Inquiry Search
Rec-ID | Code | Recommendation |
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REC322-4246 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the Interagency Protocol for Fire Management be reviewed by all relevant entities, including representatives of the Butchulla people, and be updated as a matter of priority. Entities responsible for the protocol should implement a process for regular review and evaluation of its effectiveness. This review process should be conducted after a major bushfire event, or to reflect any material change to applicable legislation and policy. It should also consider pre-arranged approvals and a range of agreed fiscal protocols between the agencies. |
REC322-4252 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services regularly review and evaluate the effectiveness of the Queensland Bushfire Plan with land managers and stakeholders, including disaster management groups. A review should occur in line with any material change to the Queensland State Disaster Management Plan, the Disaster Management Act 2003, the Prevention Preparedness Response and Recovery Guideline, or after major bushfire events, to ensure appropriate alignment and currency. |
REC322-4218 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends this report be returned to the IGEM to monitor, evaluate and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC322-4219 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends should a Queensland Government Action Plan be considered, clarity about the intent of the recommendations be sought from the Inspector-General Emergency Management to assist in informing this process. |
REC322-4220 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science monitor the progress of relevant improvement activities resulting from the K’gari (Fraser Island) Bushfire Review, through their respective lessons management programs. |
REC322-4240 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the next review of the Queensland State Disaster Management Plan examines and provides guidance in respect to the application of Queensland’s disaster management arrangements to support hazard specific events such as bushfire. |
Rec-ID | Code | Recommendation |
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REC319-4200 | 33 - Relief and recovery | Foundations of emergency management: The Inspector-General for Emergency Management recommends that Emergency Management Victoria and the entity referred to in Recommendation 13, or otherwise responsible government department – in consultation with the emergency management sector – establish policies and platforms to improve operational and personal information sharing between relief and recovery organisations. These policies and platforms should enable: |
REC319-4191 | 12 - EM agency and authority | Relief governance: The Inspector General for Emergency Management recommends that Emergency Management Victoria lead the development of relief arrangements to achieve greater clarity of roles, reporting and accountability in relief across state, regional and incident tiers. These arrangements should: |
REC319-4192 | 12 - EM agency and authority | Relief governance: The Inspector-General for Emergency Management recommends that the Emergency Management Commissioner strengthen the State Emergency Management Plan and supporting operational arrangements in accordance with his legislative obligations to ensure the roles and responsibilities of the State Emergency Relief Coordinator and the State Relief and Recovery Team are clear. These documents should enable: |
REC319-4195 | 33 - Relief and recovery | Relief and recovery funding: The Inspector-General for Emergency Management recommends that the entity referred to in Recommendation 13, or otherwise responsible government department, leads the development of a comprehensive, person-centred, trauma-informed recovery financial assistance system that establishes: |
REC319-4187 | 33 - Relief and recovery | Recovery governance: The Inspector-General for Emergency Management recommends that the entity referred to in Recommendation 13, or otherwise responsible government department, work with councils, relevant recovery organisations and communities to develop clear roles and responsibilities for: |
REC319-4196 | 33 - Relief and recovery | Relief and recovery funding: The Inspector-General for Emergency Management recommends that the entity referred to in Recommendation 13, or otherwise responsible government department, works with the emergency management sector to develop a recovery funding model that enables: |
REC319-4188 | 12 - EM agency and authority | Recovery governance: The Inspector-General for Emergency Management recommends that the Victorian Government establish a permanent and comprehensive entity dedicated to recovery management with the authority, capability, capacity and resourcing to coordinate the planning and delivery of recovery functions for all emergencies. |
REC319-4198 | 33 - Relief and recovery | Relief and recovery capability: The Inspector-General for Emergency Management recommends that the Department of Jobs, Precincts and Regions works with the entity referred to in Recommendation 13, or otherwise responsible government department and/or Municipal Association of Victoria, councils and local relief and recovery organisations to provide centralised capability development opportunities to increase local capability and capacity to plan and deliver on their relief and recovery responsibilities: |
