Inquiry Search
Rec-ID | Code | Recommendation |
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REC314-3260 | 32 - Doctrine, standards, and reform | Align risk assessment tools and processes to Risk Management Standard ISO 31000 and the National Emergency Risk Assessment Guidelines (NERAG) and communicate these on public-facing platforms. Make Bushfire Management Area Plans (BMAP) accountable for managing and reporting on region-specific risk and identifying critical infrastructure such as mobile phone towers as key risks. |
REC314-3259 | 32 - Doctrine, standards, and reform | Implement previous review recommendations for bushfire management including those relating to the 2009 amendments to the Fire and Emergency Services Act 2005, State Bushfire Coordination Committee operation, State Bushfire Management Plan, as well as urgent completion of Codes of Practice for fuel hazard reduction on all land tenures, and redevelopment of Bushfire Management Area Plans accompanied by effective community engagement to build an understanding of risk. |
REC314-3269 | 32 - Doctrine, standards, and reform | Develop and practice procedures for the CFS, DEW and local governments to access and deploy heavy plant and machinery for fuel reduction operations both before and during bushfires. |
REC314-3264 | 6 - Insurance and legal liability | Consider removing stamp duty from home insurance to encourage a wider section of the community to take out insurance. South Australian government agencies should share their risk modelling data with the Insurance Council of Australia. |
REC314-3261 | 24 - Govt responsibility | Consider amending the Fire and Emergency Services Act 2005 to align SAFECOM Board operations with accepted governance standards with the Minister appointing an Independent Chair of the SAFECOM Board. The SAFECOM Chief Executive (CE) should report to the Board and maintain SAFECOM’s role at the direction of the Board. Alternatively, SAFECOM could be abolished, moving to a model of a Department of Fire and Emergency Services where the departmental head reports to the Minister but the value proposition of any such machinery of government change would need to be thoroughly examined. |
Rec-ID | Code | Recommendation |
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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 |
REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
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REC301-2387 | 32 - Doctrine, standards, and reform | TFS, PWS and STT agree an updated version of the Interagency Fire Management Protocol which maintains the principle that there will be one state-wide point of command for major unwanted fires burning in the State of Tasmania, explicitly recognises the right of each of TFS, PWS and STT to have their objectives prioritised in incident action planning and adequate resources applied to those objectives, and provides a mechanism for executive decision-makers from TFS, PWS and STT to come together and agree objectives and resourcing levels that will then be operationalised by whole-of-State control structures. |
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. |
Rec-ID | Code | Recommendation |
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REC292-2344 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the division of tasks among the various officers responsible for responding to major high-risk situations to enable Police Forward Commanders to focus exclusively on their primary goals and that officers engaged in matters not directly related to the resolution of the incident be required to report to an officer other than the Police Forward Commander |
REC292-2374 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review give consideration to amending the Australia–New Zealand Counter-Terrorism Committee protocols to ensure that they provide sufficient guidance as to the respective roles of the ADF and state police tactical groups. Such guidance should accord with the legislative framework in Part IIIAAA of the Defence Act 1903 (Cth). |
REC292-2361 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police consider whether the provisions of the Terrorism (Police Powers) Act2002 should be amended to ensure that police officers have sufficient legal protection to respond to terrorist incidents in a manner most likely to minimise the risk to members of the public. |
REC292-2379 | 24 - Govt responsibility | I recommend that the Premier of New South Wales consider whether the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002 should be amended to ensure that there is appropriate access to health related information available to ASIO (consistent with recommendation 12 of the report of the Martin Place Siege Joint Commonwealth—New South Wales review) |
REC292-2367 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency liaise with the Australia–New Zealand Counter-Terrorism Committee to determine whether policies requiring the consideration of more proactive intervention should be developed for responding to terrorist sieges. |
REC292-2343 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force remedy the lack of detailed guidance on how State Protection Group officers should interact and communicate with the Police Forward Commander, and that such guidance be included in policy documents and reinforced with training. |
REC292-2373 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review confer with state and territory governments about the criteria governing applications for the ADF to be called out pursuant to the Defence Act 1903(Cth) with a view to determining: whether further guidance is required on the criteria to be used by states and territories in determining whether to apply for Commonwealth assistance; and if so, what criteria ought to be stipulated. |
REC292-2359 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop policies that require the recording of negotiation strategies and tactics, demands made by a hostage taker, and any progress towards resolution (or lack thereof ) in a form readily accessible by commanders and negotiators. |
REC292-2378 | 21 - Role of Commonwealth Government | I recommend that: the Commonwealth Attorney-General and ASIO confer with the Australian Psychological Society regarding the restrictions in clause A 5 2 of the Code of Ethics (2007) with respect to radicalisation, terrorism and politically motivated violence; and the Australian Psychological Society consider amending clause A 5 2 of the Code of Ethics (2007) to enable psychologists to report risks of a terrorist nature. |
REC292-2365 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia New Zealand Guidelines for Deployment of Police to High Risk Situations and the Police Tactical Group Operations Manual to ensure that they adequately describe all aspects of the DA planning and approval pro-cess and present commanders with appropriate guidance on relevant considerations. |
REC292-2341 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the Management Operational Guidelines to resolve any inconsistency between them and relevant counter terrorism protocols. |
REC292-2372 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies, procedures and training to ensure the rapid identification of persons killed or injured in high-risk situations. Those policies should provide appropriate guidance on how and when death messages ought to be conveyed following such incidents. |
REC292-2353 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy that describes the role and function of a psychological adviser engaged to assist in responses to high-risk situations and that all those involved be made familiar with that policy. |
REC292-2377 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth Attorney-General liaise with ASIO to develop a policy to ensure that where correspondence is received by a government agency, minister or public office holder, from a non government entity, and that correspondence is relevant to the security assessments of the author, the correspondence be referred to: ASIO; and a Fixated Threat Assessment Centre. |
REC292-2364 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia–New Zealand Guidelines for Deployment of Police to High-Risk Situations and the Police Tactical Group Operations Manual to ensure that those documents give commanders guidance on how to assess imminent or immediate risk. |
REC292-2382 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police undertake a review of the Law Enforcement Conduct Commission Act 2016 with a view to enabling the Law Enforcement Conduct Commission to facilitate urgent debriefs and confidential internal reviews of critical incidents focused on improving current practice. |
REC292-2340 | 32 - Doctrine, standards, and reform | I recommend that the Director of Public Prosecutions develop a policy for overseeing lawyers' exercise of the discretion not to oppose bail that takes into account the seriousness of the offences involved; the experience of the prosecutor appearing; and the views of the police officer in charge of the investigation, insofar as those views are based on facts relevant to bail determinations. |
REC292-2371 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy and set of procedures in relation to family liaison capability for high-risk situations. Those policies and procedures should ensure that: The capability is scalable depending on the nature of the incident, An appropriately senior officer is responsible for overseeing the liaison process, He or she should have direct access to officers in the Police Forward Command Post for the purpose of conveying and receiving information in a timely manner, A dedicated family liaison officer (or officers) is assigned to the family of each victim and given responsibility for managing the needs of that family Officers are given guidance on communi-cating with families, including the appropriate frequency and content of briefings both during and after an incident, Officers are advised of the proper process for gathering and disseminating intelligence from family members. |
REC292-2350 | 32 - Doctrine, standards, and reform | I recommend that the Secretariat of the Australia–New Zealand Counter-Terrorism Committee prepare guidelines regarding the interpretation and scope of the restrictions contained Clause 92 of the National Counter Terrorism Plan 2012. The Secretariat should also update relevant Australia–New Zealand Counter-Terrorism Committee documents and the New South Wales Police Force should update State Protection Group documents to refer to the latest versions of the National Counter-Terrorism Plan |
REC292-2376 | 32 - Doctrine, standards, and reform | I recommend that the Commonwealth Attorney-General, in consultation with states and territories, review existing arrangements for information sharing between federal, state and territory agencies during terrorist events to determine whether those arrangements (and the guidance provided to officers in respect of them) adequately facilitate the efficient identification and transfer of pertinent information between agencies. |
REC292-2363 | 32 - Doctrine, standards, and reform | I recommend that New South Wales Police Force policies be amended to require documentation of triggers for Emer-gency Actions. Consideration should be given to stipulating that “contingency triggers”—specific events that will require initiation of an EA or some other agreed response—should also be recorded. |
REC292-2381 | 21 - Role of Commonwealth Government | I recommend that ASIO liaise with the Fixated Threat Assessment Centre with a view to both agencies cooperating in the identification, assessment and management of fixated, radicalised individuals. |
REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
REC292-2347 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force consider developing a pro forma debriefing sheet containing standard questions relevant to all or most high risk situations, which can be supplemented by the negotiation coordinator and the tactical commander to maximise the likelihood of all available relevant information being obtained during hostage debriefings. Such measures would also aid contemporaneous documentation of information derived from debriefs and assist in relaying all relevant information to command. |
REC292-2375 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review, in consultation with the police forces of the states and territories, examine the guidance available to ADF officers and state and territory police regarding: the role of ADF liaison officers; the availability of ADF assistance in the absence of a call-out; and the procedures to apply in relation to requests for, and the provision of, equipment or advice by the ADF. |
REC292-2362 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies to ensure that the usual arrangements for placing a sniper coordinator in the Police Forward Command Post are departed from only for sound operational reasons that are recorded. |
REC292-2380 | 24 - Govt responsibility | I recommend that the New South Wales Police Force, in conjunction with NSW Health, establish a Fixated Threat Assessment Centre to identify and gather information about fixated persons, assess the risks they pose, and attempt to mitigate such risks through early intervention. |
REC292-2338 | 32 - Doctrine, standards, and reform | I recommend that the Commissioner of Police issue guidelines to assist officers to determine when they should exercise their powers of arrest and take an accused into custody rather than proceeding by way of a court attendance notice. |
REC292-2368 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a policy regarding the use of distraction devices and the training of officers in their use. |
Rec-ID | Code | Recommendation |
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REC291-1248 | 24 - Govt responsibility | The State Emergency Management Committee to establish a State Bushfire Coordinating Committee as a sub-committee of SEMC. The State Bushfire Coordinating Committee will be chaired by the Director of the Office of Bushfire Risk Management and will have the primary responsibility to: · develop a State Bushfire Management Policy and a set of long term bushfire risk management objectives; · provide a forum for key bushfire risk management stakeholder agencies; · advise the SEMC on matters pertaining to bushfire, in particular, to report against the investment in, and achievement of the bushfire risk management objectives; · provide advice and support to the proposed Chief Officer of the Rural Fire Service on bushfire risk management matters; and · report to SEMC and to the community on bushfire risk management matters on at least an annual basis. |
REC291-1247 | 32 - Doctrine, standards, and reform | The State Government to create a Rural Fire Service to enhance the capability for rural fire management and bushfire risk management at a State, regional and local level. The proposed Rural Fire Service will: · be established as a separate entity from the Department of Fire and Emergency Services or, alternatively, be established as a sub-department of the Department of Fire and Emergency Services; · have an independent budget; · be able to employ staff; · have a leadership structure which, to the greatest degree possible, is regionally based and runs the entity; · be led by a Chief Officer who reports to the responsible Minister on policy and administrative matters; and to the Commissioner for Fire and Emergency Services during operational and emergency response; · have responsibilities and powers relating to bushfire prevention, preparedness and response; and · operate collaboratively with the Department of Fire and Emergency Services, the Department of Parks and Wildlife, Local Government and volunteer Bush Fire Brigades. In creating the Rural Fire Service, the State Government to consider whether back office and corporate support services could be effectively provided by an existing Department, such as the Department of Fire and Emergency Services or the Department of Parks and Wildlife. The State Government to review the creation of the Rural Fire Service two years after its establishment, to assess whether its structure and operations are achieving the intended outcome. |
REC291-1238 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee to adopt, across all hazards, the doctrine of: · the primacy of life; · the ‘Strategic Control Priorities’ (as documented by the Department of Fire and Emergency Services); and · community warnings that are timely, tailored and relevant. Agencies will reinforce amongst emergency management personnel the importance of this doctrine through briefings and intent statements. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1249 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC287-1184 | 24 - Govt responsibility | The Tasmanian fire agencies think more broadly about how staff who are already employed by Government could support the management of future emergencies. |
REC287-1182 | 32 - Doctrine, standards, and reform | The fire agencies consider how the Regional Fire Operations Centre (RFOC) as a concept adds value once a level 3 IMT is up and running in a region. |
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. |
REC287-1186 | 9 - Community education | The Tasmanian fire agencies review: • their pre-season engagement with groups such as (but not limited to) environmental groups who might beneft from a greater understanding of fire management tactics, in order to inform them of and receive feedback on intended approaches to firefghting and fire management the work of the Public Information Section at incident management, regional and State level, to develop an increased appreciation of what information management might be most appropriate to serve the public interest in understanding the progress of the incident and to identify ways of providing surge capacity to resource effective information management in protracted and signifcant incidents. |
Rec-ID | Code | Recommendation |
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REC273-1141 | 21 - Role of Commonwealth Government | SACFS and the BoM review current weather, fuel loads and curing rates to determine the most appropriate and accurate forecast is prepared, issued and validated against current conditions. |
REC273-1133 | 32 - Doctrine, standards, and reform | That a complete review of current naming conventions of personnel and centres, in accordance with the outcomes of the Victorian Bushfire Royal Commission is undertaken, to ensure clarity around command, control and coordination within SA. |
REC273-1129 | 32 - Doctrine, standards, and reform | Incorporating ‘triggers’ within Chief Officers Standing Orders No. 17, which requires the escalation of the State Controller role to the rank of Assistant Chief Officer or greater, depending on the increased risk or activity. |
REC273-1128 | 32 - Doctrine, standards, and reform | Incorporate in operational doctrine the ability for the State Controller to determine the operational readiness levels of the state or regions based on either the predicted and/or actual risk and/or activity to some or all of the regions. |
REC273-1145 | 32 - Doctrine, standards, and reform | Review relevant Legislation associated Acts and Plans to establish a consistent approach to fire and emergency management to minimise duplication and risk of contradiction. That the Hazard and Functional area plans be amalgamated and establish a SA Bushfire Plan, under the SEMP, which clearly define role of SACFS. |
REC273-1143 | 32 - Doctrine, standards, and reform | That SACFS in consultation with SAMFS consider adopting common terminology and capability requirements for strike teams being ‘4-5 appliances and a group officer’ in line with other jurisdictions. |
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 |
REC264-1078 | 32 - Doctrine, standards, and reform | The State review and revise the community carbon monoxide response protocol and the firefghter carbon monoxide response protocol, to: |
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 |
REC264-1077 | 32 - Doctrine, standards, and reform | The State take the lead in advocating for a national compliance standard for PM |
REC264-1084 | 32 - Doctrine, standards, and reform | GDF Suez revise its Emergency Response Plan, to: • require an increased state of readiness on days of Total Fire Ban; • require pre-establishment of an Emergency Command Centre; • require pre-positioning of an accredited Incident Controller as Emergency Commander; and • require any persons nominated as Emergency Commander to have incident controller accreditation and profciency in the use of the Australasian Inter-service Incident Management System. |
REC264-1075 | 32 - Doctrine, standards, and reform | The State: • bring forward the commencement date of s.16 of the Mineral Resources (Sustainable Development) Amendment Act 2014 (Vic), to facilitate the requirement that approved work plans specifcally address fre prevention, mitigation and suppression; and • acquire the expertise necessary to monitor and enforce compliance with fre risk measures adopted by the Victorian coal mining industry under both the mine licensing and occupational health and safety regimes. |
REC264-1083 | 9 - Community education | The State, led by Emergency Management Victoria, develop a community engagement model for emergency management to ensure all State agencies and local governments engage with communities and already identifed trusted networks as an integral component of emergency management planning. |
REC264-1074 | 32 - Doctrine, standards, and reform | The State enact legislation, to: • require Integrated Fire Management Planning; and • authorise the Emergency Management Commissioner to develop and implement regional and municipal fire management plans. |
REC264-1080 | 32 - Doctrine, standards, and reform | The State develop and widely disseminate an integrated State Smoke Guide, to: • incorporate the proposed State Smoke Plan for the management of public health impacts from large scale, extended smoke events; • include updated Bushfre Smoke, carbon monoxide and PM protocols; and 2.5 • provide practical advice and support materials to employers, communities and individuals on how to minimise the harmful effects of smoke. |
REC264-1088 | 32 - Doctrine, standards, and reform | GDF Suez adopt and apply the firefghter carbon monoxide response protocol. |
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. |
REC264-1079 | 32 - Doctrine, standards, and reform | The State review and revise the Bushfre Smoke Protocol and the PM Health Protection Protocol, to: 2.5 • ensure both protocols are consistent with each other; and • ensure both protocols include assessment methods and trigger points for specifc responses. |
Rec-ID | Code | Recommendation |
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REC260-1069 | 32 - Doctrine, standards, and reform | That NPWS conduct a review of its hazard reduction policies to ensure all assets within and on the boundary of the Park are clearly identified and an adequate policy or management plan exists for the protection of all assets, including a procedure pursuant to which progress in meeting hazard reduction targets is regularly and comprehensively assessed. |
REC260-1065 | 32 - Doctrine, standards, and reform | That the National Parks and Wildlife Service review its procedures for monitoring Class 1 fires occurring in ‘severe’ or worse fire conditions that cannot be reconnoitred at ground level adequately due to terrain or dangerous conditions, and consider including aerial surveillance (if reasonably practicable) as a standard procedure in such circumstances. |
