Inquiry Search
Rec-ID | Code | Recommendation |
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REC314-3263 | 4 - Fire season preparation | Clarify and streamline processes and educate the community about their roles and responsibilities in managing native vegetation to improve hazard reduction on both public and private land. Provide additional resources to manage fuel in a shorter off fire season and develop a risk reduction target linked to prioritised objectives. |
Rec-ID | Code | Recommendation |
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REC301-2392 | 39 - Disaster Risk Management | TFS should engage in discussions with government about the construction of purpose-built State Control Centre facilities for emergency management in Tasmania. |
REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
Rec-ID | Code | Recommendation |
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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. |
REC291-1236 | 4 - Fire season preparation | The Departments of Parks and Wildlife and Fire and Emergency Services to develop options for the expansion of the ‘Bushfire Mitigation Grant Scheme’ 20 January 2016 Waroona Fire Special Inquiry utilising both State and Commonwealth Government funding to enable the implementation of hazard reduction works identified through the Bushfire Risk Management Planning process. This will target hazard reduction projects on land owned by private landholders in rural-urban interface areas, critical infrastructure protection, local government land, roadsides and land managed by utilities. |
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. |
Rec-ID | Code | Recommendation |
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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 |
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REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1076 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2552 | 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. |
REC258-2551 | 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. |
REC258-2549 | 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. |
Rec-ID | Code | Recommendation |
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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 |
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REC247-0850 | 13 - Mapping and data quality | That police and other emergency service agencies establish and maintain effective recording systems for emergency operations. |
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. |
REC247-0903 | 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. |
REC247-0935 | 4 - Fire season preparation | That the State Emergency Management Committee includes in its planning, the development of contingency emergency management plans for areas of high risk due to local conditions. |
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. |
REC247-0934 | 4 - Fire season preparation | That the State Fire Management Committee considers developing a structured, systemic and proactive bushfire hazard reduction program with municipal councils and Tasmania Fire Service; and advises the Government on any legislative or other changes required to implement such a program. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0910 | 33 - Relief and recovery | That suitable facilities are established from which to effectively control and coordinate immediate recovery operations. |
REC247-0933 | 4 - Fire season preparation | That the Government considers whether a peak body should be established, with authority to effectively implement a bushfire mitigation plan. |
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. |
REC247-0931 | 4 - Fire season preparation | That a specific risk prevention and mitigation advisory body be established for the State Emergency Management Committee. |
REC247-0851 | 13 - Mapping and data quality | That if a sound business case is developed, the Emergency Information Management and Sharing Project be supported. |
REC247-0951 | 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. |
REC247-0907 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC223-0516 | 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. |
Rec-ID | Code | Recommendation |
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REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0358 | 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. |
REC200-1700 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: |
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. |
REC200-0373 | 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. |
REC200-1698 | 39 - Disaster Risk Management | 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. |
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. |
REC200-0361 | 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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0360 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: conduct site specific assessments to assess current fuel loads assess, analyse and prioritise bushfire risk on land within and adjacent to communities develop a three year rolling mitigation works program with annual implementation and review. This work should commence independently of any decision on the most effective online integrated system. All data collected should be uploaded to the SLIP. |
REC200-1722 | 39 - Disaster Risk Management | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-0359 | 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. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3724 | 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. |
REC121-3758 | 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. |
REC121-3691 | 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. |
REC121-3713 | 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. |
REC121-3757 | 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. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3768 | 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. |
REC121-3725 | 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. |
REC121-3765 | 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. |