REC319-4189 | 33 - Relief and recovery | Donated good: The Inspector-General for Emergency Management recommends that Emergency Management Victoria and the entity referred to in Recommendation 13, or otherwise responsible government department: |
Rec-ID | Code | Recommendation |
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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: |
REC318-4183 | 13 - Mapping and data quality | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in consultation with relevant agencies – develop a system to manage personnel and asset deployments to all tiers of incident management to meet the needs of the emergency and support the health and wellbeing of personnel. Where appropriate and within occupational health and safety requirements, this may include: |
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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC314-3268 | 12 - EM agency and authority | Incorporate Farm Firefighting Units (FFUs) into the Australasian Inter Service Incident Management System (AIIMS) so that IMTs are aware of their presence on the fireground and their welfare and risks are understood. |
Rec-ID | Code | Recommendation |
---|---|---|
REC307-2437 | 13 - Mapping and data quality | The ability to share, analyse, interrogate and display information from disparate entities should be progressed as a matter of some urgency. |
Rec-ID | Code | Recommendation |
---|---|---|
REC304-2406 | 12 - EM agency and authority | Retain the Regional Bushfires Committees as regional planning and consultative bodies tasked with monitoring, reviewing and making recommendations on fire management in a Fire Control Region. |
REC304-2414 | 12 - EM agency and authority | Clarify and streamline the allocation of powers to Bushfires NT staff and volunteers involved in bushfire management operations, using a system of delegation through a chain of command similar to the arrangements described in the NT Fire and Emergency Act. |
REC304-2413 | 12 - EM agency and authority | Authorise the Director of Bushfires NT to intervene in volunteer brigade affairs where necessary to maintain an effective fire management capacity in a brigade area. |
REC304-2412 | 12 - EM agency and authority | Maintain independence of volunteer brigades as community-based organisations and clarify the status and role of volunteers within the chain of command. |
REC304-2411 | 12 - EM agency and authority | Create new seasonal paid positions to coordinate and support groups of volunteer brigades. |
REC304-2410 | 12 - EM agency and authority | Authorise Bushfires NT to establish volunteer bushfire brigades and to give authority to volunteer firefighters to take part in fire suppression and mitigation operations. |
REC304-2414 | 12 - EM agency and authority | Clarify and streamline the allocation of powers to Bushfires NT staff and volunteers involved in bushfire management operations, using a system of delegation through a chain of command similar to the arrangements described in the NT Fire and Emergency Act. |
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2403 | 12 - EM agency and authority | Take steps to ensure that both fire commissioners are seeking opportunities to engender a culture in their respective organisations that seeks to attract and foster the volunteer ethos and experience |
REC302-2401 | 12 - EM agency and authority | While the proposal to establish an integrated call and dispatch centre is being implemented, Fire and Rescue NSW should take steps to civilianise ComCen and maintain experienced senior officers from both agencies as supervisors similar to how the NSW Police Force and Ambulance Service of NSW operate |
REC302-2397 | 12 - EM agency and authority | Use the model and system in place at the Ambulance Service of NSW as a benchmark for call taking, dispatch and the provision of situational awareness when deploying resources. This will overcome the lack of a feedback loop in current bushfire operations |
Rec-ID | Code | Recommendation |
---|---|---|
REC301-2390 | 12 - EM agency and authority | TFS, PWS and STT should jointly reach a decision on whether a winch capable remote area firefighting capability should be maintained in Tasmania; which agency or agencies should be responsible for that program; and how a winch capable remote area firefighting capability can be safely trained and kept current, to include consideration of the availability of winching aircraft. If the decision is taken not to maintain this capability in the state, TFS, PWS and STT should identify how the gap in capability that this represents should be filled in future fire seasons. |
REC301-2389 | 12 - EM agency and authority | The proposed Tasmania State Air Desk should have a finance officer attached to its staff. |
REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
REC301-2391 | 12 - EM agency and authority | TFS, PWS and STT should jointly carry out work to identify acceptable shift lengths and patterns – including requirements for rest days – for all personnel working on emergency operations. Once these have been identified, systems should be put in place to ensure that HR rostering practices follow these fatigue management guidelines. And senior staff should lead by example and ensure that they, as well as the people working under them, take adequate rest breaks. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
