Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2399 | 24 - Govt responsibility | Implement a fully integrated civilianised single call and dispatch centre, that includes a redundancy option outside the Sydney CBD, which will adopt an agnostic approach to deploy the quickest most suitable resource to an emergency. Such a centre should be managed by either a non uniformed public servant staffed organisation like the Office for Emergency Management, or the NSW Police Force |
Rec-ID | Code | Recommendation |
---|---|---|
REC260-1057 | 16 - Training and behaviour | That the Rural Fire Service and National Parks and Wildlife Service introduce training, exercises or information packages, or other suitable forms of professional development, for operational fire fighters and analysts concerning the potential effects of atmospheric instability and vorticity-driven lateral spread on fire behaviours in severe-catastrophic fire danger conditions. |
REC260-1068 | 16 - Training and behaviour | That the National Park and Wildlife Service review its fire weather training regime and consider adopting or adapting the fire weather training courses introduced in Victoria following the 2009 bushfire disaster. |
REC260-1053 | 14 - Incident Mgt Teams | That in Class 3 fire-fighting operations, the Rural Fire Service consider including a fire behaviour analyst in the incident management team if feasible. |
REC260-1066 | 14 - Incident Mgt Teams | That during periods of ‘severe’ or worse fire conditions, that the National Parks and Wildlife Service consider adopting a posture of pre-emptive planning and deployment of incident management teams in national parks similar to the manner in which the Rural Fire Service does. |
REC260-1052 | 14 - Incident Mgt Teams | That the Rural Fire Service consider amending its fire prediction reports to include a checklist of significant factors that have not been able to be considered in the prediction model and a warning to be alert for them and seek intelligence on them from fire ground managers. |
REC260-1062 | 16 - Training and behaviour | That the National Parks and Wildlife Service consider incorporating “worst-case scenario” training, as proposed in Mr Conway’s report, in its suite of fire-fighting protocols, exercises and training packages for senior incident controllers and other senior managers. |
REC260-1060 | 7 - Inter-agency communication | That the Rural Fire Service and National Parks and Wildlife Service review the procedures for requesting aerial support in ‘severe’ or worse fire conditions to ensure that delays in providing it are reduced to the minimum time possible. |
REC260-1058 | 28 - Personal responsibility | That NPWS and the RFS consider developing a land management policy that requires active engagement with property owners adjoining the Park to ensure that hazard reduction and asset protection is encouraged and undertaken before the bush fire season commences |
Rec-ID | Code | Recommendation |
---|---|---|
REC126-1942 | 24 - Govt responsibility | That the ACT Attorney-General and the ACT Government - in consulation with the Chief Justice of the ACT and the ACT Chief Magistrate - take legislative action that would have the effect of funds being directly appropriated annually to the courts, preferable along the lines of the Commonwealth model as it applies to the High Court of Australia, the Federal Court of Australia, the Family Court of Australia and the Federal Magistrates Court. Alternatively, the funds could be appropriated in accordance with the South Australian model, which has a seperate Courts Administartion Authority. |
REC126-1984 | 24 - Govt responsibility | That the Emergency Services Agency, with the support of the ACT Government, develop a single, new memorandum of understanding with the NSW Department of Environment and Conservation and the NSW Rural Fire Service, providing for liaison and joint operations as soon as it becomes apparent to whichever jurisdiction is managing a fire that the fire will probably affect the other jurisdiction. Joint operations should not be limited to when an incident occurs on both sides of the border, as is the current arrangement |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |
REC126-1955 | 16 - Training and behaviour | That training of all personnel involved with emergency services be under constant review |
REC126-1992 | 9 - Community education | That implementation of the Bushfire Wise Program continue and include a letterbox drop of the updated Bushfire Information Booklet |
REC126-1969 | 16 - Training and behaviour | That a review be conducted of the adequacy of training and the numbers of firefighters experienced in performing effective, safe large-scale back-burning operations |
REC126-2003 | 9 - Community education | That the community be made aware of the risk presented by heavy loads of garden fuels and certain types of vegetation around their houses and take active, regular measures to reduce that risk |
REC126-1983 | 16 - Training and behaviour | That the Australian Federal Police and the Emergency Services Agency ensure that personnel in their respective organisations are fully briefed on the agreed policy on evacuations |
REC126-2010 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the extent to which the recommendations in the McLeod report have been implemented in order to ensure implementation of those not yet implemented |
REC126-1953 | 14 - Incident Mgt Teams | That appointments of personnel to functional positions within the incident management team be based solely on competence and experience and be made by the Chief of the ACT Rural Fire Service or, in the absence of that officer, the Deputy Chief of the ACT Rural Fire Service |
REC126-1991 | 9 - Community education | That the Emergency Services Agency establish annual targets for the introduction of community education programs and provide resources to conduct regular independent assessments of the level of community preparedness engendered as a result of the programs |
REC126-1968 | 16 - Training and behaviour | That land managers ensure their staff are properly trained in the effective use of large bulldozers at wildfires and that staff are available to be assigned to supervise bulldozer operations |
REC126-2001 | 9 - Community education | That community education programs provide information about fire behaviour, urban design principles that contribute to a specific level of risk, and the benefits of fitting basic ember protection materials in areas at risk from bushfire |
REC126-1980 | 16 - Training and behaviour | That public land management agencies ensure that their senior personnel have appropriate experience in fire management and are provided with adequate resources and suitable experienced and trained staff to effectively implement fire management programs |
REC126-2009 | 24 - Govt responsibility | That a taskforce be established to give effect to the recommendations in this report |
REC126-1952 | 25 - Inquiry, audit, lessons management and after action review | That regular periodic reviews be undertaken of changes made to the operational and management arrangements for dealing with wildfires and other emergencies in the ACT, to ensure that those arrangements continue to comply with the Australian Inter-Agency Incident Management System Incident Control System |
REC126-1990 | 9 - Community education | That the Emergency Services Agency take measures to ensure that the community regularly receives up-to-date information on the risks of bushfires |
REC126-1962 | 24 - Govt responsibility | That, because of the small jurisdiction of the ACT (equivalent to one fire district in NSW) the ACT Government consider all possible options for the provision of fire services to the ACT, among them: |
REC126-1999 | 9 - Community education | That the Canberra Urban Development Working Group referred to in Mr Peter Dunn's letter consider the report prepared by Mr Leonard and note particularly that the community awareness information currently available to householders in connection with measures they can take to better protect their homes from bushfires does not refer to the potential of wooden fences, conifers and outbuildings to contribute greatly to fire spread, particularly in suburban areas. Also noteworthy is Mr Leonard's evidence that the linear sitting of homes on house blocks in Canberra seems to be an important factor contributing to house-to-house fire spread and that this should be avoided in future developments on the urban fringe |
REC126-1979 | 24 - Govt responsibility | That the policy and practice just recommended be the subject of a memorandum of understanding between the Emergency Services Agency and the Department of Territory and Municipal Services (previously the Department of Urban Services) or other relevant department or agency, so as to ensure that the land management agency on whose land a fire starts has responsibility to respond immediately to that fire in accordance with the applicable standards for weight of response. Further, the land management agency should be responsible for efforts to suppress fire until such time as it becomes clear that the suppression task is beyond capacity of the agency, at which point the ACT Rural Fire Service should assume direct responsibility for coordinating the ongoing response |
REC126-2006 | 24 - Govt responsibility | I recommend that, as appropriate, the ACT cooperate with the Commonwealth in the implementation of the committee's recommendations and, in particular, give careful consideration to adoption of the following recommendations: |
REC126-1948 | 24 - Govt responsibility | That the Emergency Services Agency be removed from the Department of Justice and Community Safety and transformed into an independent statutory authority reporting directly to the responsible Minister. Note in this regard that Mr McLeod made a similar recommendation, and I endorse it unequivocally. Placing the agency within a government department puts unnecessary layers of bureaucracy between the agency and the responsible Minister, and the bureaucrats concerned usually have no special knowledge of or experience in emergency management, regardless of their seniority in the bureaucracy |
REC126-1987 | 7 - Inter-agency communication | That measures be taken to ensure that ACT and NSW Rural Fire Service radio communications systems are integrated, so that ACT and NSW firefighting units can communicate with each other |
REC126-1961 | 7 - Inter-agency communication | That the Emergency Services Agency review the communications systems used by the four services (the ACT Ambulance Service, the ACT Rural Fire Service, the ACT State Emergency Service and the ACT Fire Brigade), by the Australian Federal Police, by NSW emergency services and by aircraft and ensure the systems are compatible |
REC126-1996 | 9 - Community education | That the Emergency Services Agency develop a clear policy for disseminating information to the public and the media in times of emergency and that, as required, that policy incorporate advance door-knocking of homes in the area affected, as well as regular broadcasts by local radio and television stations and regular updates on the relevant website - be that Canberra Connect or a different ACT government website - as well as the Emergency Services Agency's website |
REC126-1976 | 24 - Govt responsibility | That the Emergency Services Agency have authority over the land management agencies and other landholders in order to implement preparedness and prevention measures – including fuel-reduction works where there are failures in compliance |
REC126-2005 | 9 - Community education | That community education programs include unambiguous information that at times of unusually high water demand there might be a drop in or loss of water pressure and it might be appropriate for residents who intend to remain and fight a fire to have auxilary water pumps or booster pumps |
REC126-1947 | 25 - Inquiry, audit, lessons management and after action review | That the ACT Government commission a review of coroners’ jurisdiction in order to determine whether that jurisdiction ought to be limited or expanded and, if so, to what extend |
REC126-1985 | 24 - Govt responsibility | That the Emergency Services Agency, with the suport of the ACT Government, seek to establish with the NSW Department of Environment and Conservation and the NSW Rural Fire Service a protocol that will provide for the establishment of a joint incident management team as part of unified control arrangements based on adoption of the following principles: |
REC126-2012 | 24 - Govt responsibility | If they are willing and available to participate, that the taskforce's membership include Mr Phil Cheney, Mr Tony Bartlett, Mr Val Jeffery and Mr John Lowe |
REC126-1957 | 16 - Training and behaviour | That the Emergency Services Agency review the level of understanding among firefighting personnel of the latest information available nationally and internationally about wildfire behaviour and suppression and provide additional training if warranted |
REC126-1993 | 9 - Community education | That consulations and negotiations occur between the Emergncy Services Agency and the NSW Rural Fire Service to ensure that fire risk and safety messages to the community are coordinated. Maximum use should be made of television and radio announcements throughout the ACT and southern NSW, consistent with NSW timetables for targeted programs in conjunction with the United Firefighters Union ACT Branch and volunteer fire brigade representative. The Emergency Services Agency should consider using ACT Fire Brigade staff and ACT Rural Fire Service volunteers to talk to groups in the community on request, thus furthering face-to-face community education in high-risk suburban areas of the ACT |
REC126-1970 | 35 - Business and Industry in relation to industry | That the Emergency Services Agency reconsider and revise the arrangement that exists between the ACT Fire Brigade and Canberra airport in relation to the provision of assistance |
REC126-2004 | 35 - Business and Industry in relation to industry | That the ACT Government and ActewAGL jointly develop and implement protocols that will create a procedure whereby each of the water and sewerage, electricity and gas distribution networks, or parts thereof, can safely and promptly be manipulated, controlled, shut off, isolated or disconnected under emergency conditions. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3758 | 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. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3768 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3726 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3765 | 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. |