorities Council to: |
REC098-2150 | 12 - EM agency and authority | The Committee recommends that the Commonwealth seeks to ensure that the proposed Council of Australian Governments review of the bushfire management initiate with the states, as a priority, a review of the |
REC098-2166 | 32 - Doctrine, standards, and reform | The Committee recommends that Emergency Management Australia work through the Australasian Fire Authorities Council to ensure that: |
REC098-2149 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth work with the states and territories through the proposed Council of Australian Governments to review the response to bushfires to ensure that principles of fire prevention and rapid and effective initial attack are adopted and implemented by all rural fire authorities and public land managers |
REC098-2159 | 32 - Doctrine, standards, and reform | The Committee recommends that in changing the incident management systems as proposed in recommendation 23 above all bushfire agencies review concerns about difficulties in communicating operational information from the fire front to air operations. |
REC098-2141 | 32 - Doctrine, standards, and reform | The Committee recommends that the Commonwealth through the National Heritage Trust, offer assistance to the states and the Australian Capital Territory to develop specific prescribed burning guides, at least |
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
REC098-2140 | 12 - EM agency and authority | The Committee recommends that the Commonwealth seeks to ensure that the Council of Australian Governments implements arrangements in which greater flexibility is devolved to local brigade captains in the |
Rec-ID | Code | Recommendation |
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REC037-4163 | 12 - EM agency and authority | Effective planning, organisational and training capability be maintained at regional level and developed, as appropriate, for the future. [Reference paragraphs: 260 to 261] |
REC037-4162 | 12 - EM agency and authority | There be a close integration of the responsibilities of the Minister under the State Disasters Act and the State Disaster Plan, thereby strengthening overall counter—disaster management, direction and control. To this end, the organisational arrangements shown in Annexures “J” and “K” should be adopted. The main features of these are: |
REC037-4168 | 32 - Doctrine, standards, and reform | The provisions of the State Disasters Act, 1983, be extended to cover the proposed policy and organisational amendments. (Reference paragraph: 286] |
REC037-4161 | 32 - Doctrine, standards, and reform | That separate counter—disaster systems be avoided by retaining counter—bushfire arrangements as part of the State’s total counter— disaster system. [Reference paragraph: 228] |
REC037-4167 | 32 - Doctrine, standards, and reform | The definitions of command, control and co—ordination, as stated in the Australian Counter Disaster Handbook, be standardised throughout Victoria’s counter—disaster system. [Reference paragraphs: 106 to 111] |
REC037-4160 | 32 - Doctrine, standards, and reform | The current counter—bushfire concept be retained, with the proviso that it be kept under continuous review to ensure that all relevant future developments and techniques are effectively utilised. (Reference paragraphs: 88 to 90 and 257 to 259] |
REC037-4166 | 32 - Doctrine, standards, and reform | In the future development of Victoria’s counter—disaster capability, effective utilisation and management of resources be regarded as a major objective. |
REC037-4165 | 32 - Doctrine, standards, and reform | • Proposed amendments to the State Disaster Plan be formalised |