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. |
REC291-1241 | 12 - EM agency and authority | The State Emergency Management Committee, in consultation with Western Australian Farmers Federation, the Association of Bush Fire Brigades, the Contractors Association of WA, and the Forest Industries Federation of WA, to establish systems for the voluntary registration of: · farmer firefighting units; · contractor firefighting resources; and · forestry industry brigades. |
Rec-ID | Code | Recommendation |
---|---|---|
REC290-1217 | 12 - EM agency and authority | IAP formats and processes appropriate to the nature of the emergency response. |
REC290-1216 | 12 - EM agency and authority | Resolve reoccurring issues with systems and processes |
REC290-1212 | 12 - EM agency and authority | Resourcing models appropriate to local needs, including fire risk and remoteness |
REC290-1208 | 12 - EM agency and authority | A unified and integrated fire sector across the whole fire hazard |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC287-1185 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC280-1384 | 12 - EM agency and authority | That the NSW National Parks and Wildlife Service examine its staffing policy for periods of extreme and catastrophic weather conditions to ensure that sufficient staff are available on site on fire watch. |
REC280-1380 | 13 - Mapping and data quality | That the NSW Rural Fire Service investigate mechanisms to enhance the predictability of megafires and how this information is communicated easily to the public. |
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. |
REC280-1394 | 12 - EM agency and authority | That the Minister for Police and Emergency Services examine the feasibility of relocating the NSW Rural Fire Service headquarters to a rural or regional location. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1387 | 12 - EM agency and authority | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
---|---|---|
REC273-1137 | 12 - EM agency and authority | Review all current SACFS operational facilities (Group, ICC, RCC and SCC) to provide more effective communications, connectivity and resource management. |
REC273-1136 | 12 - EM agency and authority | Plan the establishment of one multi-agency Coordination Centre with sufficient capacity and capability to deal with all incidents in South Australia. |
REC273-1130 | 12 - EM agency and authority | Reviewing how Regional resources are managed and tracked and incorporate into COSO’s to ensure that there is complete situational awareness as to the location and tasking of CFS resources. |
Rec-ID | Code | Recommendation |
---|---|---|
REC265-1127 | 33 - Relief and recovery | Consultation should be undertaken with agencies and organisations that are engaged in emergency welfare provision to identify more effective ways to provide a consistent message to the community that non-cash donations are not required. |
REC265-1126 | 33 - Relief and recovery | Development of a template contract for the clean-up of affected properties to speed-up the process; |
REC265-1125 | 33 - Relief and recovery | Consultation with the Board of the Lord Mayor’s Distress Relief Fund and other disaster appeal organisers should be undertaken to determine the potential for software development to consolidate the application and approval process, including provision of templates and application forms; |
REC265-1104 | 12 - EM agency and authority | DFES should increase and maintain urban interface bushfire skills and expertise. Appointments to senior roles within the agency should include people with experience and credibility in bushfire firefighting and management. |
REC265-1102 | 25 - Inquiry, audit, lessons management and after action review | SEMC Secretariat Community Emergency Management Officers should work with the Shire to document the Shire of Mundaring’s learnings from the Parkerville Stoneville Mt Helena fire with a view to sharing this with other local authorities particularly those facing similar situations in order to extend the range of tools available to assist local governments to understand their roles and responsibilities in future emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC264-1076 | 13 - Mapping and data quality | The State equip itself to undertake rapid air quality monitoring in any location in Victoria, to: • collect all relevant data, including data on PM , carbon monoxide and ozone; and 2.5 • ensure this data is used to inform decision-making within 24 hours of the incident occurring. |
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. |
REC264-1087 | 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 |
Rec-ID | Code | Recommendation |
---|---|---|
REC261-1501 | 12 - EM agency and authority | That the NSW National Parks and Wildlife Service examine its staffing policy for periods of extreme and catastrophic weather conditions to ensure that sufficient staff are available on site on fire watch. |
REC261-1520 | 33 - Relief and recovery | That the Ministry for Police and Emergency Services urgently review its policies for the provision of disaster welfare services to ensure that in the event of a bush fire emergency and the declaration of a fire under section 44 of the Rural Fires Act 1997, adequate funding and services, especially recovery centres and mental health services, are provided for an adequate length of time, with gradual transition to normal service delivery when those services are no longer required. |
REC261-1511 | 12 - EM agency and authority | That the Minister for Police and Emergency Services examine the feasibility of relocating the NSW Rural Fire Service headquarters to a rural or regional location. |
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: |
REC261-1504 | 12 - EM agency and authority | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
---|---|---|
REC259-1046 | 33 - Relief and recovery | That prior to the commencement of any major clean-up, firm policy be established and made known to the extent to which material removal will be the responsibility of the home owner, the Council or the State led recovery effort. |
REC259-1043 | 33 - Relief and recovery | That a single victim registration form be designed, which captures all relevant details required for use by any support agency both in the Response Phase at Evacuation centres and during the Recovery Phase. That such documents when completed form part of a wider database which can be accessed by all relevant agencies |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2551 | 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. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2528 | 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. |
REC258-2549 | 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. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
REC258-2556 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
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: |
REC257-1546 | 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. |
REC257-1539 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC254-1589 | 12 - EM agency and authority | In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
Rec-ID | Code | Recommendation |
---|---|---|
REC247-0910 | 33 - Relief and recovery | That suitable facilities are established from which to effectively control and coordinate immediate recovery operations. |
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. |
REC247-0860 | 13 - Mapping and data quality | That Tasmania Fire Service establishes suitable systems and practices for recording fire management objectives and tactics. |
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. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0851 | 13 - Mapping and data quality | That if a sound business case is developed, the Emergency Information Management and Sharing Project be supported. |
REC247-0907 | 33 - Relief and recovery | That the State Emergency Management Committee ensures that a program of debriefing on recovery issues is completed by all relevant agencies and organisations, and detailed plans and operating procedures are established ready for implementation. |
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. |
REC247-0850 | 13 - Mapping and data quality | That police and other emergency service agencies establish and maintain effective recording systems for emergency operations. |
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. |
REC247-0926 | 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. |
REC247-0896 | 33 - Relief and recovery | That the state level structural arrangements for managing recovery operations are reviewed. |
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. |
REC247-0873 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
Rec-ID | Code | Recommendation |
---|---|---|
REC226-0546 | 13 - Mapping and data quality | Maps prepared for prescribed burns should address the fuel type and burn history of the burn area as well as surrounding areas. Predicted rates of spread under prescribed and other conditions should recognise the complexity of coastal heathlands. |
REC226-0596 | 33 - Relief and recovery | An early decision on relief funding enables timely responses. D CP should review their communication of relief arrangements to ensure that they are clear. |
REC226-0595 | 33 - Relief and recovery | Shire experiences in managing these traumatic events should be captured and passed into emergency management procedures. |
REC226-0594 | 33 - Relief and recovery | Procedures to resolve issues surrounding financial assistance need to be reviewed to ensure they are as smooth, fast and transparent as possible possible. Review and streamline current financial relief procedures. |
REC226-0576 | 13 - Mapping and data quality | Better maps are required for urban/rural interface fires |
REC226-0547 | 13 - Mapping and data quality | Fuel loads on private property need to be identified and included in understanding fire behaviour in determine the contribution they make to the burn risk assessment. |
REC226-0598 | 33 - Relief and recovery | When communities are grieving there is a need to provide special forms of support to affected residents. |
Rec-ID | Code | Recommendation |
---|---|---|
REC225-0540 | 25 - Inquiry, audit, lessons management and after action review | : In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
Rec-ID | Code | Recommendation |
---|---|---|
REC224-1630 | 13 - Mapping and data quality | The Minister for Emergency Services ensure that a Statewide fuel load database that includes data from Western Power, the Department of Fire and Emergency Services and the Department of Environment and Conservation be established before the 2013-14 bushfire season. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