REC260-1064 | 32 - Doctrine, standards, and reform | That the National Parks and Wildlife Service review its protocols for control of Class 1 fires under its control to ensure that incident controllers managing fires in ‘severe’ or worse fire conditions receive as much incident management planning support as is reasonably practicable in the circumstances. |
REC260-1058 | 28 - Personal responsibility | That NPWS and the RFS consider developing a land management policy that requires active engagement with property owners adjoining the Park to ensure that hazard reduction and asset protection is encouraged and undertaken before the bush fire season commences |
REC260-1056 | 32 - Doctrine, standards, and reform | That the Rural Fire Service and National Parks and Wildlife Service consider adopting the approach to fire classification suggested by Mr Conway that “classification and resourcing of the fire ground response and incident management capability should reflect the potential of the fire rather than observed fire behaviour. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2554 | 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. |
REC258-2536 | 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. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
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. |
REC258-2552 | 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. |
REC258-2535 | 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’. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2551 | 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. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
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. |
REC258-2538 | 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. |
REC258-2549 | 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. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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: |
REC258-2537 | 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. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
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. |
REC257-1538 | 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 |
---|---|---|
REC247-0912 | 32 - Doctrine, standards, and reform | That the State Fire Commission finalise its position on the Tasmania Bushfire Safety Policy without further delay. |
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. |
REC247-0871 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service critically reviews the operation of the Six Operational Priorities to determine whether they are appropriate and effective. |
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. |
REC247-0877 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to fire management operations at night, and develop and effectively implement unambiguous policy and operating procedures. |
REC247-0895 | 6 - Insurance and legal liability | That action be taken as a priority to resolve any legal issues on mutual assistance arrangement for fire services. |
REC247-0940 | 32 - Doctrine, standards, and reform | That the Government actively support the timely development and implementation of an ongoing Strategic Fuel Management Plan. |
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. |
REC247-0950 | 32 - Doctrine, standards, and reform | That resources are committed to developing and implementing approved reforms to the emergency management arrangements. |
REC247-0870 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers adopting a primary tactic of an aggressive first attack on fires. |
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. |
REC247-0876 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to blacking out and mopping up, including its policies, operating procedures and training. |
REC247-0891 | 9 - Community education | That emergency management plans specifically include processes for effectively engaging with local communities and using community resources, including volunteers. |
REC247-0937 | 19 - Offences | That the legislation and enforcement arrangements are reviewed to ensure there are suitable offences and penalties, investigation and enforcement capabilities, and a rigorous approach is taken to breaches of the law. |
REC247-0908 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee examine whether there are any legal issues associated with continuing recovery operations where the overarching emergency management arrangements have ceased. |
REC247-0949 | 32 - Doctrine, standards, and reform | That following any review, the Emergency Management Act 2006 be amended. |
REC247-0869 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service ensures that planning for active fires includes a proactive approach wherever possible. |
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. |
REC247-0874 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews operational practices to ensure there is continuity of fire operations when fire suppression action is required. |
REC247-0883 | 32 - Doctrine, standards, and reform | That Tasmania Police ensures planning for emergency operations includes a proactive approach wherever possible. |
REC247-0930 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee determine suitable risk management tools, such as the Bushfire Risk Assessment Model, and encourages their use in assessing bushfire risk in a consistent manner. |
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. |
REC247-0944 | 9 - Community education | That the State Emergency Management Committee develops and coordinates a whole-of-government community resilience strategy for emergencies in a form that can be practically implemented, as a priority. |
REC247-0864 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its position on fire ground management to determine whether a unified command model at the fire ground should be adopted. |
REC247-0914 | 32 - Doctrine, standards, and reform | That the Tasmanian Emergency Management Plan includes a comprehensive all hazards communications policy and plan. |
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. |
REC247-0929 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee considers structuring the Tasmania Emergency Management Plan in a way that provides more specific guidance, commitment to and accountability for action to be taken. |
REC247-0882 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service documents and publishes its operational policies and procedures so they are accessible to and suitable for operational personnel. |
REC247-0898 | 32 - Doctrine, standards, and reform | That the State Special Emergency Plan–Recovery and the emergency management structure for recovery be reviewed. |
REC247-0943 | 9 - Community education | That a bushfire community education and information strategy be professionally developed and coordinated across the fire authorities by Tasmania Fire Service. |
REC247-0852 | 32 - Doctrine, standards, and reform | That the role and expected duties of the State Controller be clearly defined in the Emergency Management Act 2006. |
REC247-0913 | 32 - Doctrine, standards, and reform | That the State Fire Commission structures its Tasmania Bushfire Safety Policy so policy outcomes are identifiable and progress in achieving outcomes can be evaluated. |
REC247-0872 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers what adjustments may be necessary to the promotion and use of the Six Operational Priorities to ensure plans are suitable for the circumstances of each fire. |
REC247-0928 | 24 - Govt responsibility | That the Government take into account demographic change in its assessment of the consequences of climate change on emergency events. |
REC247-0881 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service establishes sufficient resources and expertise to research, develop, implement and review its policies and operations. |
REC247-0897 | 32 - Doctrine, standards, and reform | That a standing plan is developed to manage the transition from immediate recovery to medium and long-term recovery, and arrangements are made to ensure this plan can be effectively implemented in a timely way. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2857 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth ensure that there is a mooring buoy which will enable the mooring of SIEVs to take place and free up the Christmas Island response vessel for ongoing surveillance duties. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2853 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth liaise closely with representatives of the Christmas Island VMRS prior to purchasing or replacing any vessels for the VMRS in the future. |
REC227-2852 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth and the Shire of Christmas Island take steps to ensure that the Ethel Beach boat ramp is significantly upgraded, that it should be provided with shelter in the form of a rock groyne or similar buffer and that provision should be made so that a person can walk beside the ramp on a stable footing; or If this is not considered likely to be effective in providing an appropriate means of deploying a rescue vessel in adverse conditions, such other action be taken as is necessary to ensure that there is a means of deploying a rescue vessel in adverse conditions. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC223-0521 | 9 - Community education | The Department of Environment and Conservation develop and implement a strategy to better inform the community about the complexities and decisions surrounding prescribed burns when they are undertaken in the rural urban area. |
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. |
REC223-0523 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0256 | 22 - Role of local Gvt | Noting existing legislative and policy arrangements, there is merit in considering options for the future management of Level 3 fires in Local Government areas. |
REC201-0247 | 28 - Personal responsibility | Local residents must take a degree of shared responsibility to prepare their properties by reducing the risk of bushfire around their properties and planning for a bushfire emergency. |
Rec-ID | Code | Recommendation |
---|---|---|
REC200-0363 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-1683 | 22 - Role of local Gvt | Local Government recognise the work of the Gas Technical Regulatory Council and ensure any amendments to the Australian Standard are enforced. |
REC200-1716 | 24 - Govt responsibility | State and locals governments: |
REC200-0342 | 22 - Role of local Gvt | Local Government recognise the work of the Gas Technical Regulatory Council and ensure any amendments to the Australian Standard are enforced. Local Government provide information to residents on any changes to the Australian Standard relating to tethering gas tanks and encourage property owners to take action to comply with the Standard. |
REC200-0382 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-1688 | 9 - Community education | The Department of Education oversee the provision of bushfire education in schools that are located in bushfire prone areas, ensuring that all schools in these areas incorporate key bushfire messages in their curriculum. |
REC200-1721 | 32 - Doctrine, standards, and reform | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
REC200-0348 | 9 - Community education | The Fire and Emergency Services Authority consider alternative wording to Total Fire Ban that ensures people gain a more complete understanding of what actions are prohibited. |
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. |
REC200-1729 | 22 - Role of local Gvt | The Fire and Emergency Services Authority and local governments ensure that Community Emergency Service Managers are physically based in local government. |
REC200-0362 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-1682 | 24 - Govt responsibility | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-1715 | 22 - Role of local Gvt | Local governments institute a comprehensive program to assess fuel loads and bushfire preparedness on private properties. The program should give reference to the creation and maintenance of a Building Protection Zone, in line with FESA guidelines. |
REC200-0341 | 32 - Doctrine, standards, and reform | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-0380 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: give clear and explicit direction about when and how an incident should be declared clearly articulate the actions to be taken clearly define accountabilities provide detailed criteria for elevating issues and engaging other agencies. |
REC200-1687 | 9 - Community education | The Fire and Emergency Services Authority work in partnership with the Real Estate Institute of Western Australia to develop a package of information for new residents moving into bushfire prone areas, and a process to ensure this information is provided through real estate agents. |
REC200-1720 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: |
REC200-0347 | 9 - Community education | The Department of Education oversee the provision of bushfire education in schools that are located in bushfire prone areas, ensuring that all schools in these areas incorporate key bushfire messages in their curriculum. |
REC200-1699 | 24 - Govt responsibility | The State Government ensure that the continued development of the Fire and Emergency Service Authority's Integrated Bushfire Risk Management System is dependent on an independent comparative assessment of its functionality and cost-effectiveness against the Spatial Support System used by the Department of Environment and Conservation. |
REC200-1728 | 24 - Govt responsibility | The Water Corporation immediately review the outstanding orders for hydrant repairs and develop strategies to reduce the backlog. |
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. |
REC200-1681 | 24 - Govt responsibility | The State Government transfer responsibility for declaring bushfire prone areas from local government to the Western Australian Planning Commission. The Western Australian Planning Commission should urgently assess those areas that should be declared bushfire prone. |
REC200-1709 | 32 - Doctrine, standards, and reform | The Western Australian Police and the Fire and Emergency Services Authority jointly examine the Traffic Management System developed in response to the 2009 Victorian bushfires and seek its adaptation to use in WA with additional attention to the access and egress by bona fide residents to areas that are evacuated. |
REC200-0339 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia establish an inter-agency working group to continue the development of the new single emergency services Act. |
REC200-0379 | 24 - Govt responsibility | The State Government recognise the projected changes in climate and potential impact on future fire events. |
REC200-1686 | 9 - Community education | Local governments continue to include information on bushfire risk and preparedness with rates notices. |
REC200-1719 | 24 - Govt responsibility | The State Government recognise the projected changes in climate and potential impact on future fire events. |
REC200-0345 | 22 - Role of local Gvt | Local governments continue to include information on bushfire risk and preparedness with rates notices. |
REC200-1696 | 32 - Doctrine, standards, and reform | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-1727 | 24 - Govt responsibility | The State Government transfer responsibility for the installation, removal, maintenance of fire hydrants to the Water Corporation, in accordance with the recommendations of the 2006 CDJSC Inquiry into Fire and Emergency Services Legislation. |
REC200-0354 | 22 - Role of local Gvt | Local governments consider increasing the number of green waste collections carried out each year to encourage a more proactive approach to property (and vegetation) maintenance by residents. |
REC200-1704 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority review its use of the Australian Interagency Incident Management System to ensure that the most appropriate resources (including aerial resources) are used to respond to an incident. If resources are rejected during an incident either through the decision making process or other grounds, the reason for the decision should be documented. |
REC200-0375 | 22 - Role of local Gvt | Local governments institute a comprehensive program to assess fuel loads and bushfire preparedness on private properties. The program should give reference to the creation and maintenance of a Building Protection Zone, in line with FESA guidelines. This program should be implemented and managed under the Bush Fires Act 1954 in a manner similar to the fire break inspection program. |
REC200-1685 | 9 - Community education | The Fire and Emergency Services Authority (FESA) review its distribution of information material, including Prepare. Act. Survive. FESA should also consider including the community in pre-season exercising, in consultation with the Department for Child Protection and local governments. |
REC200-1718 | 35 - Business and Industry in relation to industry | Western Power and the Water Corporation continue to work collaboratively to assess options to better protect the power supply to water pumping stations in bushfire prone areas. |
REC200-0344 | 9 - Community education | The Fire and Emergency Services Authority (FESA) review its distribution of information material, including Prepare. Act. Survive. FESA should also consider including the community in pre-season exercising, in consultation with the Department for Child Protection and local governments. |
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. |
REC200-1695 | 22 - Role of local Gvt | The Western Australian Local Government Association explore the feasibility of local governments utilising aerial and satellite imagery to monitor firebreaks and fuel loads on private property. |
REC200-1724 | 6 - Insurance and legal liability | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-0353 | 22 - Role of local Gvt | The State Government give its full support to the Western Australian Local Government Association’s Send to Solve initiative. |
REC200-1703 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-0367 | 22 - Role of local Gvt | Main Roads Western Australia undertake more frequent examinations of its bridges located in areas prone to bushfire and ensure that the risk posed to loss of infrastructure in a fire is understood by local authorities. |
REC200-1684 | 9 - Community education | The Fire and Emergency Services Authority, in partnership with local governments, conduct more focused pre-season bushfire education, which emphasises: |
REC200-1717 | 24 - Govt responsibility | The State Government mandate that the title deeds for relevant properties be amended to indicate if the property is in a declared bushfire prone area. |
REC200-0343 | 9 - Community education | The Fire and Emergency Services Authority, in partnership with local governments, conduct more focused pre-season bushfire education, which emphasises: Water supply is not guaranteed during a bushfire Power supply is not guaranteed during a bushfire Saving life will be a priority over saving property so expect to be evacuated Once evacuated, access to affected areas may not be possible for several days Water ‘bombing’ by aircraft cannot be guaranteed in bushfire SMS warnings are advice only and may not be timely. |
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. |
REC200-1694 | 24 - Govt responsibility | The State Government give its full support to the Western Australian Local Government Association's Send to Solve initiative. |
REC200-1723 | 24 - Govt responsibility | The State Government restructure the Fire and Emergency Services Authority as a Department. As part of this restructure, Emergency Management Western Australia should either |
REC200-0349 | 9 - Community education | The Fire and Emergency Services Authority work in partnership with Main Roads Western Australia and local governments to develop and implement a comprehensive strategy for the use of mobile variable message boards to alert the community to the declaration of a total fire ban and what it means. |
REC200-1702 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
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. |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0108 | 32 - Doctrine, standards, and reform | DEC should consider publishing a new reference document that describes policy, doctrine and key systems of work of the fire management system. This document would be a “brief case” or “back pack” reference and would be reviewed annually and issued to all senior staff and fire management personnel. |
REC183-0107 | 32 - Doctrine, standards, and reform | The DEC Fire Management Policy should be reviewed and updated. |
REC183-0115 | 32 - Doctrine, standards, and reform | The Hazard Management Agency for bushfire has not been defined. Defining the HMA for bushfire should be addressed. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0132 | 9 - Community education | FESA implements an education and awareness campaign to promote the purpose and utility of community information systems. |
REC182-0127 | 9 - Community education | FESA strengthens its planning process to ensure learnings are incorporated and communicated, levels of preparedness are linked to threat analyses and public awareness and education activities are sustained. |
REC182-0126 | 9 - Community education | FESA promotes a whole-of-community approach, involving FESA, Local Governments and the community, in fire prevention functions, activities and planning. |
REC182-0123 | 32 - Doctrine, standards, and reform | FESA implements measures that will ensure unity and clarity of command. |
Rec-ID | Code | Recommendation |
---|---|---|
REC171-0070 | 32 - Doctrine, standards, and reform | That a review be conducted of DEC’s ability to manage major fires and consideration be given to increased direct involvement by FESA in fire management role in the case of major fires on reserves or on unallocated Crown lands. |
REC171-0068 | 32 - Doctrine, standards, and reform | That if the Bushfires Amendment Bill 2009 is to be enacted, procedures be put in place which would ensure that in the event of an escalating fire, FESA would receive sufficient information to make an informed judgment as to whether or not to take control of all operations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC153-1786 | 9 - Community education | That the Minister for Emergency Services and the South Australian Country Fire Service implement programs to develop in the minds of citizens a heightened awareness of bushfire risk, and in particular to encourage citizens to listen for radio announcements relating to the progression of a fire during the course of a bushfire incident |
REC153-1804 | 35 - Business and Industry in relation to industry | That the Chief Officer and the Editors of all newspapers and other media outlets develop a Memorandum of Understanding that ensures that all CFS press releases concerning total fire ban days and ongoing bushfire incidents are published in full. |
REC153-1785 | 9 - Community education | That the Minister for Emergency Services in conjunction with the South Australian Country Fire Service conduct tuition courses to be made available to the general public to enable members of the public to acquire the necessary knowledge and skills to implement their preparation and planning for bushfires |
REC153-1790 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident |
REC153-1780 | 22 - Role of local Gvt | That the Minister for Local Government cause rural councils to appoint an Officer whose duties consist entirely of bushfire prevention, such Officer being required to become a trained, operative member of the South Australian Country Fire Service during the currency of his or her appointment. |
REC153-1789 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident |
REC153-1778 | 9 - Community education | That the President of the South Australian Farmers’ Federation of South Australia draws these recommendations and findings to the attention of its members and constituents |
REC153-1788 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service cause to be included among the SACFS’ Standard Operating Procedures (SOPs) a requirement that Incident |
REC153-1774 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services, the Chief Officer of the South Australian Country Fire Service, the President of the Farmers’ Federation of South Australia and the Minister for Local Government, with a view to developing a Code of Practice, establish a body to investigate the impact of existing farming practices on bushfire risk and prevention. |
REC153-1787 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services, the South Australian Country Fire Service, the South Australia Police and the South Australian Farmers’ Federation together continue to develop strategies to reduce the risk of harm to private firefighters and in particular: |
REC153-1805 | 32 - Doctrine, standards, and reform | That the Minister for Emergency Services, the Minister for Environment, the Chief Officer of the CFS and the Native Vegetation Council, together develop a Code of Practice relating to the management of native vegetation as it affects bushfire prevention. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3134 | 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. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
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. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
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. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
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. |
REC149-3138 | 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. |
REC149-3145 | 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 |
---|---|---|
REC137-3533 | 21 - Role of Commonwealth Government | Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted. |
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3595 | 32 - Doctrine, standards, and reform | Development of framework document investigating future direction of VBIL including its role during incidents and its role in the transition from bushfire preparation to incident to bushfire recovery phases |
REC132-3592 | 32 - Doctrine, standards, and reform | Clarifying protocols for activating VBIL beyond normal working hours and for 24 hour activations |
REC132-3591 | 32 - Doctrine, standards, and reform | Joint development of templates for provision of core incident information by regional Incident Management Teams to CFA and DSE emergency coordination centres as basis for updates to the VBIL and other authorised information recipients |
Rec-ID | Code | Recommendation |
---|---|---|
REC126-1962 | 24 - Govt responsibility | That, because of the small jurisdiction of the ACT (equivalent to one fire district in NSW) the ACT Government consider all possible options for the provision of fire services to the ACT, among them: |
REC126-1996 | 9 - Community education | That the Emergency Services Agency develop a clear policy for disseminating information to the public and the media in times of emergency and that, as required, that policy incorporate advance door-knocking of homes in the area affected, as well as regular broadcasts by local radio and television stations and regular updates on the relevant website - be that Canberra Connect or a different ACT government website - as well as the Emergency Services Agency's website |
REC126-2005 | 9 - Community education | That community education programs include unambiguous information that at times of unusually high water demand there might be a drop in or loss of water pressure and it might be appropriate for residents who intend to remain and fight a fire to have auxilary water pumps or booster pumps |
REC126-1970 | 35 - Business and Industry in relation to industry | That the Emergency Services Agency reconsider and revise the arrangement that exists between the ACT Fire Brigade and Canberra airport in relation to the provision of assistance |
REC126-2012 | 24 - Govt responsibility | If they are willing and available to participate, that the taskforce's membership include Mr Phil Cheney, Mr Tony Bartlett, Mr Val Jeffery and Mr John Lowe |
REC126-1945 | 32 - Doctrine, standards, and reform | That s. 47 of the ACT Coroners Act 1997 be expanded to explicitly state that an inquest and the inquiry are not adversarial in nature and are solely inquisitorial, with a view to establishing the truth |
REC126-1985 | 24 - Govt responsibility | That the Emergency Services Agency, with the suport of the ACT Government, seek to establish with the NSW Department of Environment and Conservation and the NSW Rural Fire Service a protocol that will provide for the establishment of a joint incident management team as part of unified control arrangements based on adoption of the following principles: |
REC126-1962 | 32 - Doctrine, standards, and reform | That version 2 of the Strategic Bushfire Management Plan be completed and introduced without delay |
REC126-1993 | 9 - Community education | That consulations and negotiations occur between the Emergncy Services Agency and the NSW Rural Fire Service to ensure that fire risk and safety messages to the community are coordinated. Maximum use should be made of television and radio announcements throughout the ACT and southern NSW, consistent with NSW timetables for targeted programs in conjunction with the United Firefighters Union ACT Branch and volunteer fire brigade representative. The Emergency Services Agency should consider using ACT Fire Brigade staff and ACT Rural Fire Service volunteers to talk to groups in the community on request, thus furthering face-to-face community education in high-risk suburban areas of the ACT |
REC126-1966 | 32 - Doctrine, standards, and reform | That the Emergency Services Agency investigate and implement arrangements that will provide the capacity to use fire retardant in remote areas |
REC126-2004 | 35 - Business and Industry in relation to industry | That the ACT Government and ActewAGL jointly develop and implement protocols that will create a procedure whereby each of the water and sewerage, electricity and gas distribution networks, or parts thereof, can safely and promptly be manipulated, controlled, shut off, isolated or disconnected under emergency conditions. |
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 |
REC126-1944 | 32 - Doctrine, standards, and reform | That s. 59 of the ACT Coroners ACT 1997 be amended by deleting the words ‘by instrument’ in s. 59(1) and by deleting the words ‘by his or her instrument of appointment’ in s. 59(2)(b) |
REC126-1984 | 24 - Govt responsibility | That the Emergency Services Agency, with the support of the ACT Government, develop a single, new memorandum of understanding with the NSW Department of Environment and Conservation and the NSW Rural Fire Service, providing for liaison and joint operations as soon as it becomes apparent to whichever jurisdiction is managing a fire that the fire will probably affect the other jurisdiction. Joint operations should not be limited to when an incident occurs on both sides of the border, as is the current arrangement |
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 |
REC126-1992 | 9 - Community education | That implementation of the Bushfire Wise Program continue and include a letterbox drop of the updated Bushfire Information Booklet |
REC126-1965 | 32 - Doctrine, standards, and reform | That helicopters be used wherever possible to facilitate the rapid deployment of remote area firefighting crews |
REC126-2003 | 9 - Community education | That the community be made aware of the risk presented by heavy loads of garden fuels and certain types of vegetation around their houses and take active, regular measures to reduce that risk |
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 |
REC126-1943 | 32 - Doctrine, standards, and reform | That the ACT’s Director of Public Prosecutions Act 1990 be amended by repealing s. 6(d) of the Act |
REC126-1979 | 24 - Govt responsibility | That the policy and practice just recommended be the subject of a memorandum of understanding between the Emergency Services Agency and the Department of Territory and Municipal Services (previously the Department of Urban Services) or other relevant department or agency, so as to ensure that the land management agency on whose land a fire starts has responsibility to respond immediately to that fire in accordance with the applicable standards for weight of response. Further, the land management agency should be responsible for efforts to suppress fire until such time as it becomes clear that the suppression task is beyond capacity of the agency, at which point the ACT Rural Fire Service should assume direct responsibility for coordinating the ongoing response |
REC126-1948 | 24 - Govt responsibility | That the Emergency Services Agency be removed from the Department of Justice and Community Safety and transformed into an independent statutory authority reporting directly to the responsible Minister. Note in this regard that Mr McLeod made a similar recommendation, and I endorse it unequivocally. Placing the agency within a government department puts unnecessary layers of bureaucracy between the agency and the responsible Minister, and the bureaucrats concerned usually have no special knowledge of or experience in emergency management, regardless of their seniority in the bureaucracy |
REC126-1991 | 9 - Community education | That the Emergency Services Agency establish annual targets for the introduction of community education programs and provide resources to conduct regular independent assessments of the level of community preparedness engendered as a result of the programs |
REC126-1964 | 32 - Doctrine, standards, and reform | That remote area firefighting resources be deployed to a fire in a remote area as a matter of priority and in preference to the deployment of large tankers |
REC126-2001 | 9 - Community education | That community education programs provide information about fire behaviour, urban design principles that contribute to a specific level of risk, and the benefits of fitting basic ember protection materials in areas at risk from bushfire |
REC126-2009 | 24 - Govt responsibility | That a taskforce be established to give effect to the recommendations in this report |
REC126-1942 | 24 - Govt responsibility | That the ACT Attorney-General and the ACT Government - in consulation with the Chief Justice of the ACT and the ACT Chief Magistrate - take legislative action that would have the effect of funds being directly appropriated annually to the courts, preferable along the lines of the Commonwealth model as it applies to the High Court of Australia, the Federal Court of Australia, the Family Court of Australia and the Federal Magistrates Court. Alternatively, the funds could be appropriated in accordance with the South Australian model, which has a seperate Courts Administartion Authority. |
REC126-1978 | 32 - Doctrine, standards, and reform | That it be a matter of policy and practice that the relevant land management agency is responsible for the initial response to any fire or fires on the land under its care or management – within the overall operational response of the ACT Rural Fire Service |
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 |
REC126-1990 | 9 - Community education | That the Emergency Services Agency take measures to ensure that the community regularly receives up-to-date information on the risks of bushfires |
REC126-1964 | 32 - Doctrine, standards, and reform | That all firefighting agencies adopt a policy and practice that all fires in remote areas of the ACT be responded to as quickly as possible, with vigorous and sustained efforts made to suppress the fires and not leave them unattended – especially at night – unless there are compelling reasons relating to firefighter safety or lack of resources |
REC126-1999 | 9 - Community education | That the Canberra Urban Development Working Group referred to in Mr Peter Dunn's letter consider the report prepared by Mr Leonard and note particularly that the community awareness information currently available to householders in connection with measures they can take to better protect their homes from bushfires does not refer to the potential of wooden fences, conifers and outbuildings to contribute greatly to fire spread, particularly in suburban areas. Also noteworthy is Mr Leonard's evidence that the linear sitting of homes on house blocks in Canberra seems to be an important factor contributing to house-to-house fire spread and that this should be avoided in future developments on the urban fringe |
REC126-2006 | 24 - Govt responsibility | I recommend that, as appropriate, the ACT cooperate with the Commonwealth in the implementation of the committee's recommendations and, in particular, give careful consideration to adoption of the following recommendations: |
REC126-1976 | 24 - Govt responsibility | That the Emergency Services Agency have authority over the land management agencies and other landholders in order to implement preparedness and prevention measures – including fuel-reduction works where there are failures in compliance |
REC126-1946 | 32 - Doctrine, standards, and reform | That the ACT Government consider amending the Coroners Act 1997 to include what were ss. 56(1)(d) and 56(2)(c) of the 1956 Coroners Act |
REC126-1989 | 32 - Doctrine, standards, and reform | That formal protocols be developed and agreed with NSW authorities, so that a concerted effort that combines the resources of both NSW and the ACT can be brought to bear in the future - without impediment caused by lines on a map that make the ACT an island within the state of NSW |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3774 | 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: |
REC121-3691 | 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. |
REC121-3720 | 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. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
REC121-3768 | 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. |
REC121-3678 | 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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
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. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
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. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3726 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3712 | 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. |
REC121-3758 | 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. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3694 | 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. |
REC121-3765 | 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. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3757 | 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. |
REC121-3776 | 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. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3693 | 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. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3729 | 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. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |