Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4295 | 11 - Evacuation and shelters | Roads: That, to improve the planning and protection of road infrastructure and to ensure communities, freight movers, combat agencies and emergency services have appropriate access and egress during and following a flood event, Government, through TfNSW and NSWRA and working with combat agencies and local and federal governments as needed, should: |
REC324-4307 | 9 - Community education | Flood education: That, to build disaster resilience in future generations as floods and other natural disasters are a fact of Australian life, the Department of Education should design, implement and deliver an evidence-based, targeted education campaign (like sun exposure) in schools (new disaster curriculum). |
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: |
Rec-ID | Code | Recommendation |
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REC302-2399 | 24 - Govt responsibility | Implement a fully integrated civilianised single call and dispatch centre, that includes a redundancy option outside the Sydney CBD, which will adopt an agnostic approach to deploy the quickest most suitable resource to an emergency. Such a centre should be managed by either a non uniformed public servant staffed organisation like the Office for Emergency Management, or the NSW Police Force |
Rec-ID | Code | Recommendation |
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REC292-2377 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth Attorney-General liaise with ASIO to develop a policy to ensure that where correspondence is received by a government agency, minister or public office holder, from a non government entity, and that correspondence is relevant to the security assessments of the author, the correspondence be referred to: ASIO; and a Fixated Threat Assessment Centre. |
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. |
REC292-2381 | 21 - Role of Commonwealth Government | I recommend that ASIO liaise with the Fixated Threat Assessment Centre with a view to both agencies cooperating in the identification, assessment and management of fixated, radicalised individuals. |
REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
REC292-2380 | 24 - Govt responsibility | I recommend that the New South Wales Police Force, in conjunction with NSW Health, establish a Fixated Threat Assessment Centre to identify and gather information about fixated persons, assess the risks they pose, and attempt to mitigate such risks through early intervention. |
REC292-2379 | 24 - Govt responsibility | I recommend that the Premier of New South Wales consider whether the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002 should be amended to ensure that there is appropriate access to health related information available to ASIO (consistent with recommendation 12 of the report of the Martin Place Siege Joint Commonwealth—New South Wales review) |
REC292-2378 | 21 - Role of Commonwealth Government | I recommend that: the Commonwealth Attorney-General and ASIO confer with the Australian Psychological Society regarding the restrictions in clause A 5 2 of the Code of Ethics (2007) with respect to radicalisation, terrorism and politically motivated violence; and the Australian Psychological Society consider amending clause A 5 2 of the Code of Ethics (2007) to enable psychologists to report risks of a terrorist nature. |
Rec-ID | Code | Recommendation |
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REC260-1058 | 28 - Personal responsibility | That NPWS and the RFS consider developing a land management policy that requires active engagement with property owners adjoining the Park to ensure that hazard reduction and asset protection is encouraged and undertaken before the bush fire season commences |
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. |
Rec-ID | Code | Recommendation |
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REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
REC237-0828 | 9 - Community education | That the NSW Rural Fire Service develop a strategy to better inform the community and NSW Rural Fire Service members about the NSW bush fire management system and its components. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC164-0074 | 9 - Community education | SERCon consider a review of existing community-based educational programs, with a view to informing the community |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC126-2005 | 9 - Community education | That community education programs include unambiguous information that at times of unusually high water demand there might be a drop in or loss of water pressure and it might be appropriate for residents who intend to remain and fight a fire to have auxilary water pumps or booster pumps |
REC126-1984 | 24 - Govt responsibility | That the Emergency Services Agency, with the support of the ACT Government, develop a single, new memorandum of understanding with the NSW Department of Environment and Conservation and the NSW Rural Fire Service, providing for liaison and joint operations as soon as it becomes apparent to whichever jurisdiction is managing a fire that the fire will probably affect the other jurisdiction. Joint operations should not be limited to when an incident occurs on both sides of the border, as is the current arrangement |
REC126-2010 | 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 |
REC126-1993 | 9 - Community education | That consulations and negotiations occur between the Emergncy Services Agency and the NSW Rural Fire Service to ensure that fire risk and safety messages to the community are coordinated. Maximum use should be made of television and radio announcements throughout the ACT and southern NSW, consistent with NSW timetables for targeted programs in conjunction with the United Firefighters Union ACT Branch and volunteer fire brigade representative. The Emergency Services Agency should consider using ACT Fire Brigade staff and ACT Rural Fire Service volunteers to talk to groups in the community on request, thus furthering face-to-face community education in high-risk suburban areas of the ACT |
REC126-1948 | 24 - Govt responsibility | That the Emergency Services Agency be removed from the Department of Justice and Community Safety and transformed into an independent statutory authority reporting directly to the responsible Minister. Note in this regard that Mr McLeod made a similar recommendation, and I endorse it unequivocally. Placing the agency within a government department puts unnecessary layers of bureaucracy between the agency and the responsible Minister, and the bureaucrats concerned usually have no special knowledge of or experience in emergency management, regardless of their seniority in the bureaucracy |