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. |
REC223-0520 | 12 - EM agency and authority | The Department of Environment and Conservation review the utility of its current regional model in terms of the capability of operational centres such as Kirup to service major fire activity on land proximate to the rural urban area (this recommendation should also be considered in the context of Recommendation 5). |
Rec-ID | Code | Recommendation |
---|---|---|
REC209-1643 | 25 - Inquiry, audit, lessons management and after action review | An evaluation be conducted into the integration of the appropriate elements of the South Australian Country Fire Service “Crimson” networking system into Bushfires NT ICT. |
REC209-1668 | 12 - EM agency and authority | Maintain DNRETAS as the lead agency for all aspects of Bushfires NT’s role and maintain Bushfires NT as the lead organisation for both fire prevention and fire fighting operations in its specified districts and zones. |
REC209-1665 | 12 - EM agency and authority | Develop a long term forecast of volunteer requirements, by region, and then review the adequacy of volunteer operational grants, equipment and facilities to meet this forecast. |
REC209-1664 | 12 - EM agency and authority | Review Bushfires NT brigade boundaries to increase the catchment for possible volunteers and maximise the availability and allocation of equipment. |
REC209-1663 | 12 - EM agency and authority | Review Bushfires CRC initiatives as the basis for the implementation of a recruitment drive in the Territory. |
REC209-1649 | 12 - EM agency and authority | Regular rotation of staff across other regions of the Territory to increase knowledge, skills and expertise that can be called upon to increase response effectiveness. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
---|---|---|
REC203-0308 | 33 - Relief and recovery | Early resolution and clear communication of the financial and other support measures that will be available to affected residents is an important contributor to community resilience. |
REC203-0295 | 12 - EM agency and authority | There would be benefit in progressively aligning the geographic boundaries of each of the agencies and seeking to co-locate their headquarters within those boundaries. |
Rec-ID | Code | Recommendation |
---|---|---|
REC202-0507 | 13 - Mapping and data quality | The Minister for Emergency Services, with advice from the Interagency Bushfire Management Committee Fuel Load Management sub-committee, report to Parliament by May 2012 on the estimated cost of developing one fuel load information system across all lands in Western Australia, no matter who manages it. This system’s information should be readily accessible and easily understood by all stakeholders, including the public. |
REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0257 | 29 - Operational Health and Safety | FESA needs to place greater priority on the appointment of Safety Advisors to Level 3 incidents as is reflected in WESTPLAN Bushfire. |
Rec-ID | Code | Recommendation |
---|---|---|
REC200-0361 | 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. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-0359 | 13 - Mapping and data quality | 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. |
REC200-0389 | 12 - EM agency and authority | The Fire and Emergency Services Authority and local governments ensure that Community Emergency Service Managers are physically based in local government. |
REC200-0358 | 13 - Mapping and data quality | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments jointly develop a single, integrated system for fuel load assessment and management. The system should enable public access to allow members of the community to access information about the fuel load in a given locality. |
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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0355 | 13 - Mapping and data quality | 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. |
REC200-0383 | 12 - EM agency and authority | The State Government restructure the Fire and Emergency Services Authority as a Department. 22 As part of this restructure, Emergency Management Western Australia should either be: 1. clearly separated from the fire and emergency services response function (see figure 2); or 2. moved to the Department of the Premier and Cabinet (see figures 3 and 4) or 3. moved to the Attorney-General’s department (see figures 3 and 5). |
REC200-1705 | 29 - Operational Health and Safety | The Fire and Emergency Services Authority (FESA) review its program to decommission vehicles and ensure that when such vehicles are offered during an incident that FESA staff adhere to FESA‟s own policy of „Use of Private Vehicles in Fires‟ |
REC200-0352 | 13 - Mapping and data quality | The Fire and Emergency Services Authority and local governments ensure that the ability to: measure and map fuel loads maintain fuel load databases draw up prescriptions for, and oversee controlled burns are included as key competencies in any future recruitment of Chief Bushfire Control Officers and Community and Emergency Services Managers. |
REC200-0373 | 33 - Relief and recovery | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC196-0235 | 12 - EM agency and authority | Consider the ‘secondment’ of staff into Information Section roles during the fire season along the lines of the seasonal Project Fire Fighters model |
Rec-ID | Code | Recommendation |
---|---|---|
REC195-0320 | 12 - EM agency and authority | The Fire Services continue working towards a common and integrated information and communication platform to improve interoperability at state, regional and local levels. |
REC195-0330 | 13 - Mapping and data quality | The Fire Services develop a program that enables all communication mediums, including social media and agency websites, to be monitored in real time to provide quality assurance for outgoing messages and additional sources of information and intelligence relating to an emergency |
Rec-ID | Code | Recommendation |
---|---|---|
REC191-0262 | 12 - EM agency and authority | that QFRS include consultation with rural fire brigades as mandatory when boundary changes are proposed. |
REC191-0270 | 12 - EM agency and authority | that QFRS implement procedures to ensure that rural fire brigades receive written confirmation of the Commissioner’s approval after office bearer elections in compliance with section 81 of the Fire and Rescue Service Act 1990. |
REC191-0269 | 12 - EM agency and authority | that QFRS implement procedures to provide a clear grievance process which is available to rural fire brigade volunteers. |
REC191-0265 | 13 - Mapping and data quality | that QFRS undertake a thorough review of Firecom’s systems, including data integrity and dispatch procedures. |
REC191-0264 | 12 - EM agency and authority | that QFRS update its website to include the Rural Fire Service as part of its www.fire.qld.gov.au web presence. |
REC191-0272 | 12 - EM agency and authority | that QFRS establish the position of Assistant Commissioner, Rural Fire Service to lead the proposed Rural Fire Service division within QFRS. |
REC191-0263 | 12 - EM agency and authority | that QFRS investigate and implement an internal email system for rural fire brigades. |
REC191-0271 | 12 - EM agency and authority | that QFRS should establish a Rural Fire Service division within QFRS with the aim of integrating and strengthening the relationship between the urban and rural fire services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC188-2917 | 33 - Relief and recovery | The committee recommends that relevant Commonwealth agencies continue to monitor the wellbeing of their personnel and that counselling and support services should be provided for as long as necessary. |
REC188-2916 | 33 - Relief and recovery | The committee recommends that the Department of Regional Australia and DIAC liaise with the Christmas Island community to explore options for a permanent memorial to be erected on the island, at a site of the residents' choosing, for the victims of the tragedy. |
REC188-2915 | 33 - Relief and recovery | The committee recommends that Department of Immigration and Citizenship (DIAC) and its relevant contractors continue to monitor the wellbeing of the survivors and that counselling and support services should be provided for as long as is necessary. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0121 | 12 - EM agency and authority | A DEC fire management staff succession plan would minimise the loss of core fire management skills and experience in the future and provide a planned approach to development of prospective fire management staff. |
REC183-0106 | 12 - EM agency and authority | The DEC corporate statement should affirm a strong commitment to fire management. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0130 | 12 - EM agency and authority | FESA identifies and documents its information requirements for end-to-end information exchange and then assess the adequacy of current systems to meet these information requirements. |
REC182-0128 | 12 - EM agency and authority | FESA establishes a process (and associated systems and policies) to mobilise staff to an incident, incorporating pre-formed multi-agency Incident Management Teams. The development of Incident Management Teams should align with the principles of seamless and integrated escalation of command and control arrangements, and be based on a whole of capability approach (people, organisations, systems, training, procedures etc.). |
REC182-0135 | 33 - Relief and recovery | FESA revises its standard operating procedures to provide guidance on the format and timing of post-incident community meetings. |
REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
Rec-ID | Code | Recommendation |
---|---|---|
REC172-0024 | 12 - EM agency and authority | Transport plans for BFB resources should be prepared by the Ground Support Unit in close liaison with FESA who will liaise with the home jurisdictions of the brigades. Moving personnel whilst leaving the equipment at the fire ground staging areas is preferred to moving equipment in and out with every shift. |
REC172-0030 | 29 - Operational Health and Safety | A strategically located Staging Area serviced with check in/out personnel should be considered as early as possible at incidents involving an extended attack. |
REC172-0020 | 12 - EM agency and authority | The role of ‘BFB Task Force Liaison’ be defined and appropriately trained personnel be provided by the HMA (possibly from support brigades) to facilitate brigade movements on and off the fire ground. |
REC172-0027 | 13 - Mapping and data quality | Add an ‘Aviation’ map to the standard set of incident maps. The standard for this map will need to be developed by subject matter experts from the Air Ops group. |
Rec-ID | Code | Recommendation |
---|---|---|
REC163-1938 | 12 - EM agency and authority | That appropriate officers of the Rural Fire Service be granted the same powers as granted to officers of NSW Fire Brigades under section 19 of the Fire Brigades Act 1989. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3443 | 12 - EM agency and authority | That emergency services increase their capability/capacity to respond to marine emergencies by undertaking the necessary training, increasing their awareness of port and ship operations and ensuring knowledge of the roles/responsibilities of the relevant authorities and stakeholders. |
REC158-3442 | 12 - EM agency and authority | That emergency services continue to take the lead role in marine emergencies and operate under their respective legislation, the Emergency Management Act and the State’s emergency management arrangements. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3596 | 12 - EM agency and authority | CSC investigating possible change of location when contract for current location at Wendouree expires in 2008. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3711 | 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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 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: |
REC121-3754 | 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. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3764 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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”. |
REC121-3681 | 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. |
REC121-3726 | 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. |
REC121-3753 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3735 | 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. |
REC121-3759 | 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: |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3741 | 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. |
REC121-3680 | 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. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3740 | 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. |
REC121-3768 | 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. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
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”. |
REC121-3691 | 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. |
REC121-3733 | 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. |
REC121-3757 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3713 | 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. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3732 | 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. |
REC121-3755 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC104-2305 | 33 - Relief and recovery | That DPI actively promote as widely as possible within the community, the agricultural recovery service available during emergencies to ensure that all farmers are aware of the services provided. |
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. |
REC104-2313 | 33 - Relief and recovery | That Government review the emergency relief and financial assistance policy, and develop and communicate a predictable, consistent and equitable policy designed to assist the community to recover from emergencies, including natural disasters. |
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. |
REC104-2326 | 12 - EM agency and authority | That, as a matter of urgency, CFA and DSE: |
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. |
REC104-2202 | 13 - Mapping and data quality | That DSE and CFA map all unplanned fires greater than four hectares on public and private land in order to further develop an understanding of the risk to rural Victoria from unplanned fires. |
REC104-2312 | 33 - Relief and recovery | That all agencies engaged in recovery participate in community briefings prior to and during emergency events, to ensure recovery issues are reinforced and communities are informed of the processes established to assist individuals – including matters that are not the responsibility of Victoria, such as Centrelink payments. |
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 |
REC104-2320 | 13 - Mapping and data quality | That Government acknowledge the importance of spatial information as a key element of planning, operations and program evaluation, and support the Geospatial Emergency Information Network as a means of ensuring integrated and co-ordinated information management on a whole-ofGovernment basis. |
REC104-2292 | 25 - Inquiry, audit, lessons management and after action review | That a systematic performance audit of State Aircraft Fleet contractors be conducted jointly by agency and SAU personnel. |
REC104-2197 | 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. |
REC104-2310 | 33 - Relief and recovery | That recovery is recognised as commencing at the same time as response and that recovery planning and delivery is an integral part of the operations of the Municipal Emergency Co-ordination Centres. |
REC104-2248 | 12 - EM agency and authority | That Incident Control Centres and Municipal Emergency Co-ordination Centres be collocated, wherever practicable. |
REC104-2319 | 13 - Mapping and data quality | That all emergency service agencies, CFA and DSE in particular, give greater priority to information management – especially the collection, maintenance and quality control of base data sets necessary for planning, operations and program evaluation. |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2334 | 12 - EM agency and authority | That the Fire Management Branch of DSE be prescribed as an ‘emergency service agency’ for the purposes of s21C (1)(a) of the Emergency Management Act 1986. |
REC104-2191 | 13 - Mapping and data quality | That DSE and CFA, recognising that the Bureau of Meteorology does not routinely store all variables required to produce the calculations and indices necessary for research and planning into fire occurrence and behaviour, develop appropriate systems to ensure that such current and historical information is readily available and accessible. |
REC104-2307 | 33 - Relief and recovery | That the Victorian Government recommend to the Commonwealth Government that it reviews eligibility for those without employment who may or may not be engaged in an emergency response, and are unable to access the appropriate infrastructure to register for financial assistance. |
REC104-2237 | 12 - EM agency and authority | That CFA continues to work with its Brigades to complete the integration of AIIMS-ICS with the Group Structure for full implementation by the 2004-2005 fire season. |
REC104-2316 | 33 - Relief and recovery | That the State Emergency Recovery Committee explore opportunities to establish a 'one-stop shop’ approach wherever practicable following emergencies, including a single telephone number to connect a person to all agencies involved in the recovery process. |
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. |
REC104-2190 | 13 - Mapping and data quality | That DSE institute additional routine data storage and analysis to supplement current climate records with at least daily 3 pm values for the Grassland and Forest Fire Danger Index, and Keetch-Byram Drought Index, for selected high quality stations representing a cross-section of environments throughout Victoria. |
REC104-2306 | 33 - Relief and recovery | That VicRoads and Municipal Councils review procedures and processes to ensure that the identification and delivery of remedial works on State and Council roads following emergency events are as efficient as possible. |
REC104-2234 | 12 - EM agency and authority | That the fire agencies develop contingency plans in relation to access to water for firefighting, including where appropriate, the use of static, large volume water tanks. |
REC104-2314 | 33 - Relief and recovery | That DHS, in conjunction with Local Government, Government departments and the nongovernment sector, modify recovery planning at all levels to include a case management approach supported by an appropriate information system to be activated at the time of an emergency. |
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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC098-2162 | 13 - Mapping and data quality | The Committee recommends that the 1:100,000 national mapping program be accelerated to achieve an average life of no greater than 10 years with priority given to those areas most susceptible to national disasters. |
REC098-2140 | 12 - EM agency and authority | The Committee recommends that the Commonwealth seeks to ensure that the Council of Australian Governments implements arrangements in which greater flexibility is devolved to local brigade captains in the |
REC098-2161 | 13 - Mapping and data quality | The Committee recommends that Emergency Management Australia be required to participate in the development and delivery of spatial information systems as part of a national approach to emergency planning and management data. The first priority in policy development and of systems should be related to bushfire hazards. |
REC098-2160 | 13 - Mapping and data quality | The Committee recommends that Geoscience Australia take responsibility, in conjunction with Emergency Management Australia, for developing a national spatial data policy to coordinate the development of data systems, the collection of data and the sharing of data between all the emergency response agencies across Australia, and that both agencies participate in the development and delivery of spatial information |
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
REC098-2151 | 29 - Operational Health and Safety | The Committee recommends that the Commonwealth Attorney-General engage the Commonwealth, states and territories in a review of occupational health and safety legislation as it affects the proper and effective functioning of bush fire services. |
REC098-2150 | 12 - EM agency and authority | The Committee recommends that the Commonwealth seeks to ensure that the proposed Council of Australian Governments review of the bushfire management initiate with the states, as a priority, a review of the |
Rec-ID | Code | Recommendation |
---|---|---|
REC037-4163 | 12 - EM agency and authority | Effective planning, organisational and training capability be maintained at regional level and developed, as appropriate, for the future. [Reference paragraphs: 260 to 261] |
REC037-4162 | 12 - EM agency and authority | There be a close integration of the responsibilities of the Minister under the State Disasters Act and the State Disaster Plan, thereby strengthening overall counter—disaster management, direction and control. To this end, the organisational arrangements shown in Annexures “J” and “K” should be adopted. The main features of these are: |