Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4302 | 32 - Doctrine, standards, and reform | Disaster adaptation plans for all towns: That, to establish realistic expectations of safe spaces to live and deliver much needed housing quickly, Government through NSWRA working with local government: |
REC324-4315 | 36 - Volunteers | The Community First Responders Program: That, to better coordinate community efforts to save life and property during a disaster, Government create a ‘Community First Responders Program’, funding appropriate community equipment and training, particularly in high-risk catchments along the east coast of NSW. This training would be delivered by combat and/or other appropriate government agencies. This program could support and empower community led initiatives such as disaster response, evacuation centres and the provision of services such as psychological first aid. |
REC324-4317 | 32 - Doctrine, standards, and reform | Flood rescue capability: That, to help improve the protection of life across NSW in flood events: |
REC324-4294 | 34 - Local knowledge | Environment: That, to maximise protection for the environment in and around floodplains, Government, working with local communities especially Indigenous communities, the NSWRA, other agencies and local councils ensure Indigenous voices are well heard in land use planning and natural resource management by: |
REC324-4301 | 32 - Doctrine, standards, and reform | Floodplains as assets: That, to establish the capacity and maximise the economic, social and environmental potential and consequently unlock the value of NSW floodplains, Government adopt the following guiding principles for floodplain management: |
Rec-ID | Code | Recommendation |
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REC323-4265 | 34 - Local knowledge | That the NSW Government work with First Nations peoples to support Aboriginal organisations in their capacity to operate and respond in times of natural disasters. |
REC323-4275 | 34 - Local knowledge | That the NSW Government, in partnership with community groups, including First Nations groups, develop initiatives to build community resilience, particularly in regions at high risk of future natural disaster events. |
REC323-4276 | 34 - Local knowledge | That the NSW Government ensure that community groups, both existing and emerging, including First Nations groups, are well integrated into disaster recovery, by incorporating them into state recovery plans and engaging with them in between and in the lead up to natural disasters. |
REC323-4282 | 16 - Training and behaviour | That the NSW Government invest in the required personnel, training and vessels to ensure that all agencies involved in flood rescue can be mobilised to their fullest potential. |
REC323-4287 | 34 - Local knowledge | That the NSW State Emergency Service, in partnership with the Bureau of Meteorology, investigate ways in which local communities and local media with local knowledge can play a stronger role in flood predictions and warnings. |
REC323-4264 | 34 - Local knowledge | That the NSW Government work in partnership with key Aboriginal stakeholders, including the Jali Local Aboriginal Land Council, to prioritise the rebuild of Cabbage Tree Island, and ensure a safe and resourced evacuation plan is in place. |
Rec-ID | Code | Recommendation |
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REC314-3259 | 32 - Doctrine, standards, and reform | Implement previous review recommendations for bushfire management including those relating to the 2009 amendments to the Fire and Emergency Services Act 2005, State Bushfire Coordination Committee operation, State Bushfire Management Plan, as well as urgent completion of Codes of Practice for fuel hazard reduction on all land tenures, and redevelopment of Bushfire Management Area Plans accompanied by effective community engagement to build an understanding of risk. |
REC314-3269 | 32 - Doctrine, standards, and reform | Develop and practice procedures for the CFS, DEW and local governments to access and deploy heavy plant and machinery for fuel reduction operations both before and during bushfires. |
REC314-3267 | 16 - Training and behaviour | Invest in fireground leadership and incident management training for CFS, SES and MFS personnel to improve safety on the fireground. Invest in greater technological interoperability such as AVL, Thermal Imagery, Burnover Protection Systems (BOPS), lightning tracking and appropriate vehicle fleets for bushfire conditions including at the peri-urban interface. |
REC314-3260 | 32 - Doctrine, standards, and reform | Align risk assessment tools and processes to Risk Management Standard ISO 31000 and the National Emergency Risk Assessment Guidelines (NERAG) and communicate these on public-facing platforms. Make Bushfire Management Area Plans (BMAP) accountable for managing and reporting on region-specific risk and identifying critical infrastructure such as mobile phone towers as key risks. |
Rec-ID | Code | Recommendation |
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REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
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REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1293 | 13 - Mapping and data quality | That the Flood Reform Task Group identify an appropriate mechanism for stakeholder agencies (including the State Emergency Service, Department of Environment and Natural Resources, Bureau of Meteorology and SA Water, as a minimum) to share data and information and develop plans and strategies for management of water levels in reservoirs and spill management during floods in South Australian water catchments |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1333 | 32 - Doctrine, standards, and reform | Develop a State Relief and Recovery Plan as a distinct part of the State Emergency Management Plan which should include: a) potential locations for suitable facilities for relief and recovery centres which: are in locations safe from hazards such as flooding and bushfire; and, have appropriate access and suitable ablutions. b) formalisation of roles and capabilities of non-government organisations such as Red Cross |
REC295-1282 | 32 - Doctrine, standards, and reform | That the Office for Digital Government, in close partnership with telecommunications companies (e.g. Telstra, Optus, Vodaphone), develop a Control Agency Plan for Information and Communication Technology including mobile communications. The plan should consider: |
REC295-1314 | 32 - Doctrine, standards, and reform | That an Emergency Management Assurance Framework be established as soon as possible to support the emergency management arrangements and the State Emergency Management Plan. Consider establishing an Inspector General Emergency Management department or position. |
REC295-1292 | 32 - Doctrine, standards, and reform | That, giving consideration to the previous recommendation, the Flood |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1301 | 32 - Doctrine, standards, and reform | Establish an ‘Interstate Deployment Support Plan’ for incoming interstate resources. The plan should outline responsibilities and arrangements for this function. Consider including this plan into the State emergency management arrangements. |
REC295-1332 | 32 - Doctrine, standards, and reform | Develop a Disaster Waste Management Plan to form part of the State Emergency Management Plan which describe participating agencies and responsibilities for various aspects of waste management during and after emergencies. |
REC295-1281 | 32 - Doctrine, standards, and reform | In order to increase resilience and public safety during emergencies, the State Emergency Management Committee should request the Australia and New Zealand Emergency Management Committee to place on the agenda, and consider establishing a national position, on redundancies for mobile communications (including phone tower back-up power) and the National Broadband Network. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1290 | 32 - Doctrine, standards, and reform | Continue development of the Damage Assessment Support Plan to: |
REC295-1323 | 32 - Doctrine, standards, and reform | Review and update the role, function, workload and focus of the groups/committees that contribute to incident management and emergency management capabilities including the State Emergency Management Training Committee, Interagency Incident Management Sub-Committee and the Central Exercise Writing Team. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1331 | 32 - Doctrine, standards, and reform | Task South Australian Fire and Emergency Services Commission with further developing the Emergency Alerts capability across government agencies including to: a) establish and maintain a centralised training program for emergency alert initial and refresher training. b) establish a pool of endorsed Emergency Alert personnel from across government agencies to enable control agencies to assist each other with the emergency alert function during emergencies. c) develop supporting processes to ensure that the capability supports: emergencies involving any hazard; consistent issuing of alerts and warnings; consistent messages; and effective communication and notification of alerts issued to relevant internal and external stakeholders |
REC295-1280 | 32 - Doctrine, standards, and reform | That a State Plan be developed for managing the consequences of a black system event or other major power outage. The plan should include: |
REC295-1311 | 32 - Doctrine, standards, and reform | That the State Emergency Management Plan be reviewed and updated including: a) a better description of the responsibilities of Hazard Leaders Page xx b) establish a mechanism for a hazard leader to identify systemic failures in coordination of their hazard, with a clear process to raise those issues with SEMC and seek a remedy c) establish resilience as a key heading in the plan, with clearly documented strategies and responsibilities; and d) consider the Schar/Mulroney submission and taking a ‘fresh eyes’ approach |
REC295-1289 | 32 - Doctrine, standards, and reform | That SA Police, emergency services, health facilities, utility providers and other key service providers, review their Business Continuity Plans giving consideration to factors such as: a) identification of: business critical needs; essential services power requirements; back-up power requirements for all facilities including State, regional and local facilities such as Police, SES, MFS and CFS stations; the need for any arrangements for back-up power to be included in contracts for design and or lease of Government premises b) contingencies for black system events and extended power outages c) regular back-up generator testing regime protocols, including testing under load and for long durations d) contingencies for communications when mobile, landline and/or radios are not operational e.g. satellite phones; and e) alternative State control centre facilities that are pre-identified, equipped and have procedures for moving to the alternative facility. |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1295 | 32 - Doctrine, standards, and reform | That resources be provided to support the implementation of recommendations in the South Australian Levee Bank Management Issues Paper (DEWNR, 2015) including: a) development of relevant policy; and b) identification of responsibilities in relation to levee management and flood mitigation |
REC295-1330 | 32 - Doctrine, standards, and reform | Update the Public Information Functional Support Group Plan to include: a) standards, outputs, systems and processes required to be used by control agencies and the Public Information Functional Support Group during emergencies b) guidance on the public information cycle through the prevention, preparedness, response and recovery phases which includes the responsibilities and information requirements during different phases, and effective transition between phases c) establishing a public information intelligence cell within the Public Information Functional Service Group; and d) identifying tools or resources to monitor social media |
REC295-1277 | 32 - Doctrine, standards, and reform | That the Department of Planning, Transport and Infrastructure review their Business Continuity Plan to: |
REC295-1310 | 32 - Doctrine, standards, and reform | That additional guidance be provided in the State Emergency Management Plan regarding the activation, structure and operation of Zone Emergency Support Teams. This should include: a) the reporting relationship between the Zone Emergency Support Teams, the State Emergency Centre and the State Coordinator b) briefing requirements between the State Coordinator (or their representative) and the Zone Emergency Support Teams when the State Emergency Centre is activated c) responsibilities for provision of local public information; and d) the appointment of public information officers in Zone Emergency Support Teams (where there is no incident management team (established) to provide information to local communities |
REC295-1287 | 32 - Doctrine, standards, and reform | That the glossary of terms in the State Emergency Management Plan be reviewed to ensure all relevant language is included. All agencies need to ensure the use of clear communication and accurate use of terminology, including in describing the status of critical services e.g. Triple Zero (000), SA Government Radio Network, electrical and water supplies and infrastructure. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1294 | 13 - Mapping and data quality | That consideration and resources be given to support the implementation of recommendations in the report prepared on behalf of Department of Environment, Water and Natural Resources (Australian Water Environments, 2016), for flood warning classification of stream gauges and other locations. |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1309 | 32 - Doctrine, standards, and reform | That members of Emergency Management Council ensure they are prepared to undertake their roles and responsibilities during emergency events, including establishing: a) contingencies for communication e.g. satellite phone b) access to relevant documents such as the State Emergency Management Plan, supporting plans, ministerial guidelines, agency plans and contacts in hard copy and/or portable device c) formalised arrangements for briefings (up and down), and d) arrangements for suitable representation e.g. relevant Chief Executive(s) or their deputy, at all Emergency Management Council meetings . |
Rec-ID | Code | Recommendation |
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REC280-1392 | 36 - Volunteers | That the NSW Rural Fire Service, in order to ensure greater respect for volunteer fire fighters’ knowledge and experience in the management of fires: |
REC280-1403 | 32 - Doctrine, standards, and reform | That the Ministry for Police and Emergency Services urgently review its policies for the provision of disaster welfare services to ensure that in the event of a bush fire emergency and the declaration of a fire under section 44 of the Rural Fires Act 1997, adequate funding and services, especially recovery centres and mental health services, are provided for an adequate length of time, with gradual transition to normal service delivery when those services are no longer required. |
REC280-1391 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC280-1397 | 32 - Doctrine, standards, and reform | That the NSW National Parks and Wildlife Service adopt an interim fencing agreement in the immediate aftermath of a fire. This will enable emergency and interim works to commence, but features such as length, fencing components and site of the fence line are not binding. A final fencing agreement would be negotiated no earlier than six months following a major national park fire. |
REC280-1390 | 32 - Doctrine, standards, and reform | That the NSW Government consider enabling the default position during catastrophic and extreme fire danger periods to be the same as for section 44 fires, so that fire control centres have the same systems and resources ready to deploy should a fire break out. |
REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1389 | 32 - Doctrine, standards, and reform | That the NSW Government, as a matter of urgency, amend the Rural Fires Act 1997 to codify the current interim arrangements for command and notification requirements for class 1 and class 2 fires, which clarify that the NSW Rural Fire Service or Fire and Rescue NSW: |
REC280-1395 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service reassess the protection of pastoral assets during bush fires to ensure that priority for protection is not simply afforded to the homestead, and that land holders are, within reason, able to request which of their own assets are protected. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1393 | 36 - Volunteers | That the NSW Rural Fire Service formally recognise the Volunteer Fire Fighters Association as a legitimate advocacy organisation representing volunteer bush fire fighters, and duly consult with it on policy and operational matters. |
REC280-1380 | 13 - Mapping and data quality | That the NSW Rural Fire Service investigate mechanisms to enhance the predictability of megafires and how this information is communicated easily to the public. |
Rec-ID | Code | Recommendation |