REC126-2004 | 35 - Business and Industry in relation to industry | That the ACT Government and ActewAGL jointly develop and implement protocols that will create a procedure whereby each of the water and sewerage, electricity and gas distribution networks, or parts thereof, can safely and promptly be manipulated, controlled, shut off, isolated or disconnected under emergency conditions. |
REC126-1979 | 24 - Govt responsibility | That the policy and practice just recommended be the subject of a memorandum of understanding between the Emergency Services Agency and the Department of Territory and Municipal Services (previously the Department of Urban Services) or other relevant department or agency, so as to ensure that the land management agency on whose land a fire starts has responsibility to respond immediately to that fire in accordance with the applicable standards for weight of response. Further, the land management agency should be responsible for efforts to suppress fire until such time as it becomes clear that the suppression task is beyond capacity of the agency, at which point the ACT Rural Fire Service should assume direct responsibility for coordinating the ongoing response |
REC126-2009 | 24 - Govt responsibility | That a taskforce be established to give effect to the recommendations in this report |
REC126-1992 | 9 - Community education | That implementation of the Bushfire Wise Program continue and include a letterbox drop of the updated Bushfire Information Booklet |
REC126-1947 | 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 |
REC126-2003 | 9 - Community education | That the community be made aware of the risk presented by heavy loads of garden fuels and certain types of vegetation around their houses and take active, regular measures to reduce that risk |
REC126-1976 | 24 - Govt responsibility | That the Emergency Services Agency have authority over the land management agencies and other landholders in order to implement preparedness and prevention measures – including fuel-reduction works where there are failures in compliance |
REC126-2008 | 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 |
REC126-1991 | 9 - Community education | That the Emergency Services Agency establish annual targets for the introduction of community education programs and provide resources to conduct regular independent assessments of the level of community preparedness engendered as a result of the programs |
REC126-1942 | 24 - Govt responsibility | That the ACT Attorney-General and the ACT Government - in consulation with the Chief Justice of the ACT and the ACT Chief Magistrate - take legislative action that would have the effect of funds being directly appropriated annually to the courts, preferable along the lines of the Commonwealth model as it applies to the High Court of Australia, the Federal Court of Australia, the Family Court of Australia and the Federal Magistrates Court. Alternatively, the funds could be appropriated in accordance with the South Australian model, which has a seperate Courts Administartion Authority. |
REC126-2001 | 9 - Community education | That community education programs provide information about fire behaviour, urban design principles that contribute to a specific level of risk, and the benefits of fitting basic ember protection materials in areas at risk from bushfire |
REC126-1970 | 35 - Business and Industry in relation to industry | That the Emergency Services Agency reconsider and revise the arrangement that exists between the ACT Fire Brigade and Canberra airport in relation to the provision of assistance |
REC126-2007 | 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 |
REC126-1990 | 9 - Community education | That the Emergency Services Agency take measures to ensure that the community regularly receives up-to-date information on the risks of bushfires |
REC126-2012 | 24 - Govt responsibility | If they are willing and available to participate, that the taskforce's membership include Mr Phil Cheney, Mr Tony Bartlett, Mr Val Jeffery and Mr John Lowe |
REC126-1999 | 9 - Community education | That the Canberra Urban Development Working Group referred to in Mr Peter Dunn's letter consider the report prepared by Mr Leonard and note particularly that the community awareness information currently available to householders in connection with measures they can take to better protect their homes from bushfires does not refer to the potential of wooden fences, conifers and outbuildings to contribute greatly to fire spread, particularly in suburban areas. Also noteworthy is Mr Leonard's evidence that the linear sitting of homes on house blocks in Canberra seems to be an important factor contributing to house-to-house fire spread and that this should be avoided in future developments on the urban fringe |
REC126-1962 | 24 - Govt responsibility | That, because of the small jurisdiction of the ACT (equivalent to one fire district in NSW) the ACT Government consider all possible options for the provision of fire services to the ACT, among them: |
REC126-2006 | 24 - Govt responsibility | I recommend that, as appropriate, the ACT cooperate with the Commonwealth in the implementation of the committee's recommendations and, in particular, give careful consideration to adoption of the following recommendations: |
REC126-1985 | 24 - Govt responsibility | That the Emergency Services Agency, with the suport of the ACT Government, seek to establish with the NSW Department of Environment and Conservation and the NSW Rural Fire Service a protocol that will provide for the establishment of a joint incident management team as part of unified control arrangements based on adoption of the following principles: |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |
REC126-1996 | 9 - Community education | That the Emergency Services Agency develop a clear policy for disseminating information to the public and the media in times of emergency and that, as required, that policy incorporate advance door-knocking of homes in the area affected, as well as regular broadcasts by local radio and television stations and regular updates on the relevant website - be that Canberra Connect or a different ACT government website - as well as the Emergency Services Agency's website |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
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. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3742 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3753 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
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. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3691 | 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. |
REC121-3726 | 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. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |