Inquiry Search
Rec-ID | Code | Recommendation |
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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: |
REC318-4171 | 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: |
Rec-ID | Code | Recommendation |
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REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
Rec-ID | Code | Recommendation |
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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. |
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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REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
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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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 |
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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 |
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REC196-0233 | 16 - Training and behaviour | Further train Incident Controllers in the management of the Information Section and its roles. |
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 |
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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. |
REC195-0335 | 10 - Infrastructure | Energy Safe Victoria ensures that the standards for vegetation clearance around power lines consider the impact of fire on electrical infrastructure and the risk of loss of electricity supply to the community. |
Rec-ID | Code | Recommendation |
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REC181-0180 | 10 - Infrastructure | The State amend the regulatory framework for electricity safety to require that distribution businesses adopt, as part of their management plans, measures to reduce the risks posed by hazard trees—that is, trees that are outside the clearance zone but that could come into contact with an electric power line having regard to foreseeable local conditions. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
REC181-0170 | 17 - Assets and technology | The Country Fire Authority and the Department of Sustainability and Environment amend their policies on aerial preparedness and standby arrangements, their dispatch protocols and the management of aircraft in order to do the following: ■ require that at locations that attract the risk assessment or preparedness level A on code red days all personnel needed for air operations must be on standby by 10.00 am; ■ establish a system that enables the dispatch of aircraft to fires in high-risk areas without requiring a request from an Incident Controller or the State Duty Officer. |
REC181-0179 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to review and modify their current practices, standards and procedures for the training and auditing of asset inspectors to ensure that registered training organisations provide adequate theoretical and practical training for asset inspectors. |
REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
REC181-0178 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to change their asset inspection standards and procedures to require that all SWER lines and all 22-kilovolt feeders in areas of high bushfire risk are inspected at least every three years. |
REC181-0184 | 10 - Infrastructure | The State amend the regulatory framework for electricity safety to strengthen Energy Safe Victoria’s mandate in relation to the prevention and mitigation of electricity-caused bushfires and to require it to fulfil that mandate. |
REC181-0177 | 10 - Infrastructure | The State amend the Regulations under Victoria’s Electricity Safety Act 1998 and otherwise take such steps as may be required to give effect to the following: ■ the progressive replacement of all SWER (single-wire earth return) power lines in Victoria with aerial bundled cable, underground cabling or other technology that delivers greatly reduced bushfire risk. The replacement program should be completed in the areas of highest bushfire risk within 10 years and should continue in areas of lower bushfire risk as the lines reach the end of their engineering lives; ■ the progressive replacement of all 22-kilovolt distribution feeders with aerial bundled cable, underground cabling or other technology that delivers greatly reduced bushfire risk as the feeders reach the end of their engineering lives. Priority should be given to distribution feeders in the areas of highest bushfire risk. |
REC181-0183 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to do the following: ■ fit spreaders to any lines with a history of clashing or the potential to do so; ■ fit or retrofit all spans that are more than 300 metres long with vibration dampers as soon as is reasonably practicable. |
REC181-0175 | 16 - Training and behaviour | The Country Fire Authority and the Department of Sustainability and Environment require without exception that all relevant staff be trained in the need for Incident Controller approval to be obtained before a back-burn is lit. |
REC181-0182 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to do the following: ■ disable the reclose function on the automatic circuit reclosers on all SWER lines for the six weeks of greatest risk in every fire season; ■ adjust the reclose function on the automatic circuit reclosers on all 22-kilovolt feeders on all total fire ban days to permit only one reclose attempt before lockout. |
REC181-0171 | 17 - Assets and technology | The State, in conjunction with Emergency Management Australia and the Department of Defence, develop an agreement that allows Commonwealth aerial resources that are suitable for firefighting and support activities to be incorporated in preparedness plans and used on days of high fire risk. |
Rec-ID | Code | Recommendation |
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REC158-3430 | 17 - Assets and technology | That the nominated marine safety authority is responsible for development of a declared asset system and is required to ensure that port/channel managers utilise and maintain the declared asset system. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3432 | 17 - Assets and technology | That port/channel managers are required to ensure, through service agreements, licensing, direct acquisition or other means as appropriate, the availability of the critical Level 1declared assets. |
REC158-3431 | 17 - Assets and technology | That port/channel managers are required to identify in the declared asset system (in conjunction with the emergency services) critical Level 1 declared assets and other Level 2 declared assets, that may be required in support of a marine emergency within the port, and that identified resource availability, accessibility and call out time is recorded. |
Rec-ID | Code | Recommendation |
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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. |
REC156-3494 | 10 - Infrastructure | Energy Safe Victoria finalise the development of the passport system to improve interstate mutual aid arrangements allowing operator access to qualified interstate power restoration personnel. |
REC156-3487 | 10 - Infrastructure | Electricity distribution businesses develop and implement alternative arrangements for monitoring fallen powerlines. |
REC156-3500 | 10 - Infrastructure | The Emergency Services Telecommunications Authority, in partnership with Telstra, consider technological solutions to streamline the handover process for Triple Zero calls. |
Rec-ID | Code | Recommendation |
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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 |
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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 |
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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. |
REC104-2197 | 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. |
REC104-2294 | 16 - Training and behaviour | That training and competency programs for Incident Controllers should include aircraft firefighting capability training. |
REC104-2259 | 16 - Training and behaviour | That the MFESB continue to give priority to appropriate bushfire training for its firefighters. |
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. |
REC104-2293 | 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. |
REC104-2249 | 16 - Training and behaviour | That DSE and CFA ensure that: |
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. |
REC104-2292 | 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. |
REC104-2235 | 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. |
REC104-2333 | 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. |
REC104-2264 | 16 - Training and behaviour | That CFA and DSE provide media training to all Level 2 and Level 3 Incident Controllers. |
REC104-2286 | 17 - Assets and technology | That CFA, having regard to terrain, continue to review the mix of firefighting appliances currently in service. In particular, consideration should be given to the number and distribution of smaller ‘slip-on’ type equipment. |
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. |
REC104-2332 | 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 |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2223 | 10 - Infrastructure | That Government review legislation for utilities operating within the State to ensure their involvement in regional fire preparedness and mitigation planning. |
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. |
REC104-2260 | 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. |
Rec-ID | Code | Recommendation |
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REC016_3944 | 10 - Infrastructure | It is recommended that the water pressure be improved so that a greater volume and jet may be available for the suppression of fires on the faces and also for the purpose of wetting the berms more widely and thoroughly when necessary. It is suggested that there should be variable control of the pressure so that production need not be adversely affected in times of normal danger. |
REC016_3943 | 10 - Infrastructure | It is recommended that a more constant, running revision of the main and sprinkler system be maintained in future so that the service which it is intended to convey shall be closely and efficiently available to all parts of the berms and faces. It is emphasized that the reticulation system in the berms is fixed and stationary, whereas the faces are continually receding as their surfaces are scraped away by the dredges. |
REC016_3951 | 10 - Infrastructure | It is recommended that the State Electricity Commission adopt a policy of conciliation and good will towards its closer neighbours. It is not suggested that its policy has been essentially otherwise. In future that policy can best be assured of success by time conferring of material benefit upon its neighbours at some monetary cost to the Commission. It is suggested, with conviction, that it would prove to be of great advantage to time Commission if it were to take an active part in the clearing and bettering of its neighbours’ scrub and timber country at time cost of the Commission. The settler whose land is fully cleared and in production, or who knows that his land will be cleared for him, has no incentive to burn illegally or carelessly. If this suggestion should he adopted, it would be necessary that it should be carried out in all cases in accordance with the settler’s convenience, that he himself should take an active part in the operations, and that he should be left, not with a financial obligation, but with a definite material advantage. |
REC016_3949 | 17 - Assets and technology | It is recommended that the A.R.P. dams or earth tanks be kept filled during possible danger periods. |
REC016_3948 | 16 - Training and behaviour | It is recommended that workers and volunteers generally be instructed in accordance with a pre-arranged plan, as to what they should do in future times of emergency. Since the fighting of fires is for the greater part a matter of voluntary action, some estimate could perhaps be made, after investigation, of the numbers of men in each department who would be willing to volunteer. It would be necessary that each department should become a component part of an over-riding scheme and that it and its members should be fully instructed in the matter of whistle or siren warnings, places of assembly, reception of messages from the director of proceedings, use of equipment, and the various details which would necessarily be parts of an effective scheme. The training need not be onerous. If given once or twice at the beginning of possible danger periods, it would make for some degree of order and efficiency instead of a probable state of confusion. |
REC016_3945 | 16 - Training and behaviour | It is recommended that a large proportion of men employed in and about the open-cut be systematically trained in the use of equipment and in the tactical disposition of it. |
Rec-ID | Code | Recommendation |
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REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |
REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
Rec-ID | Code | Recommendation |
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REC004-3992 | 17 - Assets and technology | That the use of a spark-arrester and cinder-arrester by the Railway Department shall not constitute a defence to an action for damage caused by fire escaping from a locomotive, unless the Department proves that such spark-arrester and cinder-arrester were in a thoroughly efficient condition when the fire took place. |
REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |
REC004-3996 | 17 - Assets and technology | That the standard pattern of cinder arrester be affixed to the ash-pans in all locomotives during the summer months. |
REC004-3994 | 17 - Assets and technology | That the Railway Department, while gradually reducing the number of different types of locomotives, should steadily keep in view the adoption of English and American railway practice, by providing engines with larger boilers, fire boxers, and smoke-boxes, and with wide blast-pipes, in order to insure ample steaming power with a minimum of forced draught. |