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REC273-1145 | 32 - Doctrine, standards, and reform | Review relevant Legislation associated Acts and Plans to establish a consistent approach to fire and emergency management to minimise duplication and risk of contradiction. That the Hazard and Functional area plans be amalgamated and establish a SA Bushfire Plan, under the SEMP, which clearly define role of SACFS. |
REC273-1143 | 32 - Doctrine, standards, and reform | That SACFS in consultation with SAMFS consider adopting common terminology and capability requirements for strike teams being ‘4-5 appliances and a group officer’ in line with other jurisdictions. |
REC273-1133 | 32 - Doctrine, standards, and reform | That a complete review of current naming conventions of personnel and centres, in accordance with the outcomes of the Victorian Bushfire Royal Commission is undertaken, to ensure clarity around command, control and coordination within SA. |
REC273-1129 | 32 - Doctrine, standards, and reform | Incorporating ‘triggers’ within Chief Officers Standing Orders No. 17, which requires the escalation of the State Controller role to the rank of Assistant Chief Officer or greater, depending on the increased risk or activity. |
REC273-1128 | 32 - Doctrine, standards, and reform | Incorporate in operational doctrine the ability for the State Controller to determine the operational readiness levels of the state or regions based on either the predicted and/or actual risk and/or activity to some or all of the regions. |
Rec-ID | Code | Recommendation |
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REC261-1510 | 36 - Volunteers | That the NSW Rural Fire Service formally recognise the Volunteer Fire Fighters Association as a legitimate advocacy organisation representing volunteer bush fire fighters, and duly consult with it on policy and operational matters. |
REC261-1509 | 34 - Local knowledge | That the NSW Rural Fire Service, in order to ensure greater respect for volunteer fire fighters’ knowledge and experience in the management of fires: |
REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC261-1506 | 32 - Doctrine, standards, and reform | That the NSW Government, as a matter of urgency, amend the Rural Fires Act 1997 to codify the current interim arrangements for command and notification requirements for class 1 and class 2 fires, which clarify that the NSW Rural Fire Service or Fire and Rescue NSW: |
REC261-1516 | 32 - Doctrine, standards, and reform | That the NSW National Parks and Wildlife Service remove from its boundary fencing policy and standard contract the condition that requires adjoining land owners to maintain a fence that has been damaged by trees falling from national park land. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1512 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service reassess the protection of pastoral assets during bush fires to ensure that priority for protection is not simply afforded to the homestead, and that land holders are, within reason, able to request which of their own assets are protected. |
Rec-ID | Code | Recommendation |
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REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2623 | 32 - Doctrine, standards, and reform | That the F&ES Act be amended to enable fire safety inspections in and outside fire districts. |
REC244-2609 | 32 - Doctrine, standards, and reform | That the proposed ‘Permit Information Management System’ (PIMS) be implemented as soon as possible and incorporated into the Call Receipt and Dispatch process. Following implementation, amend Regulation 33 (5) (d) and (10) (c) in line with the automated notification process. |
REC244-2629 | 32 - Doctrine, standards, and reform | The power of the Chief Officer to appoint officers from the staff of the SES as well as appoint volunteer officers of the SES be clarified. A command structure section (similar to Section 70) be incorporated into the Act and include the power to register, appoint, disqualify and terminate volunteer members. |
REC244-2614 | 32 - Doctrine, standards, and reform | Consider the amendment of Section 82 (2) to include the power to order the cessation of harvesting or any other actions (including the lighting of fires authorised under Section 81) that because of the weather conditions, may cause a fire, if ignited, to get out of control. |
REC244-2635 | 32 - Doctrine, standards, and reform | The requirement to consult with members of the unit and the SESVA before an SES Unit is dissolved should remain but the need for public meetings be removed from the regulations. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2622 | 32 - Doctrine, standards, and reform | Amend Sections 28, 61 and 110 to provide the Chief Officers greater flexibility over organisational structure. |
REC244-2608 | 32 - Doctrine, standards, and reform | Consider whether Regulation 71 be amended to extend the range of offences for which expiation fees apply to include a breach of any permit condition imposed by an authorised officer. |
REC244-2628 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to reflect the SES expanded responsibilities as Hazard Leader for ‘Extreme Weather’ including their community education role. |
REC244-2613 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act amend Section 94 (4) (c) to refer to the ‘State Bushfire Coordination Committee’. |
REC244-2633 | 32 - Doctrine, standards, and reform | Amend Section 143 to strengthen the capacity of the ESOs to recover outstanding debts (e.g. penalty for late payment provisions). |
REC244-2599 | 32 - Doctrine, standards, and reform | That the MFS, CFS and SES be incorporated into a departmental structure under the direction of a Chief Executive based on interstate developments over the past two decades, which establishes this arrangement as the benchmark for the governance of Emergency Services in Australia. The MFS, CFS and SES would operate as separate units under the ultimate direction of the CEO. |
REC244-2621 | 36 - Volunteers | Greater attention needs to be given to the recruitment and retention of volunteers in alignment with the National Emergency Management Volunteer Action Plan. |
REC244-2607 | 32 - Doctrine, standards, and reform | Amend Regulation 41 to exempt the use of prescribed appliances when a Hot Work Permit compliant with AS1674.1 has been issued. |
REC244-2626 | 32 - Doctrine, standards, and reform | Section 70 (5) be amended to preclude a person from being elected as a group officer, brigade captain or brigade lieutenant if he or she is an employee of the CFS. |
REC244-2612 | 32 - Doctrine, standards, and reform | Develop a code of practice which is referenced by the F&ES Act for burning off including the option to issue seasonal permits for relevant purposes throughout the State. |
REC244-2632 | 32 - Doctrine, standards, and reform | Section 142 be amended to include the SES |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2603 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act, then Section 71 of the Act be amended to provide for the appointment of an independent presiding member of the committee. |
REC244-2625 | 32 - Doctrine, standards, and reform | Sections 42 and 97 be amended to provide greater flexibility in the engagement of contractors by Senior MFS and CFS Officers. Consideration be given to providing similar powers in Section 118 to enable the SES to engage contractors. |
REC244-2611 | 32 - Doctrine, standards, and reform | Review the format and necessity for Schedules 9 and 10 of the Regulations |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2602 | 32 - Doctrine, standards, and reform | That South Australia’s Hazard Leader Plan for Rural Fire, prepared in accordance with the State Emergency Management Plan, replace the F&ES Act requirement for a separate State Bushfire Management Plan. |
REC244-2624 | 32 - Doctrine, standards, and reform | The F&ES Act be amended to clarify the meaning of ‘closure’ in Section 38 and that provisions relating to the extension and rescission of closure orders be reviewed. |
REC244-2610 | 32 - Doctrine, standards, and reform | Amend Regulation 33 (6) and (8) to include respectively ‘notice given’ and ‘permit application’ using the online medium. |
REC244-2630 | 32 - Doctrine, standards, and reform | Clarify that Section 128 of the F&ES Act is not compromised by any other legislation. |
REC244-2615 | 32 - Doctrine, standards, and reform | In consultation with stakeholders including CFA, develop a Forest Industry Brigade standard for inclusion in the Fire and Emergency Services Regulations. |
REC244-2636 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to provide for the operation of interstate fire and emergency service workers in South Australia. The issue of liability may need to be considered. |
Rec-ID | Code | Recommendation |
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REC243-0837 | 32 - Doctrine, standards, and reform | That the Government’s Workers Rehabilitation and Compensation (SAMFS Firefighters) Amendment Bill be amended to include Country Fire Service firefighters alongside Metropolitan Fire Service firefighters. |
REC243-0844 | 32 - Doctrine, standards, and reform | That the State Government give high priority to liaising with interstate and Federal processes, and offer to take a lead, on changing the climatic and fire rating arrangements to ensure these match the conditions that can create dangerous bushfire conditions at short notice. |
REC243-0842 | 36 - Volunteers | That the Government work with the volunteer community safety and emergency service providers to organise a comprehensive advertising campaign to promote the community and personal benefits of volunteering in the sector. |
REC243-0841 | 36 - Volunteers | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: i harmonising the regime for reimbursement to community safety and emergency services volunteers for their out-of-pocket expenses; and ii reviewing the impact of work health and safety laws on the community safety and emergency service sector, particularly on the volunteer organisation. |
REC243-0840 | 36 - Volunteers | That with regard to volunteer community safety and emergency service organisations that do not own land where their facilities exist: i. the Government audit all such land and consider gifting or providing at reduced or peppercorn rental Government-owned land to an organisation (and specifically the Select Committee recommends gifting the Adelaide Shores land to Surf Life Saving South Australia); and ii. the Government consider providing rebates to Councils that do not feel morally able to impose full commercial rent on community safety and emergency service volunteer occupied land. |
REC243-0839 | 32 - Doctrine, standards, and reform | That noting the precedents for legislated charters in the Carers Recognition Act 2005 and the Health and Community Services Complaints Act 2004, that the Government support the Fire and Emergency Services (Volunteer Charters) Amendment Bill introduced by the Member for Morphett in November 2012 to enshrine the Country Fire Service and the State Emergency Service at law. |
Rec-ID | Code | Recommendation |
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REC242-2645 | 36 - Volunteers | That the Government work with the Local Government Association to resolve questions of liability by volunteers who work for Councils, as raised with the Select Committee. |
REC242-2644 | 36 - Volunteers | That the Government work with the volunteer community safety and emergency service providers to organise a comprehensive advertising campaign to promote the community and personal benefits of volunteering in the sector. |
REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
REC242-2641 | 32 - Doctrine, standards, and reform | That noting the precedents for legislated charters in the Carers Recognition Act 2005 and the Health and Community Services Complaints Act 2004, that the Government support the Fire and Emergency Services (Volunteer Charters) Amendment Bill introduced by the Member for Morphett in November 2012 to enshrine the Country Fire Service and the State Emergency Service at law. |
Rec-ID | Code | Recommendation |
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REC237-0818 | 32 - Doctrine, standards, and reform | That section 9(4)(b) of the Rural Fires Act 1997, which sets out the functions of the NSW Rural Fire Service, be amended to include protecting infrastructure, environmental, economic, cultural, agricultural and social assets from damage. |
REC237-0823 | 32 - Doctrine, standards, and reform | That section 74 of the Rural Fires Act 1997 be amended to require public authorities to report monthly to the Commissioner of the NSW Rural Fire Service on activities undertaken to reduce bush fire hazards on managed land during the preceding month and the reasons why any planned activities did not take place. |
REC237-0832 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service investigate use of appropriate modelling, such as PHOENIX RapidFire and the Bayesian Network analysis, to quantify the level of bush fire risk to critical values and assets. |
REC237-0817 | 32 - Doctrine, standards, and reform | That section 3(c) of the Rural Fires Act 1997, which sets out the objects of the Act, be extended to include protecting infrastructure, environmental, economic, cultural, agricultural and social assets from damage. |
REC237-0822 | 32 - Doctrine, standards, and reform | That section 74 of the Rural Fires Act 1997 be amended to require public authorities to report to the Commissioner of the NSW Rural Fire Service within one month of the end of the financial year on activities undertaken to reduce bush fire hazards on managed land during the preceding financial year. |
REC237-0831 | 32 - Doctrine, standards, and reform | That Bush Fire Management Committees be required to take into account fuel age and fire frequency thresholds when developing Bush Fire Risk Management Plans |
REC237-0821 | 32 - Doctrine, standards, and reform | That the definition of “bush fire hazard reduction work” in the Dictionary of the Rural Fires Act 1997 be amended to include the establishment or maintenance of fire trails. |
REC237-0827 | 32 - Doctrine, standards, and reform | The Panel notes and endorses the NSW bush fire management system based on a multi-agency, tenure blind approach using locally focused Bush Fire Management Committees, Bush Fire Management Plans and the Bush Fire Environmental Assessment Code as best practice. |
REC237-0820 | 32 - Doctrine, standards, and reform | That the Rural Fires Act 1997 be amended to allow the Commissioner of the NSW Rural Fire Service to carry out hazard reduction on land without the consent of the owner after reasonable attempts to contact the landowner have failed, without serving a notice under section 66 of the Rural Fires Act. |
REC237-0826 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service hold discussions with the Commonwealth Department of Sustainability, Environment, Water, Population and Communities about hazard reduction and roadside vegetation, including potential changes to the NSW Bush Fire Environmental Assessment Code. |
REC237-0819 | 32 - Doctrine, standards, and reform | That section 56 of the Rural Fires Act 1997 be amended to give the Commissioner of the NSW Rural Fire Service the power to direct a Bush Fire Management Committee to amend its Bush Fire Risk Management Plan if it is inadequate, in the opinion of the Commissioner. |
REC237-0824 | 32 - Doctrine, standards, and reform | That section 100I of the Rural Fires Act 1997 be amended to allow hazard reduction certificates to be issued for annual low impact works for a period of three years, where appropriate. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0072 | 32 - Doctrine, standards, and reform | SERCon consider that the proposed State Recovery Committee review the recommended considerations arising from |
REC164-0071 | 32 - Doctrine, standards, and reform | SERCon consider the establishment of a body, such as a State Recovery Committee, with responsibility for the |
REC164-0077 | 32 - Doctrine, standards, and reform | SERCon consider the continued development of a State Recovery Sub-Plan (including complementary local and district |
REC164-0076 | 32 - Doctrine, standards, and reform | SERCon consider meeting with the State Emergency Management Committee, Directors General and agency heads to |
REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3087 | 32 - Doctrine, standards, and reform | Section 90 – provisions relating to smoking, and throwing burning material be removed from the principal FES Act and placed in the Regulations. |
REC151-3106 | 32 - Doctrine, standards, and reform | A schedule for revocation of permits be included in the Regulations. |
REC151-3063 | 32 - Doctrine, standards, and reform | The preamble of the Fire and Emergency Services (FES) Act be amended to include a stronger emphasis on the strategic and policy purposes of the Commission, highlighting its key role in the governance of the emergency services sector. |
REC151-3093 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to, ‘an officer of the National Parks and Wildlife Service’ this be removed and replaced with, ‘an officer of the Department for Environment and Heritage’. |
REC151-3070 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained to determine whether additional functions now undertaken by the Commission following the devolvement of the functions of the Security and Emergency Management Office (SEMO) require an amendment to the FES Act. |
REC151-3076 | 32 - Doctrine, standards, and reform | Provisions in Section 11(1)(e)(i) and (ii) relating to appointments of volunteer associations to the SAFECOM Board be removed. |
REC151-3100 | 32 - Doctrine, standards, and reform | Section 70(12) (relating to disciplinary action) be amended to include, where the officer is an employee of a government agency, the Chief Officer shall advise an appropriate representative of the agency prior to any disciplinary action being taken. |
REC151-3086 | 32 - Doctrine, standards, and reform | Section 88 – requirement to carry fire extinguishers in a caravan be removed from the principal FES Act and placed in the Regulations. |
REC151-3105 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, the provisions in Sections 84 and 85 be reviewed in terms of enforcing hazard reduction on council or Crown land. |
REC151-3091 | 32 - Doctrine, standards, and reform | Regulation 48 regarding prescribed offences be amended to include Section 79(2)(e) or its equivalent under the amendment proposed in Recommendation 22 above. |
REC151-3111 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained as to what amendments, if necessary or appropriate, are required to satisfy Recommendation 29.9(7) of the Wangary Coronial Inquest, that a dedicated bushfire prevention officer be appointed. |
REC151-3069 | 32 - Doctrine, standards, and reform | Consistent with the requirement for Emergency Service Organisations, the FES Act be amended to require South Australian Fire and Emergency Commission (SAFECOM) to submit a workforce plan to the Board. |
REC151-3097 | 32 - Doctrine, standards, and reform | Regulation 8(4)(b) be amended to allow persons of or above 16 years of age to register as fire-fighters. |
REC151-3075 | 32 - Doctrine, standards, and reform | Section 92 include the facility to issue a warrant for the relevant authority to break into land or buildings for the purposes of determining what measures have been taken for the prevention, control or suppression of fire or for the prevention of, or for dealing with, the escape of hazardous materials; and that costs and expenses in doing so are recoverable. |
REC151-3085 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, consideration should be given to provisions within Part 4, Division 7 of the principal FES Act which would be more appropriately placed in the Regulations. |
REC151-3104 | 32 - Doctrine, standards, and reform | SAFECOM in consultation with SAMFS consider the merits of amending Sections 49- 51 to replace the right to appeal from the District Court to the South Australian Industrial Relations Commission. |
REC151-3090 | 32 - Doctrine, standards, and reform | Following the amendment to Section 79 as proposed above in Recommendation 22, a definition of, ‘properly constructed fire place’ and ‘properly constructed incinerator’ be included in the new Regulation. |
REC151-3110 | 32 - Doctrine, standards, and reform | Further to Recommendations 11 and 12 above concerning the joining of Sections 56 and 83 of the FES Act, that these existing provisions be examined to determine whether they provide sufficient authority to address Recommendation 29.9(4) of the Wangary Coronial Inquest so as to require the owners or occupiers of rural land to create fire breaks and/or 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. |
REC151-3068 | 32 - Doctrine, standards, and reform | The FES Act be amended so as to allow the Chief Executive (CE) to manage the Commission (SAFECOM) Office by removing provisions relative to the SAFECOM Board’s managerial and administrative oversight of the Commission. |
REC151-3096 | 32 - Doctrine, standards, and reform | All Regulations relating to constitutions be deleted; the FES Act be amended to allow the Chief Officers to prescribe the constitution; and the process for the management of a SACFS brigade/group and a SASES unit to be in the form of an administrative instruction. |
REC151-3074 | 32 - Doctrine, standards, and reform | Sections 56 and 83 (amended as suggested above) include the facility to issue a warrant for the relevant authority to break into land or buildings to carry out requirements regarding flammable undergrowth or material; and that costs and expenses in doing so are recoverable. |
REC151-3084 | 32 - Doctrine, standards, and reform | Section 79(1) – provisions relating to lighting or maintaining a fire in the open air during the fire danger season be retained in the principal FES Act; Section 79(2) be amended to provide that a fire may be lit or maintained in accordance with the Regulations; provisions specifying the conditions under which a fire can be lit or maintained, and currently under Section 79(2), be placed in the Regulations. |
REC151-3103 | 32 - Doctrine, standards, and reform | Provisions be included in the Regulations for mediation in appropriate circumstances. |
REC151-3089 | 32 - Doctrine, standards, and reform | The definition of ‘officer’ in Section 3 be amended to include reference to the designation being made by the Chief Officer. |
REC151-3109 | 36 - Volunteers | As a matter of priority, SAFECOM examine what further measures can be taken to provide support and protection for volunteers as potential witnesses in public enquiries. |
REC151-3065 | 32 - Doctrine, standards, and reform | The FES Act be amended to create the position which currently has the working title of ‘Commissioner of Fire and Emergencies’ to replace the position of CE and that the FES Act be amended in places where this position is mentioned. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3073 | 32 - Doctrine, standards, and reform | Sections 56 and 83 be repealed and replaced with a single section which unifies their provisions. |
REC151-3082 | 32 - Doctrine, standards, and reform | The Regulations be amended to include appropriate references to the Unit Managers Advisory Group (SASES) consistent with those of the Group Committee (SACFS). |
REC151-3102 | 32 - Doctrine, standards, and reform | Regulations 22 and 62 be reviewed to ensure reports regarding conduct must be relevant to the enquiry. |
REC151-3088 | 32 - Doctrine, standards, and reform | Sections 68 and 116 – provisions relating to the establishment/dissolution of SACFS Brigades and SASES Units be amended so as to retain the head of power in the principal FES Act and that the procedural provisions within each of these sections be placed in the Regulations. |
REC151-3108 | 36 - Volunteers | Liability and immunity as these provisions apply in Section 127 be reassessed in terms of burden of proof so as to ensure the best protection for volunteers. |
REC151-3064 | 32 - Doctrine, standards, and reform | The FES Act be amended to include a definition of ‘operations’ and/or ‘operational’. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3072 | 32 - Doctrine, standards, and reform | Provisions in the FES Act relating to, “land management principles” be reviewed in consultation with appropriate agencies and having due regard to the recommendations of the Wangary Coronial Inquest. |
REC151-3081 | 32 - Doctrine, standards, and reform | So as to increase the pool of volunteers from which the Minister can appoint Advisory Board members, Section 18(3)(c) and (d) be amended to include nominations from the Group Committee (SACFS) and Unit Managers Advisory Group (SASES). |
REC151-3101 | 32 - Doctrine, standards, and reform | Divisions and Subdivisions and Regulations 22 and 62 headings relating to conduct and discipline be changed to have similar wording and should include, “Conduct, Discipline and Grievance Procedures for Members”. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3599 | 32 - Doctrine, standards, and reform | In order to improve the response to animal health emergencies, that the Department of Primary Industries prioritise the finalisation of Memoranda of Understanding with the four jurisdictions bordering New South Wales. |
REC128-3610 | 32 - Doctrine, standards, and reform | That the Minister for Primary Industries consider amending the Stock Diseases Act 1923 to ban the supply of waste swill to pig owners by food retailing businesses such as bakeries, restaurants and supermarkets. |
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
REC128-3609 | 16 - Training and behaviour | That the Department of Primary Industries be conscious of its responsibilities in maintaining the continued enthusiasm of Industry Liaison Officers and offer training and refresher training as required. |
REC128-3608 | 16 - Training and behaviour | That emergency animal health training be included in induction programs for newly recruited District Veterinarians and all District Veterinarians be encouraged to maintain their skills by attending regular refresher training as appropriate. |
REC128-3607 | 16 - Training and behaviour | That the Department of Primary Industries should continue efforts to develop the skills of private sector veterinarians to increase the level of resources available in emergency responses. |
REC128-3600 | 34 - Local knowledge | The Department of Primary Industries continue to consult local community about emergency planning and sites for disposal to retain confidence in the event of a genuine emergency. |
REC128-3618 | 32 - Doctrine, standards, and reform | That the Department of Primary Industries should complete a review of the Memorandum of Understanding and ensure the roles of the Department and Rural Lands Protection Boards are more clearly identified outlined for effective delivery of animal health programs. |
Rec-ID | Code | Recommendation |
---|---|---|
REC122-3790 | 32 - Doctrine, standards, and reform | The Committee recommends that prescribed burning should only be undertaken by professionally trained personnel. |
REC122-3789 | 32 - Doctrine, standards, and reform | The Committee recommends that the native vegetation planning and approval process for prescribed burning be amended to allow flexibility for burning on optimum days. |
REC122-3788 | 32 - Doctrine, standards, and reform | The Committee recommends that the Native Vegetation Council have a consistent approach to prescribed burning on both public and private lands. |
REC122-3786 | 32 - Doctrine, standards, and reform | The Committee recommends that the Native Vegetation Act be amended to allow for prescribed burning. |
REC122-3784 | 34 - Local knowledge | The Committee recommends that the government provide authority to a single community representative body to authorise clearing of native vegetation for fire management. (The community representative body must incorporate the CFS, DEH, Native Vegetation Council and local council) |
REC122-3791 | 16 - Training and behaviour | The Committee recommends that training be provided to landholders to enable them to assist with prescribed burns. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
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. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3758 | 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. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
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. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
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. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3757 | 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. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
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. |
REC121-3726 | 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. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3753 | 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. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
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. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |