Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC325-4335 | 16 - Training and behaviour | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services update and deliver training on the workflow reviewed (as per Recommendation 3) of the current Emergency Alert system to all persons responsible at a local, district and state level by 1 November 2022. Training should address system constraints and system complexities in addition to the process of requesting, composing (including Clear Explicit Translatable Language [CETL]), authorising and issuing Emergency Alerts. |
REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
Rec-ID | Code | Recommendation |
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REC324-4308 | 26 - Research | Compound mental helath studies: That, to inform Government policies and programs for mental health and disasters, Government commission a longitudinal study on the effect of consecutive disasters on community mental health. |
REC324-4294 | 34 - Local knowledge | Environment: That, to maximise protection for the environment in and around floodplains, Government, working with local communities especially Indigenous communities, the NSWRA, other agencies and local councils ensure Indigenous voices are well heard in land use planning and natural resource management by: |
REC324-4298 | 37 - Funding | Housing and development funding options: That, to empower vulnerable people and communities to avoid significant impacts from flood as well as drive broader investment in adaptation, Government through NSWRA: |
REC324-4319 | 26 - Research | Climate and weather research: That, to enable effective mitigation and adaptation measures in response to changing climate risks, Government establish NSW as a world centre of disaster research and technology development. This should include: |
Rec-ID | Code | Recommendation |
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REC322-4229 | 16 - Training and behaviour | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services identifies stakeholders that would benefit from predictive service products. Suitable advice and training should be provided to these stakeholders to assist with using and interpreting the products. |
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. |
REC322-4248 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the prescribed burn program for K’gari be developed by the Department of Environment and Science, in collaboration with the Locality Specific Fire Management Group and the Butchulla people, based on the principles of the National Position on Prescribed Burning. This program should incorporate a process for monitoring and evaluation of outcomes and integration of evolving fire management practices. |
REC322-4244 | 16 - Training and behaviour | The Inspector-General Emergency Management recommends the Department of Environment and Science review its training framework and minimum mandatory training requirements for Queensland Parks and Wildlife Service Incident Controllers to ensure they are appropriately trained to manage significant events. |
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. |
REC322-4227 | 34 - Local knowledge | The Inspector-General Emergency Management recommends the membership of the K’gari Locality Specific Fire Management Group be expanded to include representatives of the Butchulla people, community associations from each township and tourism and business operators with interests on the island. |
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. |
REC322-4230 | 34 - Local knowledge | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services engages with land managers and other stakeholders on K’gari to source data to inform Predictive Services products. |
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. |
REC322-4250 | 34 - Local knowledge | The Inspector-General Emergency Management recommends the Locality Specific Fire Management Group for K’gari meet at least twice per year, in person or virtually. |
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. |
REC322-4223 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the Department of Environment and Science implements the proposed treatments for fire identified in the Queensland Parks and Wildlife Service K’gari Compliance Strategy. |
Rec-ID | Code | Recommendation |
---|---|---|
REC319-4186 | 34 - Local knowledge | Supporting local recovery: The Inspector-General for Emergency Management recommends that the entity referred to in Recommendation 13, or otherwise responsible government department work with councils and communities before, during and after emergencies to strengthen: |
Rec-ID | Code | Recommendation |
---|---|---|
REC318-4182 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in partnership with agencies engaged in state, regional and incident control centres: |
REC318-4181 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in collaboration with the emergency management sector and as part of the emergency management planning reforms: |
REC318-4178 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in collaboration with the Country Fire Authority and local government – undertake a review of the current residual risk target to ensure that it remains contemporary in terms of its designated percentage value. The review should: |
REC318-4176 | 26 - Research | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) lead the development and distribution of evidence-based land and fuel management tools for use by all legislated fuel management organisations to ensure a common approach to fuel management. |
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: |
REC318-4172 | 26 - Research | The Inspector-General for Emergency Management recommends that the State support the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) and its partners to expand the Safer Together program to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC314-3273 | 26 - Research | Collate data and research the impact of bushfires upon communities, firefighters and animals (both native and domestic) to identify appropriate medium and long-term welfare and support requirements. |
REC314-3267 | 16 - Training and behaviour | Invest in fireground leadership and incident management training for CFS, SES and MFS personnel to improve safety on the fireground. Invest in greater technological interoperability such as AVL, Thermal Imagery, Burnover Protection Systems (BOPS), lightning tracking and appropriate vehicle fleets for bushfire conditions including at the peri-urban interface. |
Rec-ID | Code | Recommendation |
---|---|---|
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
Rec-ID | Code | Recommendation |
---|---|---|
REC309-2474 | 16 - Training and behaviour | The provision of system-wide tools, education, guidance and testing for requests for assistance is strengthened to enhance understanding and outcomes. |
REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2479 | 34 - Local knowledge | Local groups should plan for and establish clear arrangements to effectively manage offers of assistance including the management of goods, services and volunteers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC308-2464 | 16 - Training and behaviour | The provision of system-wide education, guidance and testing to enhance requests for Assistance is strengthened. |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
Rec-ID | Code | Recommendation |
---|---|---|
REC307-2445 | 16 - Training and behaviour | All agencies should identify the capacity and appropriate positions for the role of liaison officers, and ensure sufficient numbers are trained. |
REC307-2435 | 16 - Training and behaviour | Building capacity in fire simulation and predictive capabilities, including the capability of people to read and interpret these products through training, should be investigated and considered. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
---|---|---|
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
Rec-ID | Code | Recommendation |
---|---|---|
REC292-2358 | 16 - Training and behaviour | I recommend that the New South Wales Police Force develop a cadre of counterterrorist negotiators and provide them with appropriate training to equip them to respond to a terrorist siege. |
REC292-2352 | 16 - Training and behaviour | The New South Wales Police Force should consider drawing on international experience when reviewing its negotiator training |
REC292-2351 | 16 - Training and behaviour | The sections above dealing with negotiators’ attempts to engage with Monis, their responses to his demands, and their assessment of progress demonstrate deficiencies in current practice. To respond to those deficiencies, I recommend that the New South Wales Police Force conduct a general review of the training afforded to negotiators and the means by which they are assessed and accredited. Specifically, the review should consider the training provided regarding: measuring progress in negotiations; recording of information, including the systems by which that occurs; the use of third-party intermediaries; additional approaches to securing direct contact with a person of interest; and handovers. |
REC292-2337 | 16 - Training and behaviour | I recommend that the Director of Public Prosecutions initiate reviews of the training in file management given to lawyers employed by the Office of the Director of Public Prosecutions to ensure important original documents are not discarded and that the files accurately reflect relevant events. |
REC292-2366 | 16 - Training and behaviour | I recommend that the New South Wales Police Force review the training provided to officers in relation to DA planning and approval. |
REC292-2369 | 26 - Research | I recommend that the New South Wales Police Force evaluate whether the use of noise-attenuation devices should be mandated when explosive distraction devices are used. |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
Rec-ID | Code | Recommendation |
---|---|---|
REC291-1237 | 5 - Hazard reduction burns | The Department of Fire and Emergency Services, utilising the Office of Bushfire Risk Management, to develop a simplified and fast track hazard reduction burn (and other fuel mitigation techniques) planning and approval process to ensure the timely conduct of township and asset protection burns by Bush Fire Brigades and individual property owners. The process is to be agile and adaptable for the range of stakeholders which may participate in low risk, small scale, low complexity burn planning and approvals. |
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. |
REC291-1235 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to continue emphasis on landscape hazard reduction burning with the annual objective of treating 140,000 hectares per annum in Land Management Zone C. In combination with Recommendation 2 (above) the strategic objective will be that a fuel age of less than six years will be maintained across 45% of the landscape on State Forest, National Parks and other Parks and Wildlife managed lands in the South West and Perth Hills. This will address the current backlog (created from under achievements of the recent two decades of burn programs) by the end of the 2020-2021 burning season (i.e. within the next 5 years). |
REC291-1234 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to plan for the highest priority hazard reduction burning effort around settlements and critical assets in the South West and Perth Hills. The annual objective is to treat a total of 60,000 hectares of priority hazard reduction per annum, comprising 20,000 hectares per annum of Land Management Zone A and 40,000 hectares per year of Land Management Zone B. |
REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
Rec-ID | Code | Recommendation |
---|---|---|
REC290-1213 | 34 - Local knowledge | Structures to incorporate local knowledge and situational awareness into the fire response |
Rec-ID | Code | Recommendation |
---|---|---|
REC287-1190 | 16 - Training and behaviour | That a full review be undertaken of the benefts and costs of training a cadre of Tasmanian volunteer firefghters in remote area firefghting, with reference to the experience of jurisdictions interstate that already do so. |
REC287-1189 | 16 - Training and behaviour | That suffcient Tasmanian firefghters are trained in winch operations to sustain a ‘first strike’ capability until they can be reinforced (if necessary) by interstate capability; and that consideration be given to how winch-capable aircraft can be sourced to support this activity at fire incidents. |
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. |
REC287-1187 | 16 - Training and behaviour | All Tasmanian fire agency staff who are assigned to aviation-related roles be required to complete the formal nationally recognised training appropriate to that role. Tasmanian fire agencies arrange secondments to larger states for staff who are going to undertake aviation-related roles, to give them practical experience of the role in advance of any major incidents. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
REC287-1183 | 16 - Training and behaviour | Further conversations take place between TFS and SES to identify what skills and capabilities may be transferable between the agencies, not just in the event of a future fire, but in case of future hazards for which SES is the primary response agency, including food, earthquake and tsunami. |
REC287-1181 | 16 - Training and behaviour | The Tasmanian fire agencies develop a multi-agency position to ensure that training for incident controllers includes training in how the transition from local incident control to Divisional Command is managed. |
Rec-ID | Code | Recommendation |
---|---|---|
REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
REC281-1205 | 16 - Training and behaviour | Department of Premier and Cabinet Regional Coordinators: Continue to build the capability of the Department of Premier and Cabinet Regional Coordinator role in recovery operations by providing: · on the ground support for Regional Coordinators during recovery operations by REMOs or OEM Recovery Team · training and developmental opportunities for Regional Coordinators to prepare them for working in the disaster recovery environment. |
Rec-ID | Code | Recommendation |
---|---|---|
REC265-1115 | 16 - Training and behaviour | Training and awareness raising should be conducted to enhance the appreciation and understanding of DFES State and Regional operational personnel, including potential Incident Management Team members, of the nationally adopted Bushfire Alert and Messaging Matrix, in order to ensure that the most appropriate alert levels and associated community messaging are applied during bushfire incidents. |
REC265-1103 | 16 - Training and behaviour | DFES should review its training courses and Standard Operating Procedures to satisfy itself that all incident management personnel have the required level of understanding of WA emergency management arrangements, including those that relate to the roles of the Incident Management Team and Incident Support Group and the declaration of incident levels. |
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 |
REC264-1072 | 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. |
REC264-1081 | 26 - Research | The State should continue the long-term health study, and: • extend the study to at least 20 years; • appoint an independent board, which includes Latrobe Valley community representatives, to govern the study; and • direct that the independent board publish regular progress reports |
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 |
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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. |
REC260-1055 | 34 - Local knowledge | That the Rural Fire Service together with other land managers develop a program whereby local stakeholders come together regularly (every 2 months during non-fire season and monthly during the fire season) to share intelligence and to consider hazard and incident management measures for implementation. |
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. |
REC260-1070 | 5 - Hazard reduction burns | The NPWS conduct a review of its prescribed burns program to ensure, as far as reasonably practicable, that all necessary managerial approvals for a prescribed burn are provided as promptly as possible. |
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. |
REC260-1063 | 5 - Hazard reduction burns | That the National Parks and Wildlife Service consider reviewing its guidelines and protocols in respect of hazard reduction planning and burning-off operations in the light of the evidence from experts witnesses in these proceedings that the incidence of, and intensity of, major fires is increasing and in the light of expert evidence given in these proceedings concerning the dangers of vorticity-driven lateral spread. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
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. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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: |
REC257-1540 | 16 - Training and behaviour | Commanding Officer Defence Explosive Ordnance Training School, assisted by Joint Logistics Command Regional Explosive Ordnance Serices staff, conduct explosive ordnance accounting training for all instructional staff as a matter of priority and that such training be conducted for Defence Explosive Ordnance Training School staff on an annual basis. |
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. |
REC257-1536 | 16 - Training and behaviour | The Australian defence Force Explosive Ordnance Disposal course be reviewed by Manager Joint Training - Air Force, to ensure the assessments meet the learning outcomes specificed in the relevant Training Management Package. |
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 |
---|---|---|
REC256-1560 | 37 - Funding | The Australian Government should: |
REC256-1559 | 37 - Funding | The Australian Government should gradually increase the amount of annual mitigation funding it provides to state and territory governments to $200 million. Initially, this funding should be distributed to state and territory governments in accordance with the allocation under the National Partnership Agreement on Natural Disaster Resilience. |
REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
REC256-1558 | 37 - Funding | Funding to state and territory governments for community recovery should be provided as untied grants, with a transition period pending the development of a framework to assess community recovery costs. During the transition period, the Australian Government should continue to provide funding for community recovery through a reimbursement model. |
REC256-1557 | 37 - Funding | Where asset management plans at the local, state or territory level pre-identify and cost betterment of assets (improving asset resilience to natural disasters), the Australian Government should share 50 per cent of the betterment component of reconstruction costs following damage from a (eligible) natural disaster. |
REC256-1556 | 37 - Funding | The Australian Government should fund natural disaster recovery by: |
REC256-1577 | 37 - Funding | The Australian Government should develop a formula for allocating mitigation funding to state and territory governments on the basis of where such funding is likely to achieve the greatest net benefits, taking into account the future risks of natural disasters. This should be completed within five years and in consultation with state and territory governments. |
Rec-ID | Code | Recommendation |
---|---|---|
REC254-1583 | 16 - Training and behaviour | Once Recommendation 1 has been actioned, all agencies give greater priority to the promulgation of Red Flag warnings in order to enhance situational awareness on the fireground. |
REC254-1581 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
Rec-ID | Code | Recommendation |
---|---|---|
REC247-0863 | 34 - Local knowledge | That Tasmania Fire Service considers measures to bring local knowledge into Incident Management Team operations. |
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. |
REC247-0925 | 16 - Training and behaviour | That training and development of personnel to establish a suitable state of readiness, be included in the recommended review by Tasmania Police of its approach to emergency management. |
REC247-0938 | 5 - Hazard reduction burns | That Tasmania Fire Service or another suitable agency provides information to the community which shows, in simple form, the legislation applicable to approvals for lighting fires on private property and the various relationships between that legislation. |
REC247-0866 | 26 - Research | That fire agencies continue to develop their predictive modelling capability for use in actively managing fires. |
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. |
REC247-0924 | 16 - Training and behaviour | That an exercise program — to establish and maintain an acceptable state of readiness for agencies and organisations required to be involved in emergency operations — be developed and implemented. |
REC247-0849 | 26 - Research | That Tasmania Fire Service supports the relevant authorities to continue developing methodologies to forecast and simulate fire risk. |
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. |
REC247-0868 | 16 - Training and behaviour | That Tasmania Fire Service, Forestry Tasmania, and Parks and Wildlife Service have a process for ensuring fire strategy and tactics are appropriate and remain focussed. |
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. |
REC247-0903 | 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. |
REC247-0875 | 34 - Local knowledge | That Tasmania Fire Service reviews its integration of rural local knowledge and volunteer brigades into fire operations, develops and maintains appropriate strategies, and aims to be a best-practice fire service in this regard. |
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. |
REC247-0873 | 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. |
REC247-0865 | 34 - Local knowledge | That Tasmania Fire Service reviews its position on using local experienced officers on the fire ground in the command model in a structured and systemic way. |
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. |
REC247-0936 | 16 - Training and behaviour | That the State Fire Management Committee note the decline in machinery and skilled operators from the forestry industry in the private sector and determines how this reduction in fire management capability can be addressed. |
REC247-0932 | 37 - Funding | That the resources available to the Parks and Wildlife Service, to manage bushfire risk following the recent increase in land under its tenure, is reviewed. |
REC247-0939 | 5 - Hazard reduction burns | That Tasmania Fire Service conducts a review of the fire permit system in the Fire Service Act 1979, and implements change to improve the efficiency and effectiveness of the system by: • considering whether it is appropriate to authorise persons or organisations to conduct fuel reduction burning during a permit period • providing a better match between the period, area and fire risk • maintaining a timely and efficient process for issuing permits • naming the period in a way that draws attention to bushfire risk • establishing a reporting and accountability process. |
REC247-0921 | 26 - Research | That Tasmania Fire Service promotes a structured approach to research across Australia, to provide a shared understanding and the capacity to benchmark and judge performance. |
Rec-ID | Code | Recommendation |
---|---|---|
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
Rec-ID | Code | Recommendation |
---|---|---|
