Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4320 | 12 - EM agency and authority | Knowledge resources to support flood management: That, to provide more accurate and complete data for flood threat identification, warning and modelling systems, Government through the proposed new NSW Reconstruction Authority (NSWRA) work with the Australian Government to: |
REC324-4309 | 12 - EM agency and authority | SES and RFS back-office merger: That, to help protect life and property across NSW in storm and flood events, and to improve resourcing and NSW State Emergency Service (SES) frontline capability, Government implement, before the next storm season, a merger of the SES and NSW Rural Fire Services (RFS) back-office and corporate service functions, while maintaining their separate legislative identity, brand, uniform and volunteer membership. This ‘joined-up’ RFS/SES corporate support structure would be under the command of the RFS given its corporate and operational maturity and would be responsible for: |
REC324-4316 | 12 - EM agency and authority | Resilience NSW and recovery: That, in order to enhance NSW disaster preparedness, response and recovery, and meet the needs of the people of NSW prior to, during and after a disaster, and provide clarity on agency roles and responsibilities, Resilience NSW be reshaped to ‘Recovery NSW’. The new agency will be more streamlined and agile to drive recovery in the first 100 days post disaster. To achieve this, Resilience NSW’s functions should be reallocated as follows: |
REC324-4318 | 12 - EM agency and authority | Permanent SEOCON: That, to improve NSW’s ability to prepare and respond to floods and other disasters, Government establish a new Deputy Commissioner of NSW Police Force to take on permanently the SEOCON role. This role, in addition to current SEOCON functions, would be responsible for: |
Rec-ID | Code | Recommendation |
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REC302-2403 | 12 - EM agency and authority | Take steps to ensure that both fire commissioners are seeking opportunities to engender a culture in their respective organisations that seeks to attract and foster the volunteer ethos and experience |
REC302-2401 | 12 - EM agency and authority | While the proposal to establish an integrated call and dispatch centre is being implemented, Fire and Rescue NSW should take steps to civilianise ComCen and maintain experienced senior officers from both agencies as supervisors similar to how the NSW Police Force and Ambulance Service of NSW operate |
REC302-2397 | 12 - EM agency and authority | Use the model and system in place at the Ambulance Service of NSW as a benchmark for call taking, dispatch and the provision of situational awareness when deploying resources. This will overcome the lack of a feedback loop in current bushfire operations |
Rec-ID | Code | Recommendation |
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REC291-1239 | 14 - Incident Mgt Teams | The State Government to establish an arrangement to develop a ‘network’ of Western Australian State Government agency personnel who can be called upon for bushfire and emergency incident management capability within Western Australia. The arrangement will be led by the State Emergency Management Committee and modelled on systems used by the Department of Parks and Wildlife. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1241 | 12 - EM agency and authority | The State Emergency Management Committee, in consultation with Western Australian Farmers Federation, the Association of Bush Fire Brigades, the Contractors Association of WA, and the Forest Industries Federation of WA, to establish systems for the voluntary registration of: · farmer firefighting units; · contractor firefighting resources; and · forestry industry brigades. |
REC291-1240 | 14 - Incident Mgt Teams | The Departments of Parks and Wildlife and Fire and Emergency Services to adopt the policy that all bushfire Level 3 Incident Management Teams in the Perth Hills and the South West will be integrated and pre-formed from the start of the 2016/17 fire season with substantial involvement of both the Departments of Parks and Wildlife and Fire and Emergency Services personnel on all teams. |
Rec-ID | Code | Recommendation |
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REC290-1212 | 12 - EM agency and authority | Resourcing models appropriate to local needs, including fire risk and remoteness |
REC290-1208 | 12 - EM agency and authority | A unified and integrated fire sector across the whole fire hazard |
REC290-1217 | 12 - EM agency and authority | IAP formats and processes appropriate to the nature of the emergency response. |
REC290-1216 | 12 - EM agency and authority | Resolve reoccurring issues with systems and processes |
REC290-1214 | 14 - Incident Mgt Teams | Flexible pre‐formed multi‐ agency IMTs |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC277-1164 | 14 - Incident Mgt Teams | Establish multi-agency preformed IMTs: An effective IMT for large and complex fire incidents requires the capacity and expertise of multiple agencies. Establishing multi-agency preformed IMTs will have three main benefits: adequate IMT resources can be deployed with ease • strong working relationships will be built between IMT members • common approaches to incident management and fire response can be embedded. |
Rec-ID | Code | Recommendation |
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REC267-1158 | 28 - Personal responsibility | Farm Management Deposits |
Rec-ID | Code | Recommendation |
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REC265-1104 | 12 - EM agency and authority | DFES should increase and maintain urban interface bushfire skills and expertise. Appointments to senior roles within the agency should include people with experience and credibility in bushfire firefighting and management. |
REC265-1102 | 25 - Inquiry, audit, lessons management and after action review | SEMC Secretariat Community Emergency Management Officers should work with the Shire to document the Shire of Mundaring’s learnings from the Parkerville Stoneville Mt Helena fire with a view to sharing this with other local authorities particularly those facing similar situations in order to extend the range of tools available to assist local governments to understand their roles and responsibilities in future emergencies. |
REC265-1109 | 14 - Incident Mgt Teams | Future appointments to the role of Incident Controller should be limited to one for the entire duration of the incident, with nominated Deputy Incident Controllers to assist or ‘take charge’ in the Incident Controller’s absence. This measure will provide for a single point of responsibility and control for the incident and assist with any subsequent review or enquiry. If it is not possible to implement this proposal for liability reasons, the number of Incident Controllers should nevertheless be reduced to the minimum. |
Rec-ID | Code | Recommendation |
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REC254-1587 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC254-1585 | 14 - Incident Mgt Teams | DFES and Local Government Bushfire Brigades ensure that only those with the required AIIMS competence have the authority to manage Level 1 incidents, noting they may not be Fire Control Officers. |
REC254-1589 | 12 - EM agency and authority | In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC226-0550 | 14 - Incident Mgt Teams | Greater investment in training on specific functions within the AIIMS structure will improve the support provided to the Incident Controller. |
REC226-0574 | 14 - Incident Mgt Teams | Clear direction to divisional and sector commanders and a common communications platform enables maximum return to be gained from the application of tactical resources and this rests on good incident action planning, and good command and control. |
REC226-0557 | 14 - Incident Mgt Teams | An intensive exercise/training program should be developed and maintained across agencies to identify and establish a pool of current Incident Controllers who are capable of managing a Level 3 incident. |
REC226-0587 | 14 - Incident Mgt Teams | To be effective, multi-agency IMTs will need to be exercised regularly and supported by sound and comprehensive doctrine. |
REC226-0565 | 14 - Incident Mgt Teams | Contingency planning is a critical function in the early stages of an escalating incident, and should provide the foundation of an IAP. |
REC226-0573 | 14 - Incident Mgt Teams | Strategic direction seeks to identify and resource those areas of tactical action that offer the greatest advantage. |
REC226-0556 | 14 - Incident Mgt Teams | Within the AIIMS IMT doctrine the roles of the Incident Controller and Deputy Incident Controllers should be defined and well-practiced. |
REC226-0586 | 14 - Incident Mgt Teams | At Level 3, the available fire management expertise should be applied overwhelmingly to the fire management aspects of emergency management, possibly in incident control, and certainly in situations planning and operations roles. |
REC226-0564 | 14 - Incident Mgt Teams | The expected scenario, with a view to the worst-case scenario should provide the basis for an IAP. |
REC226-0572 | 14 - Incident Mgt Teams | Contingency planning before the fire may have supported the IMT in recognising and seizing strategic opportunities earlier. |
REC226-0555 | 14 - Incident Mgt Teams | The state should identify the number of fully trained, experienced and accredited Level 3 Incident Controllers required to be available at any time and establish a process for identification of suitable personnel, ongoing training and accreditation. |
REC226-0585 | 14 - Incident Mgt Teams | DEC’s fire management expertise should be augmented by multi-agency IMTs that incorporate the expertise of other agencies and in fast developing situations the appropriate decisions will need to be made early. |
REC226-0563 | 14 - Incident Mgt Teams | Procedures to relocate IMTs need to be established in doctrine and exercised to ensure continuity of control. |
REC226-0570 | 14 - Incident Mgt Teams | Logistics and resource officers in IMTs need to collaborate and establish full awareness and control over the available resources. |
REC226-0554 | 14 - Incident Mgt Teams | For incidents of this complexity, effective control in the critical phase (first 24-36 hours of the fire) requires an appropriately resourced IMT. |
REC226-0584 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command and not through agency chains of command |
REC226-0562 | 14 - Incident Mgt Teams | Opportunities be sought to utilise local government representatives in other areas of the IMT particularly in public information or other community related functions. |
REC226-0567 | 14 - Incident Mgt Teams | IMTs need to establish early and effective liaison with Local Governments. |
REC226-0551 | 14 - Incident Mgt Teams | As presently implemented, the AIIMS planning role is under-developed and provides insufficient support to the Incident Controller. |
REC226-0575 | 14 - Incident Mgt Teams | In multi-agency responses the culture, training and equipment characteristics of each of the agencies should be considered in their employment. |
REC226-0558 | 14 - Incident Mgt Teams | Predetermined locations for Level 3 IMTs should be reviewed and adequately resourced with necessary communications and IT capacity. |
REC226-0566 | 14 - Incident Mgt Teams | Incident Controllers should be supported by a planning function that combines experienced weather forecasters, fire behaviour experts and local knowledge. |
Rec-ID | Code | Recommendation |
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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. |
REC225-0538 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
Rec-ID | Code | Recommendation |
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REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0520 | 12 - EM agency and authority | The Department of Environment and Conservation review the utility of its current regional model in terms of the capability of operational centres such as Kirup to service major fire activity on land proximate to the rural urban area (this recommendation should also be considered in the context of Recommendation 5). |
Rec-ID | Code | Recommendation |
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REC203-0294 | 14 - Incident Mgt Teams | Opportunities should be sought to embed other local government representatives in other areas of the IMT particularly in public information. |
REC203-0300 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command, and not through agency chain of command. |
REC203-0295 | 12 - EM agency and authority | There would be benefit in progressively aligning the geographic boundaries of each of the agencies and seeking to co-locate their headquarters within those boundaries. |
Rec-ID | Code | Recommendation |
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REC201-0248 | 14 - Incident Mgt Teams | To provide Level 3 IC‘s (and FESA) with a level of confidence and to maintain currency across the pool of accredited IC‘s, regular exercising of IC‘s and Level 3 IMT‘s is required. |
REC201-0258 | 14 - Incident Mgt Teams | FESA should review the size of the existing pre-formed IMT to include additional Information and Planning officers and increased resourcing of scribes and management support for all Level 3 incidents. |
REC201-0247 | 28 - Personal responsibility | Local residents must take a degree of shared responsibility to prepare their properties by reducing the risk of bushfire around their properties and planning for a bushfire emergency. |
REC201-0255 | 14 - Incident Mgt Teams | FESA and DEC need to appoint accredited Level 3 IC‘s based on experience, competency and currency. |
REC201-0254 | 14 - Incident Mgt Teams | FESA should continue to develop with DEC and Local Government a number of rostered pre-formed IMT‘s available throughout the fire season, regardless of predicted weather. |
REC201-0253 | 14 - Incident Mgt Teams | Review the command function of the MROC for Level 3 incidents when the SOC is activated. |
REC201-0251 | 14 - Incident Mgt Teams | All responding crews and the incident command appointments should adopt a ‘Size Up‘ reporting format. |
Rec-ID | Code | Recommendation |
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REC200-0383 | 12 - EM agency and authority | The State Government restructure the Fire and Emergency Services Authority as a Department. 22 As part of this restructure, Emergency Management Western Australia should either be: 1. clearly separated from the fire and emergency services response function (see figure 2); or 2. moved to the Department of the Premier and Cabinet (see figures 3 and 4) or 3. moved to the Attorney-General’s department (see figures 3 and 5). |
REC200-0366 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0361 | 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. |
REC200-0391 | 14 - Incident Mgt Teams | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. This should include provision for a formal review of the performance of individual Level 3 Incident Controllers after every incident. |
REC200-1706 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-0389 | 12 - EM agency and authority | The Fire and Emergency Services Authority and local governments ensure that Community Emergency Service Managers are physically based in local government. |
REC200-1701 | 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. |
REC200-0384 | 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. |
Rec-ID | Code | Recommendation |
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REC183-0106 | 12 - EM agency and authority | The DEC corporate statement should affirm a strong commitment to fire management. |
REC183-0113 | 14 - Incident Mgt Teams | A summary Incident Action Plan could allow the Incident Controller to more quickly appreciate the situation and articulate a plan early in an incident. |
REC183-0114 | 14 - Incident Mgt Teams | Higher level DEC guidance to Level 3 Incident Controllers could be improved by introducing a more explicit and robust process of questioning, engagement, monitoring and oversight of Level 3 Incident Controllers. |
REC183-0112 | 14 - Incident Mgt Teams | DEC’s incident management capability could be enhanced by: – Appointing a Deputy Incident Controller for every Level 3 IMT. – Establishing a fast response “short” IMT capability for each Level 3 IMT. – Establish clear triggers to initiate sending in a “short” IMT to a fire. – Including FESA officers in pre-formed Level 3 IMT’s. – Establishing additional pre-formed Level 3 IMT’s with FESA. – Where appropriate, appointing a local Bush Fire Brigade officer as Deputy Operations Officer. |
REC183-0121 | 12 - EM agency and authority | A DEC fire management staff succession plan would minimise the loss of core fire management skills and experience in the future and provide a planned approach to development of prospective fire management staff. |
REC183-0111 | 14 - Incident Mgt Teams | Conducting a pre-fire season exercise for each Pre-Formed Incident Management Team could be used to “re-accrediting” each team on an annual basis. |
Rec-ID | Code | Recommendation |
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REC182-0131 | 14 - Incident Mgt Teams | FESA establishes a dedicated intelligence function in Incident Management Teams for major bushfires and ensure this function is appropriately supported with threat based tools and systems. |
REC182-0130 | 12 - EM agency and authority | FESA identifies and documents its information requirements for end-to-end information exchange and then assess the adequacy of current systems to meet these information requirements. |
REC182-0128 | 12 - EM agency and authority | FESA establishes a process (and associated systems and policies) to mobilise staff to an incident, incorporating pre-formed multi-agency Incident Management Teams. The development of Incident Management Teams should align with the principles of seamless and integrated escalation of command and control arrangements, and be based on a whole of capability approach (people, organisations, systems, training, procedures etc.). |
Rec-ID | Code | Recommendation |
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REC173-0105 | 19 - Offences | That the Department of the Attorney General, in consultation with FESA and Western Australia Police (WAPOL), consider options for legislative amendments to extend criminal liability to all damage, injury or death directly caused by arson. |
Rec-ID | Code | Recommendation |
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REC172-0020 | 12 - EM agency and authority | The role of ‘BFB Task Force Liaison’ be defined and appropriately trained personnel be provided by the HMA (possibly from support brigades) to facilitate brigade movements on and off the fire ground. |
REC172-0005 | 14 - Incident Mgt Teams | Potential IMG membership should be identified in local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA. |
REC172-0010 | 14 - Incident Mgt Teams | The responsibilities and obligations for an OAM and OAMG (when established) needs to clarified and codified in Westplan Bushfire with regard to • Provision of information to participating organisations about the progress and potential of an incident; • Dealing with information disseminated to the public; and • Sourcing, coordinating and prioritising resources required by incidents within the Operations Area. There is lack of clarity in current arrangements concerning the role of the agency undertaking control operations e.g. DEC or a local govt and the transfer of these responsibilities to an OAMG when established. |
REC172-0004 | 14 - Incident Mgt Teams | A formal IMG meeting should be convened as early as possible at initiating incidents with potential. At the very least early advice to potential IMG members should be made that a meeting is likely to be convened. The initial IMG should include all IMG representatives to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0009 | 14 - Incident Mgt Teams | When an OAMG is established, a formal declaration of its establishment needs to be transmitted to all organisation/agencies involved. The declaration should clearly establish the reporting arrangements for Incident Controllers to the OAM as described in Westplan Bushfire. |
REC172-0008 | 14 - Incident Mgt Teams | Potential OAMG membership should be identified in DEMC protocols and local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA.] |
REC172-0035 | 14 - Incident Mgt Teams | At Level 3 incidents the Information Services Unit should be adequately resourced with information technology and at least 6 persons, all of whom are very experienced and capable in dealing with the information demands of a Level 3 incident. |
REC172-0007 | 14 - Incident Mgt Teams | A formal OAMG meeting should be convened as early as possible for incidents with the potential to be Level 3 incidents. At the very least early advice to potential OAMG members should be made on days that exhibit extreme fire weather and other high ignition risk factors that a meeting is likely to be convened. The initial OAMG should include all OAMG representatives identified by LEMAC and DEMAC for each area to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0024 | 12 - EM agency and authority | Transport plans for BFB resources should be prepared by the Ground Support Unit in close liaison with FESA who will liaise with the home jurisdictions of the brigades. Moving personnel whilst leaving the equipment at the fire ground staging areas is preferred to moving equipment in and out with every shift. |
REC172-0006 | 14 - Incident Mgt Teams | Prior to the bushfire season, potential IMG members, many of whom are members of the Local Emergency Management Committee (LEMC) should be made aware of, and possibly exercise, their role as an IMG member. |
Rec-ID | Code | Recommendation |
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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 |
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REC163-1935 | 19 - Offences | The prescribed penalty notice penalty amount for section 99(6) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1941 | 19 - Offences | A working group be established to consider methods of preventing criminal firestarting. |
REC163-1934 | 19 - Offences | The prescribed penalty notice penalty amount for section 100(2) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1940 | 19 - Offences | That legislation be prepared by the Criminal Law Review Division of the Attorney General’s Department allowing designated officers of the Rural Fire Service to apply for a warrant in certain circumstances. |
REC163-1938 | 12 - EM agency and authority | That appropriate officers of the Rural Fire Service be granted the same powers as granted to officers of NSW Fire Brigades under section 19 of the Fire Brigades Act 1989. |
REC163-1937 | 19 - Offences | That the Attorney General’s Department’s Crime Prevention Division consider the causes of, and any solution to, the high number of juveniles involved in causing bushfires. |
REC163-1936 | 19 - Offences | The prescribed penalty notice penalty amount for section 66(7) of the Rural Fires Act 1997 be increased to $1,100. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3768 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3765 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3758 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3713 | 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. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3757 | 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. |
REC121-3693 | 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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3753 | 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. |