Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
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. |
REC315-3838 | 29 - Operational Health and Safety | That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members. |
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. |
REC315-3858 | 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. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3840 | 29 - Operational Health and Safety | That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters. |
Rec-ID | Code | Recommendation |
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REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
Rec-ID | Code | Recommendation |
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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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REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
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REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
REC292-2370 | 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. |
Rec-ID | Code | Recommendation |
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REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
Rec-ID | Code | Recommendation |
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REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
REC286-1438 | 25 - Inquiry, audit, lessons management and after action review | Consider outcomes of national review of warnings and review resilience of warning systems’ infrastructure. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
Rec-ID | Code | Recommendation |
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REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
Rec-ID | Code | Recommendation |
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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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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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REC260-1061 | 18 - Access to fire ground | That the National Parks and Wildlife Service, in consultation with the relevant local Council(s), devise a policy that enables the John Renshaw Parkway to be closed at either end of the Warrumbungle National Park during a bush fire in such a way that its closure would not impede access by emergency services vehicles into the park. |
Rec-ID | Code | Recommendation |
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REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0899 | 18 - Access to fire ground | That appropriate plans are made to mobilise resources quickly to re-open roads affected by emergencies. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0885 | 18 - Access to fire ground | That arrangements are made for and appropriate pre-planning occurs to effectively implement the policy on road closures and traffic management. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0884 | 18 - Access to fire ground | That Tasmania Police reviews its Emergency Traffic Management Points policy; and develops a multi-agency policy in the emergency management plans for road closures and traffic management, including clarity in decision making, coordination and sufficient operational flexibility. |
REC247-0937 | 19 - Offences | That the legislation and enforcement arrangements are reviewed to ensure there are suitable offences and penalties, investigation and enforcement capabilities, and a rigorous approach is taken to breaches of the law. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0906 | 18 - Access to fire ground | That emergency management plans recognise the need to provide priority access to areas of emergency operations for critical infrastructure providers. |
Rec-ID | Code | Recommendation |
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REC246-0788 | 25 - Inquiry, audit, lessons management and after action review | TFS seek to address the following outstanding items from the recommendations of the Victorian Bushfires Royal Commission. § 45 out of 53 Community Bushfire Response Plans for “at risk” communities have been finalized. The remaining eight should be completed as a priority action. § That TFS progress the development of Community Bushfire Mitigation Plans for the 53 at risk communities, possibly as an action for reactivated Fire Management Area Committees. § TFS, together with other ESOs and local government, should develop a common comprehensive approach to the option of planned evacuation from dangerous or potentially dangerous areas to safer areas and eventual return. § TFS should include factors for consideration for evacuation during a bushfire into their training doctrine for Incident Controllers. § The IAP Template and its application be reinforced as an important operational requirement for IMT’s during the 2013-14 pre-season briefing program. 10 § That TFS review their use of IRMS to ascertain if either its full potential is not being realized through a lack of operator training or it is in fact not providing the required functionality and there is a need to research an improved resource management system which enhances interoperability. § The TFS Publication: Guidelines for Development in Bushfire Prone Areas of Tasmania http://www.fire.tas.gov.au/userfiles/stuartp/file/Publications/BushDeve… s2012.pdf requires an update to reflect the provisions of Planning Directive #5 Bushfire-Prone Areas Code. |
Rec-ID | Code | Recommendation |
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REC238-0799 | 18 - Access to fire ground | Develop and implement a program of cost-effective road improvement works that can enhance flood evacuation capacity in the short-medium term. |
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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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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REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
Rec-ID | Code | Recommendation |
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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 |
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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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3742 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3726 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3713 | 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. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3765 | 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. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3758 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3757 | 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. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3691 | 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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3753 | 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. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
Rec-ID | Code | Recommendation |
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REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
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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. |
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. |