Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC326-4343 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures a communications plan is in place, including the communication of guidelines to potential applicants. |
REC326-4344 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: establishes and follows guidelines that align with relevant good practice guidance including accountabilities, key assessment steps and clear assessment criteria. |
REC326-4340 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: documents all key decisions and approvals in line with record keeping obligations. |
REC326-4341 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures regular monitoring is in place as part of funding deeds. |
REC326-4342 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures staff declare conflicts of interest prior to the commencement of a grants stream, and that these conflicts of interest are recorded and managed. |
Rec-ID | Code | Recommendation |
---|---|---|
REC315-3823 | 42 - Culture and Heritage | That, in order to increase the respectful, collaborative and effective use of Aboriginal land management practices in planning and preparing for bush fire, Government commit to pursuing greater application of Aboriginal land management, including cultural burning, through a program to be coordinated by Aboriginal Affairs and Department of Planning, Industry and Environment working in partnership with Aboriginal communities. This should be accompanied by a program of evaluation alongside the scaled-up application of these techniques. |
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. |
REC315-3842 | 24 - Govt responsibility | That, in order to prioritise early suppression and keep fires small: |
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. |
REC315-3854 | 7 - Inter-agency communication | That, in order to ensure emergency response agencies can communicate across state and territory borders, the Commonwealth Government allocate 10 + 10 MHz as a dedicated spectrum for Public Safety Mobile Broadband (PSMB) at no cost to states and territories. |
REC315-3822 | 42 - Culture and Heritage | That Government adopt the principle that cultural burning is one component of a broader practice of traditional Aboriginal land management and is an important cultural practice, not simply another technique of hazard reduction burning. |
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. |
REC315-3841 | 12 - EM agency and authority | That, in order to ensure suitably skilled and experienced personnel operate as Divisional Commanders during major fire incidents, Bush Fire Management Committees identify appropriate personnel as part of their plan of operations. |
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: |
REC315-3853 | 7 - Inter-agency communication | That, in order to ensure the State Emergency Operations Centre (SEOC) can maintain communications during emergencies, the Government provide the SEOC with independent Public Safety Network functionality. |
REC315-3813 | 35 - Business and Industry in relation to industry | That, in order to ensure tourism businesses are prepared for natural disasters including bush fires, Resilience NSW work with NSW RFS and Destination NSW to develop bush fire preparedness support for tourism businesses, based on research into existing models. Over time, this support could be expanded to include other natural hazards. |
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. |
REC315-3834 | 12 - EM agency and authority | That, in order to ensure all firefighters understand how local situational awareness reflects (or may not reflect) the broader scale situation presented by a large/extreme bush fire and the implications this may have on asset protection and fire suppression strategies, the NSW RFS: |
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. |
REC315-3799 | 9 - Community education | That at the start of each fire season, based on advice from the Bush Fire Coordinating Committee, Government provide a public statement with an evaluation of the likely fire season risk and the effectiveness of the planning and preparation for the upcoming season. This should be based on sophisticated monitoring of the key risk factors and signals for an extreme fire season. It should form the basis for clear public communication about these risks on a regional basis and the actions that Government proposes in preparation. |
REC315-3852 | 7 - Inter-agency communication | That, in order to improve fireground communications between NSW agencies and interstate personnel: a) Government ensure all NSW fire authority personnel and vehicles can access and utilise the Public Safety Network (PSN). This should include access to NSW RFS Private Mobile Radio networks where PSN coverage is not yet available. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3833 | 3 - Biodiversity | That Government invest in long-term ecosystem and land management monitoring, modelling, forecasting, research and evaluation, and harness citizen science in this effort. This will include, among other things: |
REC315-3869 | 42 - Culture and Heritage | That, in order to ensure Aboriginal people can access appropriate support during evacuation, Resilience NSW work with Local Emergency Management Committees and Aboriginal Affairs to ensure: |
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. |
REC315-3850 | 3 - Biodiversity | That Government develop and implement a policy on injured wildlife response, rescue and rehabilitation including: |
REC315-3810 | 24 - Govt responsibility | That, to ensure updated resource-sharing arrangements are in place, the NSW and Victorian Governments progress and finalise a multi-agency Memorandum of Understanding before the 2020-21 fire season commences. |
REC315-3857 | 12 - EM agency and authority | That, in order to ensure timely payment and maintain positive ongoing supplier relationships during large-scale bush fires, the NSW RFS implements an automated logistics solution, informed by the outcomes of the Emergency Logistics Project. |
REC315-3828 | 9 - Community education | That, in order to improve bush fire planning and protection of road infrastructure and to ensure communities, freight movers and fire fighting agencies have appropriate access and egress in a bush fire event, Government, working with local government as needed: |
REC315-3864 | 9 - Community education | That, in order to ensure people can access clear information on cross-border fires, the NSW RFS: |
REC315-3846 | 12 - EM agency and authority | That, in order to maximise the efficiency and effectiveness of heavy plant used in dry fire fighting techniques, the NSW RFS expand and introduce the following in respect to heavy plant: |
REC315-3808 | 22 - Role of local Gvt | That, in order to strengthen the capability of local councils in future emergency events: |
REC315-3855 | 7 - Inter-agency communication | That, in order to ensure all agencies have a clear understanding of cross-border communication channels during bush fires, all MoUs between state or territory agencies include an agreed protocol about how agencies will communicate across borders and that these are reflected in Incident Action Plans. |
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2399 | 24 - Govt responsibility | Implement a fully integrated civilianised single call and dispatch centre, that includes a redundancy option outside the Sydney CBD, which will adopt an agnostic approach to deploy the quickest most suitable resource to an emergency. Such a centre should be managed by either a non uniformed public servant staffed organisation like the Office for Emergency Management, or the NSW Police Force |
REC302-2397 | 12 - EM agency and authority | Use the model and system in place at the Ambulance Service of NSW as a benchmark for call taking, dispatch and the provision of situational awareness when deploying resources. This will overcome the lack of a feedback loop in current bushfire operations |
REC302-2403 | 12 - EM agency and authority | Take steps to ensure that both fire commissioners are seeking opportunities to engender a culture in their respective organisations that seeks to attract and foster the volunteer ethos and experience |
REC302-2401 | 12 - EM agency and authority | While the proposal to establish an integrated call and dispatch centre is being implemented, Fire and Rescue NSW should take steps to civilianise ComCen and maintain experienced senior officers from both agencies as supervisors similar to how the NSW Police Force and Ambulance Service of NSW operate |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3719 | 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. |
REC121-3765 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
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. |
REC121-3751 | 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. |
REC121-3677 | 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. |
REC121-3718 | 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. |
REC121-3758 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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: |
REC121-3654 | 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. |
REC121-3712 | 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. |
REC121-3746 | 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. |
REC121-3675 | 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. |
REC121-3717 | 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. |
REC121-3757 | 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. |
REC121-3693 | 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. |
REC121-3722 | 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. |
REC121-3768 | 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. |
REC121-3650 | 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. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3672 | 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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3691 | 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. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
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. |
REC121-3715 | 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. |
REC121-3753 | 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. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3776 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |