Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC315-3803 | 16 - Training and behaviour | That Government support training initiatives to increase the capacity of fire authorities to fight the kind of megafires seen in the 2019-20 season. The training initiatives should include: |
REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3861 | 16 - Training and behaviour | That, in order to expand the pool of trained personnel able to undertake the Public Information Functional Area Coordinator (PIFAC) role, Resilience NSW and the NSW Police Media Unit (PIFAC) develop and deliver a training package for Emergency Management Media Liaison Officers. |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3807 | 16 - Training and behaviour | That, in order to expand NSW’s specialist aviation personnel safety and capacity, Government expand simulator capabilities at the NSW RFS Training Academy. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
Rec-ID | Code | Recommendation |
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REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
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. |
REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
Rec-ID | Code | Recommendation |
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REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1240 | 14 - Incident Mgt Teams | The Departments of Parks and Wildlife and Fire and Emergency Services to adopt the policy that all bushfire Level 3 Incident Management Teams in the Perth Hills and the South West will be integrated and pre-formed from the start of the 2016/17 fire season with substantial involvement of both the Departments of Parks and Wildlife and Fire and Emergency Services personnel on all teams. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1239 | 14 - Incident Mgt Teams | The State Government to establish an arrangement to develop a ‘network’ of Western Australian State Government agency personnel who can be called upon for bushfire and emergency incident management capability within Western Australia. The arrangement will be led by the State Emergency Management Committee and modelled on systems used by the Department of Parks and Wildlife. |
Rec-ID | Code | Recommendation |
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REC290-1214 | 14 - Incident Mgt Teams | Flexible pre‐formed multi‐ agency IMTs |
Rec-ID | Code | Recommendation |
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REC281-1205 | 16 - Training and behaviour | Department of Premier and Cabinet Regional Coordinators: Continue to build the capability of the Department of Premier and Cabinet Regional Coordinator role in recovery operations by providing: · on the ground support for Regional Coordinators during recovery operations by REMOs or OEM Recovery Team · training and developmental opportunities for Regional Coordinators to prepare them for working in the disaster recovery environment. |
REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
Rec-ID | Code | Recommendation |
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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. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC279-1232 | 16 - Training and behaviour | Volunteer Charter: by December 2014, agree a charter with volunteers that clarifies roles and expectations including commitments by: a) SES to support volunteers to prepare for and respond to emergencies b) SES to make the best use of volunteers’ time by introducing user-friendly systems and reducing the administrative burden on them c) volunteers to turn-out when called to respond to emergencies. |
REC279-1231 | 16 - Training and behaviour | Training Strategy: By April 2015, develop a training strategy that identifies volunteer training priorities and provides for ongoing review to ensure operational currency, flexibility of delivery and evaluation |
Rec-ID | Code | Recommendation |
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REC277-1164 | 14 - Incident Mgt Teams | Establish multi-agency preformed IMTs: An effective IMT for large and complex fire incidents requires the capacity and expertise of multiple agencies. Establishing multi-agency preformed IMTs will have three main benefits: adequate IMT resources can be deployed with ease • strong working relationships will be built between IMT members • common approaches to incident management and fire response can be embedded. |
Rec-ID | Code | Recommendation |
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REC276-1178 | 16 - Training and behaviour | Within six months, consider improved processes for consulting with and engaging volunteers and continue to work with LGs to improve information sharing and communication. Specifically, DFES should improve communication around its decisions on equipment and training as well as provide better information about access to services. |
Rec-ID | Code | Recommendation |
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REC265-1102 | 25 - Inquiry, audit, lessons management and after action review | SEMC Secretariat Community Emergency Management Officers should work with the Shire to document the Shire of Mundaring’s learnings from the Parkerville Stoneville Mt Helena fire with a view to sharing this with other local authorities particularly those facing similar situations in order to extend the range of tools available to assist local governments to understand their roles and responsibilities in future emergencies. |
REC265-1115 | 16 - Training and behaviour | Training and awareness raising should be conducted to enhance the appreciation and understanding of DFES State and Regional operational personnel, including potential Incident Management Team members, of the nationally adopted Bushfire Alert and Messaging Matrix, in order to ensure that the most appropriate alert levels and associated community messaging are applied during bushfire incidents. |
REC265-1103 | 16 - Training and behaviour | DFES should review its training courses and Standard Operating Procedures to satisfy itself that all incident management personnel have the required level of understanding of WA emergency management arrangements, including those that relate to the roles of the Incident Management Team and Incident Support Group and the declaration of incident levels. |
REC265-1109 | 14 - Incident Mgt Teams | Future appointments to the role of Incident Controller should be limited to one for the entire duration of the incident, with nominated Deputy Incident Controllers to assist or ‘take charge’ in the Incident Controller’s absence. This measure will provide for a single point of responsibility and control for the incident and assist with any subsequent review or enquiry. If it is not possible to implement this proposal for liability reasons, the number of Incident Controllers should nevertheless be reduced to the minimum. |
Rec-ID | Code | Recommendation |
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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. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
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. |
REC260-1066 | 14 - Incident Mgt Teams | That during periods of ‘severe’ or worse fire conditions, that the National Parks and Wildlife Service consider adopting a posture of pre-emptive planning and deployment of incident management teams in national parks similar to the manner in which the Rural Fire Service does. |
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. |
REC260-1053 | 14 - Incident Mgt Teams | That in Class 3 fire-fighting operations, the Rural Fire Service consider including a fire behaviour analyst in the incident management team if feasible. |
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. |
REC260-1052 | 14 - Incident Mgt Teams | That the Rural Fire Service consider amending its fire prediction reports to include a checklist of significant factors that have not been able to be considered in the prediction model and a warning to be alert for them and seek intelligence on them from fire ground managers. |
Rec-ID | Code | Recommendation |
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REC254-1587 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC254-1581 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
REC254-1585 | 14 - Incident Mgt Teams | DFES and Local Government Bushfire Brigades ensure that only those with the required AIIMS competence have the authority to manage Level 1 incidents, noting they may not be Fire Control Officers. |
REC254-1583 | 16 - Training and behaviour | Once Recommendation 1 has been actioned, all agencies give greater priority to the promulgation of Red Flag warnings in order to enhance situational awareness on the fireground. |
Rec-ID | Code | Recommendation |
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REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
Rec-ID | Code | Recommendation |
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REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
Rec-ID | Code | Recommendation |
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REC226-0557 | 14 - Incident Mgt Teams | An intensive exercise/training program should be developed and maintained across agencies to identify and establish a pool of current Incident Controllers who are capable of managing a Level 3 incident. |
REC226-0587 | 14 - Incident Mgt Teams | To be effective, multi-agency IMTs will need to be exercised regularly and supported by sound and comprehensive doctrine. |
REC226-0565 | 14 - Incident Mgt Teams | Contingency planning is a critical function in the early stages of an escalating incident, and should provide the foundation of an IAP. |
REC226-0573 | 14 - Incident Mgt Teams | Strategic direction seeks to identify and resource those areas of tactical action that offer the greatest advantage. |
REC226-0556 | 14 - Incident Mgt Teams | Within the AIIMS IMT doctrine the roles of the Incident Controller and Deputy Incident Controllers should be defined and well-practiced. |
REC226-0586 | 14 - Incident Mgt Teams | At Level 3, the available fire management expertise should be applied overwhelmingly to the fire management aspects of emergency management, possibly in incident control, and certainly in situations planning and operations roles. |
REC226-0564 | 14 - Incident Mgt Teams | The expected scenario, with a view to the worst-case scenario should provide the basis for an IAP. |
REC226-0572 | 14 - Incident Mgt Teams | Contingency planning before the fire may have supported the IMT in recognising and seizing strategic opportunities earlier. |
REC226-0555 | 14 - Incident Mgt Teams | The state should identify the number of fully trained, experienced and accredited Level 3 Incident Controllers required to be available at any time and establish a process for identification of suitable personnel, ongoing training and accreditation. |
REC226-0585 | 14 - Incident Mgt Teams | DEC’s fire management expertise should be augmented by multi-agency IMTs that incorporate the expertise of other agencies and in fast developing situations the appropriate decisions will need to be made early. |
REC226-0563 | 14 - Incident Mgt Teams | Procedures to relocate IMTs need to be established in doctrine and exercised to ensure continuity of control. |
REC226-0570 | 14 - Incident Mgt Teams | Logistics and resource officers in IMTs need to collaborate and establish full awareness and control over the available resources. |
REC226-0554 | 14 - Incident Mgt Teams | For incidents of this complexity, effective control in the critical phase (first 24-36 hours of the fire) requires an appropriately resourced IMT. |
REC226-0584 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command and not through agency chains of command |
