Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC292-2370 | 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. |
REC292-2366 | 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. |
REC292-2358 | 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. |
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. |
REC260-1063 | 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. |
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. |
REC260-1060 | 7 - Inter-agency communication | That the Rural Fire Service and National Parks and Wildlife Service review the procedures for requesting aerial support in ‘severe’ or worse fire conditions to ensure that delays in providing it are reduced to the minimum time possible. |
REC260-1071 | 4 - Fire season preparation | The NPWS to consider developing a land management policy that requires hazard reduction around identified assets within the Park and the clearing of fire trials within the Park before the bush fire season commences. Consideration should also be given to developing additional fire trails in the Park, bearing in mind the lack of available fire trails to the south of the John Renshaw Parkway in the park. |
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. |
REC260-1070 | 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. |
Rec-ID | Code | Recommendation |
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REC227-2849 | 20 - Role of police | I recommend that the AFP takes steps to ensure that there are on Christmas Island at all times appropriately trained AFP officers who have completed the National Police Search and Rescue Manager’s Course and that upskilling should be ongoing to establish a cadre of trained search and rescue personnel. |
Rec-ID | Code | Recommendation |
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REC166-3008 | 1 - Land-use and building regs | That any building fitted with heat-activated closing devices or fire and smoke doors be assessed to establish if it constitutes a fire hazard under section 165 of the Building Act 2000 and that, where appropriate, such doors be replaced with smoke activated doors. |
REC166-3006 | 20 - Role of police | That the recommendations contained in the Police Operational Debrief Report of 22 October 2007 to 7 November 2007, submitted to the Coroner, be further considered by the Tasmania Police for adoption where considered appropriate by Tasmania Police. |
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: |
REC166-2999 | 35 - Business and Industry in relation to industry | That Aurora ensure that regular audits are conducted of all electrical systems of all commercial buildings to confirm that they comply with modern standards. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC153-1779 | 4 - Fire season preparation | That the South Australian Farmers’ Federation encourage its members and constituents to keep and maintain on rural land in proper working order machinery that is capable of removing, modifying or reducing cropping stubble at short notice in order to minimise or mitigate bushfire risk. |
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. |
REC153-1777 | 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. |
REC153-1795 | 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. |
REC153-1806 | 40 - Equipment and consumables | That the Minister for Emergency Services and the Minister for Local Government cause local council plant and equipment that is suitable for use in bushfire fighting be fitted with radios connected to the Government Radio Network. |
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. |
REC153-1804 | 35 - Business and Industry in relation to industry | That the Chief Officer and the Editors of all newspapers and other media outlets develop a Memorandum of Understanding that ensures that all CFS press releases concerning total fire ban days and ongoing bushfire incidents are published in full. |
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. |
Rec-ID | Code | Recommendation |
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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 |
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REC126-1951 | 4 - Fire season preparation | That before each fire season the Emergency Services Agency, in conjunction with the Bush Fire Council – after consultation with the relevant ACT agencies, the Bureau of Meteorology, relevant NSW agencies and the community – conduct a qualitative risk analysis of the conditions and circumstances prevailing and forecast and develop strategies to ensure heightened preparedness during seasons identified as severe |
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 |
REC126-1961 | 7 - Inter-agency communication | That the Emergency Services Agency review the communications systems used by the four services (the ACT Ambulance Service, the ACT Rural Fire Service, the ACT State Emergency Service and the ACT Fire Brigade), by the Australian Federal Police, by NSW emergency services and by aircraft and ensure the systems are compatible |
REC126-2000 | 1 - Land-use and building regs | That the ACT Government consider taking measures to implement the provisions of Australian Standard 3959, Construction of Buildings in Bushfire Prone Areas, for the ACT urban area |
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 |
REC126-1950 | 39 - Disaster Risk Management | That the Emergency Services Agency adopt a more rigorous risk management approach to incident management and prediction – with particular emphasis on the development of improved community information strategies and protocols |
REC126-1977 | 4 - Fire season preparation | That a program be implemented to ensure that existing fire tracks and trails are cleared and accessible at all times and that a network of additional fire trails be established so as to allow direct fire suppression operations without undue delay in the event of a wildfire |
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 |
REC126-1988 | 39 - Disaster Risk Management | That protocols and arrangements between the ACT and NSW require that each jurisdiction be fully involved in examining and planning for the threat posed by any fire likely to affect one or other jurisdiction and in coordinating the response to that fire |
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 |
REC126-1970 | 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 |
REC126-1947 | 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 |
REC126-1975 | 5 - Hazard reduction burns | That prescribed burning operations be conducted according to agreed standard burning prescriptions |
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 |
REC126-1987 | 7 - Inter-agency communication | That measures be taken to ensure that ACT and NSW Rural Fire Service radio communications systems are integrated, so that ACT and NSW firefighting units can communicate with each other |
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 |
REC126-1969 | 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 |
REC126-1974 | 4 - Fire season preparation | That responsibility for fuel management lie with the land management agency that controls the area and that land managers be given authority to implement prescribed fuel-reduction burns within their area |
REC126-1955 | 16 - Training and behaviour | That training of all personnel involved with emergency services be under constant review |
REC126-1986 | 39 - Disaster Risk Management | That the ACT and NSW authorities conduct a comprehensive risk analysis based on the most up to date knowledge relating to fire behaviour and spread in order to establish the degree of risk to each others' jurisdiction from fires ignitting in the other jurisdiction and to ensure that both jurisdictions remain fully informed and participate in risk assessments, the development of suppression strategies, and the development and dissemination of community information messages or warnings |
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. |
REC126-1968 | 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 |
REC126-1973 | 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 |
REC126-1952 | 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 |
REC126-1983 | 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 |
REC126-1967 | 40 - Equipment and consumables | That the Emergency Services Agency give priority to ensuring it has guaranteed access to an adequate number and type of bulldozers, as well as experienced operators, during the fire season, for immediate deployment as required |
REC126-2002 | 1 - Land-use and building regs | That consideration be given when building to the positioning of outbuildings around residential structures such that their potential impact on the main structure is reduced |
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 |