Inquiry Search
Rec-ID | Code | Recommendation |
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REC321-4207 | 25 - Inquiry, audit, lessons management and after action review | We recommend that DELWP reviews its target for the number of fuel hazard assessments conducted and ensures that this measure is evidence based, accurately reflects regional performance, and that the department monitors and reports on each region’s performance against it. |
Rec-ID | Code | Recommendation |
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REC318-4182 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in partnership with agencies engaged in state, regional and incident control centres: |
REC318-4181 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in collaboration with the emergency management sector and as part of the emergency management planning reforms: |
REC318-4178 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in collaboration with the Country Fire Authority and local government – undertake a review of the current residual risk target to ensure that it remains contemporary in terms of its designated percentage value. The review should: |
REC318-4171 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the State review (and where necessary amend) legislation including but not limited to the Country Fire Authority Act 1958, Forest Act 1958 and Local Government Act 2020 to: |
Rec-ID | Code | Recommendation |
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REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
REC315-3838 | 29 - Operational Health and Safety | That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members. |
REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3809 | 37 - Funding | That Government work with other Australian governments to provide long-term funding certainty to AFAC, including the National Resource Sharing Centre (NRSC) and the National Aerial Firefighting Centre (NAFC). |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3840 | 29 - Operational Health and Safety | That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters. |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
Rec-ID | Code | Recommendation |
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REC299-1344 | 25 - Inquiry, audit, lessons management and after action review | That a review of the cross‑tenure approach be undertaken to determine its effectiveness and to address issues that arise in fire prevention on private and public land. |
REC299-1343 | 25 - Inquiry, audit, lessons management and after action review | That the Government conduct a review of fire prevention |
Rec-ID | Code | Recommendation |
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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. |
REC292-2360 | 2 - Emergency powers | I recommend that the Commissioner of Police consider seeking an agreement with news media outlets whereby the New South Wales Police Force will establish a way for such outlets to rapidly and confidentially determine whether publishing specific material could compromise the response to an ongoing high-risk incident and the media in turn will agree not to publish such material without first alerting a nominated senior police officer of their intention to do so. |
Rec-ID | Code | Recommendation |
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REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
Rec-ID | Code | Recommendation |
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REC261-1492 | 37 - Funding | That the NSW Government commit to and fund a long term program of prescribed burning based on the recommendation of the 2009 Victorian Bushfires Royal Commission of an annual rolling target of a minimum of five per cent of public land per year, and that the NSW Government commit to extending the funding for the National Parks and Wildlife Service five year hazard reduction program past 2016. |
REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC260-1054 | 2 - Emergency powers | That the Rural Fire Service consider extending pre-emptive section 44 to whole of Castlereagh RFS/Warrumbungle Shire area. |
Rec-ID | Code | Recommendation |
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REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC181-0214 | 37 - Funding | The State replace the Fire Services Levy with a property-based levy and introduce concessions for low-income earners. |
REC181-0176 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment adopt the title ‘safety officer’ (as opposed to ‘safety adviser’) and require without exception that a safety officer be appointed to every level 3 incident management team. |
REC181-0204 | 2 - Emergency powers | The State amend the Country Fire Authority Act 1958 to enable the Chief Officer to delegate the power to issue fire prevention notices. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
REC181-0174 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures for investigating safety incidents and ‘near-misses’ to ensure that all dangerous incidents, including back-burns, are fully investigated and that all relevant people are consulted and informed of the results. |
REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
Rec-ID | Code | Recommendation |
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REC163-1939 | 2 - Emergency powers | That the Rural Fires Act 1997 be amended to provide to designated Fire Investigation Officers of the Rural Fire Service the power to enter any land upon which a bushfire has occurred for the purposes of investigation for a period of up to 24 hours after a fire has been declared out. |
Rec-ID | Code | Recommendation |
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REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
Rec-ID | Code | Recommendation |
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REC155-3470 | 37 - Funding | That the Victorian Government provide recurring funding for a significant increase in regionally-based, permanent, or long-tenured, fire management personnel dedicated to the prescribed burning program. The increase in personnel should be consistent with the level required to achieve an annual prescribed burning target of 385,000 hectares. |
REC155-3466 | 25 - Inquiry, audit, lessons management and after action review | A comprehensive review of the effectiveness of the increased prescribed burning target in meeting ecological and bushfire suppression needs should be conducted every three years. |
REC155-3469 | 37 - Funding | That the Victorian Government establish a five year rolling fund which allows unused prescribed burning monies to be rolled over into future financial years for the purpose of subsequent prescribed burning activities. |
Rec-ID | Code | Recommendation |
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REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3713 | 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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3765 | 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. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3758 | 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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3753 | 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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3726 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3768 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
Rec-ID | Code | Recommendation |
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REC104-2240 | 37 - Funding | That Government supports the immediate development of financial models to analyse and determine the appropriate level of investment in fire management planning, preparedness and suppression on public land. |
REC104-2245 | 37 - Funding | That DSE includes the cost of tracks, as above, in the development of financial models to analyse and determine the appropriate level of investment in fire management planning, preparedness and suppression on public land. |
REC104-2197 | 25 - Inquiry, audit, lessons management and after action review | That a review of the fuel management zones be implemented with a view to reducing the number of zones so as to focus clearly on (i) asset protection (especially at the Public/Private land interface), and (ii) ecological burns. |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2270 | 29 - Operational Health and Safety | That DSE and CFA continue to stress firefighter safety as their highest priority for incident managers and fire ground supervisors |
REC104-2244 | 37 - Funding | That DSE assesses the environmental and monetary cost of establishment and rehabilitation of temporary tracks, per 100 km, constructed during firefighting operations, and compare this with the recurrent costs of a program of maintaining existing tracks. |
REC104-2282 | 25 - Inquiry, audit, lessons management and after action review | That quality control or performance assessments are routinely completed post fire season, to ensure that contractors who have not performed to an agreed standard are not re-engaged for the consequential rehabilitation works. |
REC104-2333 | 25 - Inquiry, audit, lessons management and after action review | That in doing so, this Review must consult with the agencies mentioned above, and others such as VICSES and the Departments of Human Services and Primary Industries. |
REC104-2243 | 37 - Funding | That Government reviews the funding for DSE for the 2004-2005 fire season to ensure that appropriate resources are available for fire prevention planning and preparedness. |
REC104-2281 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA work cooperatively to review the management and application of bulldozers in fire suppression operations to ensure that they are used effectively, appropriately and are adequately supervised. |
REC104-2332 | 25 - Inquiry, audit, lessons management and after action review | That the Review of emergency operations centres by the Departments of Premier and Cabinet and Treasury and Finance and the Office of the Emergency Services Commissioner: |
REC104-2242 | 37 - Funding | That the financial arrangements incorporate full cost recovery for prescribed burning to be undertaken over a number of weekends utilising Project Firefighters, CFA volunteers and MFESB members. |
REC104-2318 | 37 - Funding | When the research into prescribed burning and optimum fire protection described in Chapter 11, and the financial analysis of appropriate funding levels for prevention and suppression recommended in Chapter 15, are completed, DSE should develop a business case with Department of Treasury and Finance for assured funding to an agreed level over a three-year rolling cycle. |
REC104-2277 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review methods of gathering and processing fire information to ensure all methods are pursued to greatest effect. |
REC104-2293 | 25 - Inquiry, audit, lessons management and after action review | That aviation contractors be required to submit a copy of their annual independent regulatory compliance audit prepared for Civil Aviation Safety Authority to the State Aircraft Unit. |
REC104-2220 | 2 - Emergency powers | That CFA should not be given the power to direct Forest Industry Brigades to engage in fire prevention and suppression activities off their land and that decision should remain the responsibility of the plantation company. |
REC104-2241 | 37 - Funding | That the financial models incorporate changes in public land use, particularly ‘Our Forests Our Future’, and the subsequent changes in fire management priorities. |
REC104-2308 | 37 - Funding | That Government funding for Community Development Officers engaged in community support and rebuilding incorporates flexible resources to enable the purchase of services from a range of providers to ensure choice for those requiring support. |
REC104-2228 | 25 - Inquiry, audit, lessons management and after action review | That the Government identifies an appropriate body, or bodies, to undertake the audit of the Municipal Fire Management Plans. |
REC104-2292 | 25 - Inquiry, audit, lessons management and after action review | That a systematic performance audit of State Aircraft Fleet contractors be conducted jointly by agency and SAU personnel. |
Rec-ID | Code | Recommendation |
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REC015_3959 | 37 - Funding | It is recommended that an annual grant be made to the Association for distribution among the brigades for the purposes of purchase of equipment of which the brigades are in urgent need. |