REC239-2682 | 37 - Funding | That a budget based on the desired functional accountabilities should be appropriated to the Portfolio Business as part of the Government budget process. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2729 | 16 - Training and behaviour | That the Queensland Fire and Rescue Service work to change the culture of entitlement so that firefighters recognise firefighting is only one of a range of skills they bring to their core role of emergency management. |
REC239-2781 | 34 - Local knowledge | That the current provisions enabling there to be a Ministerial Direction be maintained and actioned as the Minister sees fit. |
REC239-2681 | 37 - Funding | That the funding model for the Portfolio Business is not based on fee- for-service arrangements or notional contributions from the operational services. |
REC239-2780 | 37 - Funding | That should the Westgate project proceed, that consideration must be given to opportunities to partner the investment with the private and public sectors. The business case should also consider alternative facilities such as Australian Defence Force sites. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2671 | 16 - Training and behaviour | That all Queensland Corrective Service provision of training should be contestable. |
REC239-2779 | 37 - Funding | That a new business case for Westgate project should be prepared by an independent party. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2753 | 37 - Funding | That the proposed Chief Executive Officer Portfolio Business be responsible for developing a cost attribution model for portfolio agencies, including the Queensland Police Service, as a priority. |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2741 | 16 - Training and behaviour | That the annual training calendar identify course, training location and the coordinating authority. |
REC239-2683 | 37 - Funding | That the Office of Portfolio Business follows the same budget processes as other agencies. |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2740 | 16 - Training and behaviour | That impediments to the publication of an annual training calendar of core skills be removed. |
Rec-ID | Code | Recommendation |
---|---|---|
REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
REC238-0813 | 26 - Research | Develop and maintain a comprehensive flood model and flood modelling framework for the Hawkesbury-Nepean Valley. |
REC238-0807 | 26 - Research | Develop a comprehensive road evacuation network model for floods in the Hawkesbury-Nepean floodplain to inform evacuation capacity assessments and strategic transport and land use planning, and to assist with the real-time operational management of evacuation during floods. |
REC238-0804 | 26 - Research | Clarify roles, responsibilities and consider funding options for post-event collection of data and flood intelligence. |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
Rec-ID | Code | Recommendation |
---|---|---|
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
Rec-ID | Code | Recommendation |
---|---|---|
REC226-0553 | 5 - Hazard reduction burns | Rolling risk assessment conducted during ignition of prescribed burns should identify whether an escape is likely to develop into a Level 3 incident. As soon as possible after it has been identified that the escape cannot be contained, the incident should be declared a Level 3. |
REC226-0545 | 26 - Research | Improved understanding of fire behaviour in coastal heathlands would support sound risk management through the southwest of W |
REC226-0544 | 5 - Hazard reduction burns | Prescribed burns which meet the ‘red flag’ criteria should have mandated risk Establish risk management criteria for management criteria imposed. |
REC226-0543 | 5 - Hazard reduction burns | There should be clearly established criteria for burns which are specially challenging, and these criteria need to extend beyond the intended boundaries of the prescribed burn. |
REC226-0561 | 34 - Local knowledge | Suitably experienced local representatives should be engaged to provide advice to the IMT in all Level 2 and Level 3 incidents at the earliest opportunity. |
REC226-0542 | 5 - Hazard reduction burns | A risk management approach is needed which considers risks both inside the prescribed burn and the risks that will need to be managed if the fire escapes. This risk assessment should be dynamic in line with the four day and seven day weather forecast. |
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. |
REC225-0532 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
Rec-ID | Code | Recommendation |
---|---|---|
REC223-0514 | 5 - Hazard reduction burns | The Department of Environment and Conservation review its current policies and operational guidelines in particular by: * strengthening the governance of operations by ensuring the Guidelines are relevant and practical; * ensuring the processes that are implemented for prescribed burns are: (a) value adding to the decisions and approvals required (b) informed by substantive input (c) focussed on outcome rather than process; *completing the draft management plan for the Leeuwin-Naturaliste Capes Area Parks and Reserves in accordance with the provisions of the Conservation and Land Management Act 1989; * exploring the possibility of automating and streamlining the various processes for formulating a prescription for prescribed burns for ease of access and updating; and * clarifying the guidance provided to decision makers as to the ‘edging’ and security of prescribed burns. |
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. |
REC223-0517 | 26 - Research | The Department of Environment and Conservation be supported to conduct further research into the fuel management of coastal heath in the south west of Western Australia exploring alternatives to burning as well as best practice for burning. |
REC223-0518 | 16 - Training and behaviour | The Department of Environment and Conservation explore human resourcing models that: · make succession planning a priority; · look at options for the attraction and retention of staff; and · review how the salary levels of staff matches the decision making required in major activities such as prescribed burns. |
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. |
REC223-0519 | 34 - Local knowledge | The Department of Environment and Conservation review its practices and procedures in the undertaking of prescribed burns so as to fully utilise the skills available to it in a seamless way including but not limited to: · volunteer bushfire brigades, especially in regard to use as a source of local advice; and · staff of the Fire and Emergency Services Authority of Western Australia. |
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. |
REC223-0515 | 5 - Hazard reduction burns | The Department of Environment and Conservation urgently undertake a review of its risk management practices as they relate to prescribed burns including but not limited to: *reviewing risk management practices to ensure that they are in accordance with AS/NZS ISO 31000:2009; * finalising and implementing the new complexity model developed in house by the DEC; * considering a broader set of parameters of risk by conducting an environmental scan or similar tool for areas under consideration for a prescribed burn; *updating the prescribed fire plans to reflect the broader risk considerations discovered through environmental scanning; *better informing the risk considerations by updating the ‘Red Book’ to reflect current research on burning in coastal heath; and * reconsidering the utility of the ‘Red Flag Burn’ notification on files and either adopting it as a policy across the State or removing it as a consideration. |
Rec-ID | Code | Recommendation |
---|---|---|
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
Rec-ID | Code | Recommendation |
---|---|---|
REC209-1641 | 16 - Training and behaviour | Knowledge and skills in AIIMS and WebEOC and incident management are further developed through regular scenario planning and incident management simulation exercise. |
REC209-1677 | 37 - Funding | A specialist investigation be conducted, using expertise from NT Treasury, to identify more appropriate ways to optimise the use of available funding for bushfire management. |
REC209-1652 | 16 - Training and behaviour | Increase the capacity and capability of the Alice Springs Regional Committee. |
REC209-1662 | 37 - Funding | Identify where Australian Government funding is available and apply for funding for integrating weed management, controlled burning, bushfire management and carbon farming initiatives. |
REC209-1650 | 16 - Training and behaviour | Secondment of expertise in fire management planning and fire control from other jurisdictions, in a training capacity, be investigated in preparation for the 2012 fire season. |
REC209-1642 | 37 - Funding | That a cost benefit analysis of an integrated ICT desktop and portable capability including iPads and iPhones for all operational personnel be conducted. |
REC209-1648 | 16 - Training and behaviour | Recruitment strategies, be developed, including “growing their own”, that result in the appointment and retention of skilled people to the vacant Bushfires NT positions. The vacant senior position in Alice Springs should be immediately advertised as a permanent position at the appropriate level to attract skilled applicants. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2877 | 37 - Funding | Explore opportunities to re-phase investments in large scale projects and programs such as the Strategic Radar Enhancement Program, the NexGen Forecast and Warning System Products and the Improving Water Information Program. |
REC207-2893 | 37 - Funding | Explore options to obtain revenue from advertising on the Bureau’s website |
REC207-2892 | 37 - Funding | Apply a consistent cost-recovery model to all services delivered to state/territory fire agencies. |
REC207-2890 | 37 - Funding | Review and rebalance relative investment in long term climate modelling and medium-term seasonal outlook. |
REC207-2889 | 37 - Funding | Review level of investment in research activities to free up budget and reduce pressure on computing capacity |
REC207-2879 | 37 - Funding | Firm up approval processes and funding for any departures from provision of the basic product set |
Rec-ID | Code | Recommendation |
---|---|---|
REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
Rec-ID | Code | Recommendation |
---|---|---|
REC203-0280 | 5 - Hazard reduction burns | Contingency plans for escaping burns should be prepared in advance. |
REC203-0285 | 5 - Hazard reduction burns | A rolling risk assessment is required which captures the risks of the burn escaping and provides adequate resources. |
REC203-0279 | 5 - Hazard reduction burns | Once a burn is ignited, it needs to be the subject of continuing risk assessment and appropriate mitigation. |
REC203-0284 | 5 - Hazard reduction burns | DEC should investigate embedding an experienced forecaster in the state operations centre. |
REC203-0278 | 5 - Hazard reduction burns | Prescriptions should mandate consideration of measures to retire risk. |
REC203-0293 | 34 - Local knowledge | Suitably experienced personnel with local knowledge should be connected to the Operations and Planning section in all Level 3 incidents in the vicinity of substantial settlements. |
REC203-0283 | 5 - Hazard reduction burns | Core ignition, particularly of red flag burns, should be informed by the 4 & 7 day forecasts (including a longer term perspective over 3 to 4 months) |
REC203-0277 | 5 - Hazard reduction burns | A risk-management approach is needed which considers risks both inside the prescribed burn and the risks that will need to be managed if the fire escapes. The risk assessment should be organised and in line with the four and seven day weather. |
REC203-0282 | 5 - Hazard reduction burns | The burn prescription should capture the fuel characteristics and potential rate of spread for those areas outside the burn that will likely be critical during the initial attack on any escaping fire. |
REC203-0276 | 5 - Hazard reduction burns | There should be clearly established criteria for burns which are specially challenging, and these criteria need to extend beyond the intended boundaries of the prescribed burn. The criteria should be clarified and adopted as agency S OPs. |
REC203-0281 | 5 - Hazard reduction burns | Prescriptions need to be interpreted by experienced and knowledgeable personnel to ensure risk is fully understood. It is important that the background and justification for these decisions are captured at each stage and are visible to all levels in WA fire management hierarchy. |
REC203-0286 | 5 - Hazard reduction burns | Decisions taken on the basis of this risk assessment need to be captured and distributed across district and state. |
Rec-ID | Code | Recommendation |
---|---|---|
REC200-0390 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: measuring and mapping fuel loads maintaining fuel load databases drawing up prescriptions for, and overseeing controlled burns building effective working relationships with all relevant stakeholders. |
REC200-1731 | 16 - Training and behaviour | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. |
REC200-1725 | 37 - Funding | The State Government move the responsibility for the management and distribution of the Emergency Services Levy to the Department of Finance. |
REC200-0385 | 37 - Funding | The State Government move the responsibility for the management and distribution of the Emergency Services Levy to the Department of Finance. |
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. |
REC200-1730 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: |
REC200-0356 | 5 - Hazard reduction burns | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-0384 | 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. |
REC200-0351 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: Reducing fuel load Improving inter-operability A mutual understanding of the fire fighting techniques of each agency. |
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. |
REC200-1697 | 26 - Research | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments closely monitor the research and development of alternative fuel reduction techniques to ensure that the most efficient and effective programs are adopted. |
REC200-1692 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: |
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. |
REC200-0350 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth’s urban/rural interface to compliment DEC’s existing landscape-scale program. |
REC200-1691 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth‟s urban/rural interface to compliment DEC's existing landscape-scale program. |
REC200-0357 | 26 - Research | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments closely monitor the research and development of alternative fuel reduction techniques to ensure that the most efficient and effective programs are adopted. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0492 | 34 - Local knowledge | the state comprehensively pursue the objective of achieving (where possible) the priority outcomes of the National Strategy for Disaster Resilience and the imperative of shared responsibility, in particular by: • requiring that local knowledge is considered as a critical component of all phases of emergency management • involving local communities in the development and ownership of community resilience plans based on an ‘all hazards’ approach and tailored for the specific needs of each community • encouraging local communities to form resilience committees to develop and administer community resilience plans • nominating Victoria Police as the lead agency in initiating the strategy to develop community resilience committees; and • requiring emergency service agencies to consult and engage with local community resilience committees in the preparation, planning, response and recovery phases of emergency management. |
REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0421 | 34 - Local knowledge | the state take the necessary measures to require that local knowledge is considered in flood risk planning, including verification of flood maps and flood response plans. |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0416 | 26 - Research | the state establish appropriate arrangements to ensure the capacity to maintain technical expertise for flood intelligence is initiated, including appropriate agreements with commercial experts. |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
Rec-ID | Code | Recommendation |
---|---|---|
REC198-2904 | 16 - Training and behaviour | The CFA, in collaboration with the other agencies develop a case study of the response to and recovery from the TriTech fire as a training and development opportunity. |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1757 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, examine options to enable the engagement of an adequate instructor strength to serve the training needs of volunteers. Those options should include making more use of volunteers as instructors. |
REC197-1765 | 16 - Training and behaviour | The CFA continue the development of Vector Command Training and its availability and utilisation by volunteers. The feasibility of this training being provided online be explored by the CFA as part of the consideration of the use of the NBN. |
REC197-1751 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to training budgets and, in particular, with respect to what relates to volunteer training and what relates to career staff training. |
REC197-1756 | 16 - Training and behaviour | CFA develop an individual training pathway for operational volunteers to enable volunteers to be able to better identify their career and training options and pursue a pathway that meets their expectation. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1764 | 16 - Training and behaviour | A. The CFA, in consultation with volunteers, employees, the VFBV and the UFU, examine the feasibility of utilising the TAFE system for training delivery. |
REC197-1750 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to the identification and meeting of training demand, and plans to meet such demand. |
REC197-1755 | 16 - Training and behaviour | The CFA examine options to enable sufficient training materials to be available to ensure effective training delivery. As part of this examination, the CFA explore the feasibility of utilising the TAFE system. |
REC197-1763 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review the process for RCC and RPL with the view to making that process transparent, efficient and fair. |
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
REC197-1754 | 16 - Training and behaviour | The CFA proceed with the update of facilities and infrastructure at Fiskville to enable its better utilisation by volunteers and employees for training. Where necessary, the Government support this update when determining CFA funding. |
REC197-1762 | 16 - Training and behaviour | The CFA provide greater opportunities for leadership training for volunteers at all levels but particularly at the brigade level. The CFA, as far as practicable, endeavour to ensure that persons appointed to positions of leadership have the necessary capability. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1768 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby more volunteers are qualified to participate in Incident Management Teams. |
REC197-1753 | 16 - Training and behaviour | The CFA continue the Mobile Training Infrastructure Project and the Fixed Training Infrastructure Project. Where necessary, the Government support these initiatives in determining CFA funding. |
REC197-1761 | 16 - Training and behaviour | The CFA continue the development of key principles in relation to training, in consultation with volunteers and paid personnel. In the development of those principles, account should be taken of matters raised by volunteers to this Inquiry and the comments that I have made about training delivery. Account should also be taken of principles contained in any statement of Vision, Mission and Values adopted by the CFA. |
REC197-1747 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review its arrangements with respect to First Aid training and maintenance of currency of qualifications, with a view to the delivery of such training and maintenance best meeting brigade needs. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC196-0238 | 34 - Local knowledge | Encourage ICCs to use local knowledge to review templates prior to release. |
REC196-0233 | 16 - Training and behaviour | Further train Incident Controllers in the management of the Information Section and its roles. |
REC196-0234 | 34 - Local knowledge | Ensure that local knowledge, local flavour and local language is used where possible in the development of all community bushfire warnings. |
REC196-0232 | 16 - Training and behaviour | Increase the regularity of training for ICC Information Section staff and encourage pre-season drilling and trials in the use of OSOM and Emergency Alert particularly under critical capacity conditions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC195-0326 | 16 - Training and behaviour | The Fire Services recognise the specialised role of Information Sections and enhance training and resources accordingly. |
REC195-0314 | 16 - Training and behaviour | The Fire Services enhance and increase joint training and exercise programs at all levels of command and control, including the State Control Centre. (These programs need to enable volunteer participation.) |
REC195-0310 | 16 - Training and behaviour | The Fire Services Commissioner ensures that there is a comprehensive understanding of the State Command and Control Arrangements for Bushfires in Victoria across the Fire Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0110 | 16 - Training and behaviour | DEC should emphasise the principle of foresight by adopting an appreciation and decision making process and training staff in that process. |
REC183-0122 | 16 - Training and behaviour | A staff recognition and reward framework for service to fire management should be considered for DEC fire staff. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3304 | 26 - Research | It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is located within a reservoir in a horizontal or high angle position at great depth). |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
Rec-ID | Code | Recommendation |
---|---|---|
REC172-0041 | 16 - Training and behaviour | Media liaison personnel are needed to ‘ride’ shotgun’ on media personnel to facilitate them getting their stories without imposing on the effectiveness of operations. |
REC172-0031 | 16 - Training and behaviour | Pre-season refresher training to include an emphasis on check in/out procedures |
REC172-0023 | 16 - Training and behaviour | Pre-season multi- agency refresher training for Ground Controllers should be undertaken each year. |
REC172-0038 | 34 - Local knowledge | The ISU should be provided with a person with local knowledge at Level 3 incidents. |
Rec-ID | Code | Recommendation |
---|---|---|
REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3002 | 16 - Training and behaviour | That the Tasmania Fire Service provide additional training in the use of thermal camera imaging: |
REC166-3001 | 16 - Training and behaviour | That the Tasmania Fire Service provide further training in respect to sprinkler systems, namely: |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC156-3495 | 16 - Training and behaviour | The Department of Primary Industries should work through the appropriate Ministerial Councils to seek alignment of competency standards for line workers across jurisdictions. |
REC156-3506 | 26 - Research | The Office of the Emergency Services Commissioner facilitate further research into technologies that will reduce the need for the public to speak to an operator during an emergency as a component of the proposed emergency warning and alert system and Victorian Emergency Information Line. |
Rec-ID | Code | Recommendation |
---|---|---|
REC153-1794 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of all Incident Management Team members, in particular but not limited to the Incident Controller and Planning Officer, of the need to conduct a full risk assessment that not only addresses operational risk, but the risk posed to the general public by an existing incident and at all times to consider and identify the ‘worst case scenario’ outcome. |
REC153-1776 | 26 - Research | That the Minister for Emergency Services cause independent scientific or other research to be undertaken to establish means by which risk of bushfires, as created by continuous cropping, minimum tillage, direct drilling seeding practices and the retention of cropping stubble across the landscape, can be minimised. |
REC153-1793 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the need to deliver to the Deputy State Coordinator timely, accurate and relevant information pertaining to an ongoing fire incident. |
REC153-1798 | 16 - Training and behaviour | That the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public. |
REC153-1775 | 26 - Research | That the Minister for Emergency Services cause independent scientific or other research to be undertaken to identify the effects of continuous cropping, minimum tillage, direct drilling seeding practices and of the retention of cropping stubble, in respect of bushfire risk and prevention. |
REC153-1777 | 5 - Hazard reduction burns | That the Minister for Emergency Services and the Minister for Local Government consider the enactment of legislation that would empower Local Government to require the owners or occupiers of rural land to create fire breaks on the land of a kind that Local Government may determine and/or to require the removal of flammable materials from the land, as measures for preventing the outbreak of a bushfire, or for preventing the spread or extension of a bushfire. |
REC153-1792 | 16 - Training and behaviour | That the Minister for Emergency Services and the Chief Officer of the South Australian Country Fire Service reinforce in the minds of those Officers who perform the role of Regional Duty Officer the duties and responsibilities attaching to that position insofar as they apply to an ongoing fire incident, and in particular to recognise the need to conduct a risk assessment in relation to an incident and the need to scrutinise, evaluate and validate the strategies and Incident Action Plans of Incident Management Teams. |
REC153-1797 | 16 - Training and behaviour | That the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in identifying and implementing feasible and appropriate containment measures designed to bring control to a fire incident so as to minimise the risk posed to the general public. |
REC153-1796 | 16 - Training and behaviour | That the South Australian Country Fire Service design tuition courses aimed specifically at developing among its members skill and competency in risk assessment. |
REC153-1795 | 16 - Training and behaviour | That the South Australian Country Fire Service develop as part of competency for inclusion on a Level 2 or Level 3 Incident Management Team a minimum requirement of demonstrated skill and competency in risk assessment. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3553 | 37 - Funding | RHH Neonatal Emergency Transport Service receive DHHS funding for a Senior Registrar to assume the responsibilities of retrieval staffing, quality assurance, data collection and reporting demands. |
REC140-3552 | 37 - Funding | Department of Health and Human Services (DHHS) to fund 3 Full-Time Equivalent (FTE) Senior Registrar positions at the Royal Hobart Hospital (RHH) for the Tasmanian Medical Retrieval Service (TMRS). One registrar in the Anaesthesia Department, one in the Intensive Care Unit and one in Emergency Department is proposed. |
REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
REC140-3568 | 37 - Funding | The State Medical Retrieval Cost Centre (TMRS and NETS) be formed and be supported by the appropriate administrative and resource accountant expertise. This cost centre should be placed with those responsible for its management. |
REC140-3567 | 37 - Funding | A uniform retrieval charge to the region of referral should be considered. This should be independent of the mode of transport used. |
REC140-3554 | 37 - Funding | DHHS fund the equivalent of 2 FTE Consultant positions for retrieval duties (1.5 FTE existing, 0.5 FTE new) |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3593 | 26 - Research | Analysing information from the joint CFA/DSE Post 2006 Wildfire Community Survey about public perceptions of information provision during January bushfires. Note implications for the VBIL and other information provision methods |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC126-1972 | 5 - Hazard reduction burns | That clarification be provided and information be made public in connection with the hazard reduction proposed under the Strategic Bushfire Management Plan for the area designated ‘Land Management Zone’, which appears to cover about 70 per cent of the ACT landscape and might be excluded from fuel-reduction burning |
REC126-2007 | 34 - Local knowledge | That the views and concerns expressed by the ACT Sustainable Rural Lands Group be taken into account when implementing the recommendations in this report |
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 |
REC126-1955 | 16 - Training and behaviour | That training of all personnel involved with emergency services be under constant review |
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 |
REC126-1971 | 5 - Hazard reduction burns | That a hazard-reduction program be introduced, involving regular and strategic burning in all areas of the ACT – including the catchment areas – with a view to having fuel-reduced areas in a pattern across the landscape, excluding only small areas of particular ecological or conservation importance |
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 |
REC126-1980 | 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 |
REC126-1947 | 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 |
REC126-1969 | 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 |
REC126-1975 | 5 - Hazard reduction burns | That prescribed burning operations be conducted according to agreed standard burning prescriptions |
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 |
REC126-1958 | 37 - Funding | That the ACT Government allocate sufficient funds to enable full-time and volunteer firefighters to participate in relevant courses and programs |
REC126-1973 | 5 - Hazard reduction burns | If it is not part of the proposed version 2 of the Strategic Bushfire Management Plan, that the plan be revised to provide for a fuel-reduction burning regime in the ‘Land Management Zone’ that is equivalent to that contemplated for the corridors designated as the ‘Landscape Division Zone’ and that the regime involve burning areas in rotation to achieve an appropriately varying fire age spectrum across the entire landscape |
REC126-2008 | 34 - Local knowledge | That, if he is willing to participate, Mr John Lowe be made a member of the implementation taskforce to which I refer in recommendation 70 |
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 |
Rec-ID | Code | Recommendation |
---|---|---|
REC124-3885 | 5 - Hazard reduction burns | Align policies and processes, within the year round 365 day focus on fire management, to provide consistency in the approach to fire regardless of its origins,- that is fuel reduction burning, regeneration and ecological burning or unplanned fire; |
REC124-3884 | 5 - Hazard reduction burns | Develop new prescriptions for prescribed burning to accommodate local conditions in those areas where standard prescriptions are assessed to be inappropriate: |
REC124-3890 | 16 - Training and behaviour | Update education and training programs relating to prescribed burning to reflect revised organisational priorities including year round (365 day) fire management program: |
Rec-ID | Code | Recommendation |
---|---|---|
REC123-3877 | 25 - Inquiry, audit, lessons management and after action review | All agencies review formal and informal incident notification processes to ensure they support the earliest possible reporting of emergencies to all stakeholders involved in the Airport Emergency Plan and in so doing, ensure early access to specialist advice and support. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3768 | 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. |
REC121-3654 | 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. |
REC121-3756 | 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. |
REC121-3675 | 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. |
REC121-3713 | 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. |
REC121-3717 | 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. |
REC121-3765 | 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. |
REC121-3650 | 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. |
REC121-3751 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3746 | 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. |
REC121-3693 | 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. |
REC121-3715 | 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. |
REC121-3757 | 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. |
REC121-3744 | 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. |
REC121-3691 | 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. |
REC121-3714 | 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. |
REC121-3719 | 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. |
REC121-3677 | 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. |
REC121-3726 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC118-3642 | 26 - Research | Establish a Regional Centre of Excellence for Tsunamis to focus Australian and international science/research and collaboration on the challenge of understanding tsunamis and mitigating their consequences. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC104-2201 | 26 - Research | That DSE undertake a formal study of the level of prescribed burning in south western Australia for its possible application in Victoria by comparing respective fuel arrays, terrain, weather, ground access, staff, prescribed burning days, areas conducive to prescribed burning and fire response systems. |
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. |
REC104-2235 | 16 - Training and behaviour | That DSE and CFA review selection and training programs for Incident Controllers and Incident Management Team members to ensure that they include all necessary competencies in recognition that technical skills are only one component of the required attributes. |
REC104-2264 | 16 - Training and behaviour | That CFA and DSE provide media training to all Level 2 and Level 3 Incident Controllers. |
REC104-2243 | 37 - Funding | That Government reviews the funding for DSE for the 2004-2005 fire season to ensure that appropriate resources are available for fire prevention planning and preparedness. |
REC104-2281 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA work cooperatively to review the management and application of bulldozers in fire suppression operations to ensure that they are used effectively, appropriately and are adequately supervised. |
REC104-2332 | 25 - Inquiry, audit, lessons management and after action review | That the Review of emergency operations centres by the Departments of Premier and Cabinet and Treasury and Finance and the Office of the Emergency Services Commissioner: |
REC104-2263 | 16 - Training and behaviour | That the person appointed by DSE or CFA as Incident Controller for any incident should have formal qualifications and accreditation in the Incident Control System, be fully aware of the Victorian emergency management arrangements and have access to local fire prevention and response planning, including the Municipal Fire Management Plan |
REC104-2242 | 37 - Funding | That the financial arrangements incorporate full cost recovery for prescribed burning to be undertaken over a number of weekends utilising Project Firefighters, CFA volunteers and MFESB members. |
REC104-2277 | 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. |
REC104-2318 | 37 - Funding | When the research into prescribed burning and optimum fire protection described in Chapter 11, and the financial analysis of appropriate funding levels for prevention and suppression recommended in Chapter 15, are completed, DSE should develop a business case with Department of Treasury and Finance for assured funding to an agreed level over a three-year rolling cycle. |
REC104-2293 | 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. |
REC104-2260 | 16 - Training and behaviour | That VICSES, with the support of the CFA, includes basic fire safety training as one of the competencies for the VICSES Volunteers. |
REC104-2241 | 37 - Funding | That the financial models incorporate changes in public land use, particularly ‘Our Forests Our Future’, and the subsequent changes in fire management priorities. |
REC104-2246 | 34 - Local knowledge | That DSE undertake community consultation on policies relating to roads and access tracks on public land, particularly in respect to fire management. |
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. |
REC104-2308 | 37 - Funding | That Government funding for Community Development Officers engaged in community support and rebuilding incorporates flexible resources to enable the purchase of services from a range of providers to ensure choice for those requiring support. |
REC104-2292 | 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. |
REC104-2259 | 16 - Training and behaviour | That the MFESB continue to give priority to appropriate bushfire training for its firefighters. |
REC104-2240 | 37 - Funding | That Government supports the immediate development of financial models to analyse and determine the appropriate level of investment in fire management planning, preparedness and suppression on public land. |
REC104-2233 | 34 - Local knowledge | That communities, public land managers, Water Authorities and Catchment Management Authorities jointly identify and implement local and environmentally sound solutions to improve the availability of water for firefighting through the Municipal Fire Management Planning process. |
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. |
REC104-2327 | 16 - Training and behaviour | That all fire agencies include a formal mentoring scheme as part of their workforce development programs; and that consideration be given to the use of suitably competent and experienced individuals (such as retired staff), to act as coaches or mentors with inexperienced Incident Controllers. |
REC104-2245 | 37 - Funding | That DSE includes the cost of tracks, as above, in the development of financial models to analyse and determine the appropriate level of investment in fire management planning, preparedness and suppression on public land. |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2249 | 16 - Training and behaviour | That DSE and CFA ensure that: |
REC104-2294 | 16 - Training and behaviour | That training and competency programs for Incident Controllers should include aircraft firefighting capability training. |
REC104-2244 | 37 - Funding | That DSE assesses the environmental and monetary cost of establishment and rehabilitation of temporary tracks, per 100 km, constructed during firefighting operations, and compare this with the recurrent costs of a program of maintaining existing tracks. |