REC226-0562 | 14 - Incident Mgt Teams | Opportunities be sought to utilise local government representatives in other areas of the IMT particularly in public information or other community related functions. |
REC226-0567 | 14 - Incident Mgt Teams | IMTs need to establish early and effective liaison with Local Governments. |
REC226-0551 | 14 - Incident Mgt Teams | As presently implemented, the AIIMS planning role is under-developed and provides insufficient support to the Incident Controller. |
REC226-0575 | 14 - Incident Mgt Teams | In multi-agency responses the culture, training and equipment characteristics of each of the agencies should be considered in their employment. |
REC226-0558 | 14 - Incident Mgt Teams | Predetermined locations for Level 3 IMTs should be reviewed and adequately resourced with necessary communications and IT capacity. |
REC226-0566 | 14 - Incident Mgt Teams | Incident Controllers should be supported by a planning function that combines experienced weather forecasters, fire behaviour experts and local knowledge. |
REC226-0550 | 14 - Incident Mgt Teams | Greater investment in training on specific functions within the AIIMS structure will improve the support provided to the Incident Controller. |
REC226-0574 | 14 - Incident Mgt Teams | Clear direction to divisional and sector commanders and a common communications platform enables maximum return to be gained from the application of tactical resources and this rests on good incident action planning, and good command and control. |
Rec-ID | Code | Recommendation |
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REC225-0540 | 25 - Inquiry, audit, lessons management and after action review | : In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
REC225-0538 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC225-0532 | 16 - Training and behaviour | All agencies ensure fire managers are trained to correctly interpret the new Spot Fire Weather Forecast and to familiarise themselves with the entire format – ensuring consideration of the whole forecast - not just the tabular data containing the 12 hour forecast. |
Rec-ID | Code | Recommendation |
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REC223-0518 | 16 - Training and behaviour | The Department of Environment and Conservation explore human resourcing models that: · make succession planning a priority; · look at options for the attraction and retention of staff; and · review how the salary levels of staff matches the decision making required in major activities such as prescribed burns. |
REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1867 | 16 - Training and behaviour | The Minister for Emergency Services ensure that the Fire and Emergency Services Authority’s peer support program is rejuvenated as soon as possible with increased funding to provided added training for staff volunteering for this program |
REC222-1865 | 16 - Training and behaviour | The Minister for Police immediately instigate processes to ensure that the psychological well-being of officers is at the forefront of the Western Australia Police’s staff planning. These processes should include all officers being trained in psychological first aid, with subsequent regular refresher courses. Senior officers should be the first priority for psychological first aid training. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
Rec-ID | Code | Recommendation |
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REC221-2860 | 19 - Offences | Housing should ensure it has sound systems, processes and controls in place that minimise the opportunity for fraud and gives it the best chance of detecting it by: |
Rec-ID | Code | Recommendation |
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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 |
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REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
Rec-ID | Code | Recommendation |
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REC203-0300 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command, and not through agency chain of command. |
REC203-0294 | 14 - Incident Mgt Teams | Opportunities should be sought to embed other local government representatives in other areas of the IMT particularly in public information. |
Rec-ID | Code | Recommendation |
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REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
REC202-0494 | 16 - Training and behaviour | The Minister for Emergency Services introduce by the 2012-13 bushfire season psychological testing of all FESA career staff and bushfire and rescue volunteers. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
Rec-ID | Code | Recommendation |
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REC201-0248 | 14 - Incident Mgt Teams | To provide Level 3 IC‘s (and FESA) with a level of confidence and to maintain currency across the pool of accredited IC‘s, regular exercising of IC‘s and Level 3 IMT‘s is required. |
REC201-0258 | 14 - Incident Mgt Teams | FESA should review the size of the existing pre-formed IMT to include additional Information and Planning officers and increased resourcing of scribes and management support for all Level 3 incidents. |
REC201-0255 | 14 - Incident Mgt Teams | FESA and DEC need to appoint accredited Level 3 IC‘s based on experience, competency and currency. |
REC201-0254 | 14 - Incident Mgt Teams | FESA should continue to develop with DEC and Local Government a number of rostered pre-formed IMT‘s available throughout the fire season, regardless of predicted weather. |
REC201-0253 | 14 - Incident Mgt Teams | Review the command function of the MROC for Level 3 incidents when the SOC is activated. |
REC201-0251 | 14 - Incident Mgt Teams | All responding crews and the incident command appointments should adopt a ‘Size Up‘ reporting format. |
Rec-ID | Code | Recommendation |
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REC200-0391 | 14 - Incident Mgt Teams | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. This should include provision for a formal review of the performance of individual Level 3 Incident Controllers after every incident. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0366 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0390 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: measuring and mapping fuel loads maintaining fuel load databases drawing up prescriptions for, and overseeing controlled burns building effective working relationships with all relevant stakeholders. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1731 | 16 - Training and behaviour | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1730 | 16 - Training and behaviour | The Fire and Emergency Services Authority and local governments examine the current competencies of Chief Bushfire Control Officers and Community Emergency Services Managers (or Community Fire Managers) and consider what further development is needed to ensure these staff are capable of: |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-1706 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
Rec-ID | Code | Recommendation |
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REC183-0110 | 16 - Training and behaviour | DEC should emphasise the principle of foresight by adopting an appreciation and decision making process and training staff in that process. |
REC183-0122 | 16 - Training and behaviour | A staff recognition and reward framework for service to fire management should be considered for DEC fire staff. |
REC183-0111 | 14 - Incident Mgt Teams | Conducting a pre-fire season exercise for each Pre-Formed Incident Management Team could be used to “re-accrediting” each team on an annual basis. |
REC183-0114 | 14 - Incident Mgt Teams | Higher level DEC guidance to Level 3 Incident Controllers could be improved by introducing a more explicit and robust process of questioning, engagement, monitoring and oversight of Level 3 Incident Controllers. |
REC183-0113 | 14 - Incident Mgt Teams | A summary Incident Action Plan could allow the Incident Controller to more quickly appreciate the situation and articulate a plan early in an incident. |
REC183-0112 | 14 - Incident Mgt Teams | DEC’s incident management capability could be enhanced by: – Appointing a Deputy Incident Controller for every Level 3 IMT. – Establishing a fast response “short” IMT capability for each Level 3 IMT. – Establish clear triggers to initiate sending in a “short” IMT to a fire. – Including FESA officers in pre-formed Level 3 IMT’s. – Establishing additional pre-formed Level 3 IMT’s with FESA. – Where appropriate, appointing a local Bush Fire Brigade officer as Deputy Operations Officer. |
Rec-ID | Code | Recommendation |
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REC182-0131 | 14 - Incident Mgt Teams | FESA establishes a dedicated intelligence function in Incident Management Teams for major bushfires and ensure this function is appropriately supported with threat based tools and systems. |
Rec-ID | Code | Recommendation |
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REC173-0105 | 19 - Offences | That the Department of the Attorney General, in consultation with FESA and Western Australia Police (WAPOL), consider options for legislative amendments to extend criminal liability to all damage, injury or death directly caused by arson. |
Rec-ID | Code | Recommendation |
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REC172-0008 | 14 - Incident Mgt Teams | Potential OAMG membership should be identified in DEMC protocols and local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA.] |
REC172-0023 | 16 - Training and behaviour | Pre-season multi- agency refresher training for Ground Controllers should be undertaken each year. |
REC172-0007 | 14 - Incident Mgt Teams | A formal OAMG meeting should be convened as early as possible for incidents with the potential to be Level 3 incidents. At the very least early advice to potential OAMG members should be made on days that exhibit extreme fire weather and other high ignition risk factors that a meeting is likely to be convened. The initial OAMG should include all OAMG representatives identified by LEMAC and DEMAC for each area to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0006 | 14 - Incident Mgt Teams | Prior to the bushfire season, potential IMG members, many of whom are members of the Local Emergency Management Committee (LEMC) should be made aware of, and possibly exercise, their role as an IMG member. |
REC172-0035 | 14 - Incident Mgt Teams | At Level 3 incidents the Information Services Unit should be adequately resourced with information technology and at least 6 persons, all of whom are very experienced and capable in dealing with the information demands of a Level 3 incident. |
REC172-0005 | 14 - Incident Mgt Teams | Potential IMG membership should be identified in local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA. |
REC172-0010 | 14 - Incident Mgt Teams | The responsibilities and obligations for an OAM and OAMG (when established) needs to clarified and codified in Westplan Bushfire with regard to • Provision of information to participating organisations about the progress and potential of an incident; • Dealing with information disseminated to the public; and • Sourcing, coordinating and prioritising resources required by incidents within the Operations Area. There is lack of clarity in current arrangements concerning the role of the agency undertaking control operations e.g. DEC or a local govt and the transfer of these responsibilities to an OAMG when established. |
REC172-0041 | 16 - Training and behaviour | Media liaison personnel are needed to ‘ride’ shotgun’ on media personnel to facilitate them getting their stories without imposing on the effectiveness of operations. |
REC172-0004 | 14 - Incident Mgt Teams | A formal IMG meeting should be convened as early as possible at initiating incidents with potential. At the very least early advice to potential IMG members should be made that a meeting is likely to be convened. The initial IMG should include all IMG representatives to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0009 | 14 - Incident Mgt Teams | When an OAMG is established, a formal declaration of its establishment needs to be transmitted to all organisation/agencies involved. The declaration should clearly establish the reporting arrangements for Incident Controllers to the OAM as described in Westplan Bushfire. |
REC172-0031 | 16 - Training and behaviour | Pre-season refresher training to include an emphasis on check in/out procedures |
Rec-ID | Code | Recommendation |
---|---|---|
REC171-0067 | 14 - Incident Mgt Teams | That to the extent it has not already done so, DEC take action to ensure that in future cases relevant weather forecast information, particularly information as to significant wind changes, is promptly transmitted through the Incident Management Team and made available to persons with field operation responsibility. |
Rec-ID | Code | Recommendation |
---|---|---|
REC170-0065 | 16 - Training and behaviour | Agencies should: train their staff who will be involved in emergencies in incident management. |
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC163-1934 | 19 - Offences | The prescribed penalty notice penalty amount for section 100(2) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1941 | 19 - Offences | A working group be established to consider methods of preventing criminal firestarting. |
REC163-1940 | 19 - Offences | That legislation be prepared by the Criminal Law Review Division of the Attorney General’s Department allowing designated officers of the Rural Fire Service to apply for a warrant in certain circumstances. |
REC163-1937 | 19 - Offences | That the Attorney General’s Department’s Crime Prevention Division consider the causes of, and any solution to, the high number of juveniles involved in causing bushfires. |
REC163-1936 | 19 - Offences | The prescribed penalty notice penalty amount for section 66(7) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1935 | 19 - Offences | The prescribed penalty notice penalty amount for section 99(6) of the Rural Fires Act 1997 be increased to $1,100. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC128-3598 | 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. |
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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3719 | 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. |
REC121-3726 | 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. |
REC121-3768 | 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. |
REC121-3677 | 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. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3718 | 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. |
REC121-3713 | 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. |
REC121-3654 | 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. |
REC121-3756 | 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. |
REC121-3765 | 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. |
REC121-3675 | 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. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3717 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3650 | 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. |
REC121-3751 | 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. |
REC121-3758 | 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. |
REC121-3672 | 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. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3746 | 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. |
REC121-3757 | 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. |
REC121-3670 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3715 | 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. |
REC121-3691 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3902 | 14 - Incident Mgt Teams | Government should: establish a State-wide command structure across volunteer Bush Fire Brigades for fighting major bushfires, to more effectively manage the coordination of personnel and resources |
REC113-3905 | 16 - Training and behaviour | Firefighting organisations should: address their key training and development issues |
Rec-ID | Code | Recommendation |
---|---|---|
REC019-4144 | 16 - Training and behaviour | No opportunity be lost of encouraging the formation of bush fire brigades and the maintenance of enthusiasm and that the Bush Fires Board assist the brigades in any way possible to obtain adequate training and equipment. |
REC019-4139 | 19 - Offences | Local authorities prosecute in all cases of deliberate breaches of the provisions of the Bush Fires Act and thay failing this the Bush Fires Board take appropriate action to initiate such prosecutions. |
REC019-4158 | 16 - Training and behaviour | That needs in the direction of a fire emergency service be met as far as practicable by the Bush Fires Board in its training programme and in the tactical organisation of existing brigades for use as reserves in districts other than their own. |
Rec-ID | Code | Recommendation |
---|---|---|
REC013_3982 | 19 - Offences | To prohibit persons taking into a harvest field or through any grass or bush lands any motor, tractor, harvester, &c., which is not supplied with an approved fire extinguisher or without the exhaust being properly fitted and protected, under a penalty not exceeding $50. |
REC013_3983 | 19 - Offences | To prohibit persons throwing lighted cigarettes, cigars and tobacco among any straw, stubble, grass or herbage during the months of September to March in any Bush Fire area, under a penalty not exceeding $10. |