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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REC315-3873 | 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. |
REC315-3817 | 5 - Hazard reduction burns | That Government, noting that hazard reduction targeted in proximity to assets is on balance more likely to provide help than hinder, should: |
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. |
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. |
REC315-3816 | 5 - Hazard reduction burns | That Government re-commit to the current, regionally based approach to planning and coordinating hazard reduction activities across all tenures through Bush Fire Management Committees but ensure that it is actually being implemented at a high-level of quality across NSW. Getting it to a high-level of quality requires: |
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. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
REC315-3858 | 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. |
REC315-3838 | 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. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
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. |
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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REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
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. |
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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REC292-2351 | 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. |
REC292-2370 | 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. |
REC292-2337 | 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. |
REC292-2366 | 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 |
Rec-ID | Code | Recommendation |
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REC288-1195 | 5 - Hazard reduction burns | The Committee finds that on the evidence presented, that the Fuel Reduction Burn Program should be maintained and have its budget directly funded to ensure that the program continues and does not hinder other services or programs. |
Rec-ID | Code | Recommendation |
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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. |
REC287-1183 | 16 - Training and behaviour | Further conversations take place between TFS and SES to identify what skills and capabilities may be transferable between the agencies, not just in the event of a future fire, but in case of future hazards for which SES is the primary response agency, including food, earthquake and tsunami. |
REC287-1181 | 16 - Training and behaviour | The Tasmanian fire agencies develop a multi-agency position to ensure that training for incident controllers includes training in how the transition from local incident control to Divisional Command is managed. |
REC287-1190 | 16 - Training and behaviour | That a full review be undertaken of the benefts and costs of training a cadre of Tasmanian volunteer firefghters in remote area firefghting, with reference to the experience of jurisdictions interstate that already do so. |
REC287-1189 | 16 - Training and behaviour | That suffcient Tasmanian firefghters are trained in winch operations to sustain a ‘first strike’ capability until they can be reinforced (if necessary) by interstate capability; and that consideration be given to how winch-capable aircraft can be sourced to support this activity at fire incidents. |
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. |
REC287-1187 | 16 - Training and behaviour | All Tasmanian fire agency staff who are assigned to aviation-related roles be required to complete the formal nationally recognised training appropriate to that role. Tasmanian fire agencies arrange secondments to larger states for staff who are going to undertake aviation-related roles, to give them practical experience of the role in advance of any major incidents. |
Rec-ID | Code | Recommendation |
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REC286-2053 | 40 - Equipment and consumables | Personal protective equipment (masks, gowns, gloves, goggles) – enhance stocktake methods. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
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. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2021 | 40 - Equipment and consumables | Review temporary bridge stockpile for adequacy (DSG). |
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. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
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. |
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1444 | 16 - Training and behaviour | Maintain adequate seasonal fire crew resources across the fire agencies. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-2054 | 40 - Equipment and consumables | Personal protective equipment (masks, gowns, gloves, goggles) – review supply/distribution arrangements. |
REC286-1434 | 16 - Training and behaviour | Improve the strategic resource-to-risk skills mix (recruitment, retention, capacity), including investigating difference models of volunteering within the TFS Brigade Network. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
REC286-2057 | 16 - Training and behaviour | Provide training sessions to GPs to improve their understanding of their roles, options and obligations relating to human influenza pandemic. |
REC286-1441 | 5 - Hazard reduction burns | Continue the Fuel Reduction Program. |
Rec-ID | Code | Recommendation |
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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. |
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. |
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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REC280-1378 | 5 - Hazard reduction burns | That the NSW Rural Fire Service: -improve accountability in relation to the implementation of bush fire risk management plans as a means of delivering more hazard reduction. |
REC280-1377 | 5 - Hazard reduction burns | That the NSW Rural Fire Service, in collaboration with the NSW National Parks and Wildlife Service, review and improve the system of bush fire management zones to ensure that greater priority is given to hazard reduction on land classified within land management zones. |
REC280-1376 | 5 - Hazard reduction burns | That the NSW National Parks and Wildlife Service establish a regime of frequent mosaic burning within the Warrumbungle National Park, where conditions permit, to be monitored and evaluated via a formal fully funded research program. This program should then inform the Service’s approach to the wider national park estate. |
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. |
REC280-1375 | 5 - Hazard reduction burns | That the NSW Government commit to and fund a long term program of prescribed burning based on the recommendation of the 2009 Victorian Bushfires Royal Commission of an annual rolling target of a minimum of five per cent of public land per year, and that the NSW Government commit to extending the funding for the National Parks and Wildlife Service five year hazard reduction program past 2016. |
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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REC261-1495 | 5 - Hazard reduction burns | That the NSW Rural Fire Service: |
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. |
REC261-1493 | 5 - Hazard reduction burns | That the NSW National Parks and Wildlife Service establish a regime of frequent mosaic burning within the Warrumbungle National Park, where conditions permit, to be monitored and evaluated via a formal fully funded research program. This program should then inform the Service’s approach to the wider national park estate. |
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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REC260-1070 | 5 - Hazard reduction burns | The NPWS conduct a review of its prescribed burns program to ensure, as far as reasonably practicable, that all necessary managerial approvals for a prescribed burn are provided as promptly as possible. |
REC260-1063 | 5 - Hazard reduction burns | That the National Parks and Wildlife Service consider reviewing its guidelines and protocols in respect of hazard reduction planning and burning-off operations in the light of the evidence from experts witnesses in these proceedings that the incidence of, and intensity of, major fires is increasing and in the light of expert evidence given in these proceedings concerning the dangers of vorticity-driven lateral spread. |
REC260-1068 | 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. |
REC260-1062 | 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. |
REC260-1057 | 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. |
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. |
REC247-0936 | 16 - Training and behaviour | That the State Fire Management Committee note the decline in machinery and skilled operators from the forestry industry in the private sector and determines how this reduction in fire management capability can be addressed. |
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. |
REC247-0925 | 16 - Training and behaviour | That training and development of personnel to establish a suitable state of readiness, be included in the recommended review by Tasmania Police of its approach to emergency 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. |
REC247-0939 | 5 - Hazard reduction burns | That Tasmania Fire Service conducts a review of the fire permit system in the Fire Service Act 1979, and implements change to improve the efficiency and effectiveness of the system by: • considering whether it is appropriate to authorise persons or organisations to conduct fuel reduction burning during a permit period • providing a better match between the period, area and fire risk • maintaining a timely and efficient process for issuing permits • naming the period in a way that draws attention to bushfire risk • establishing a reporting and accountability process. |
REC247-0924 | 16 - Training and behaviour | That an exercise program — to establish and maintain an acceptable state of readiness for agencies and organisations required to be involved in emergency operations — be developed and implemented. |
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. |
REC247-0938 | 5 - Hazard reduction burns | That Tasmania Fire Service or another suitable agency provides information to the community which shows, in simple form, the legislation applicable to approvals for lighting fires on private property and the various relationships between that legislation. |
REC247-0868 | 16 - Training and behaviour | That Tasmania Fire Service, Forestry Tasmania, and Parks and Wildlife Service have a process for ensuring fire strategy and tactics are appropriate and remain focussed. |
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. |
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 |
---|---|---|
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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REC193-0220 | 16 - Training and behaviour | The State Fire Management Council work with local government councils to improve the availability of relevant professional development. |
REC193-0219 | 16 - Training and behaviour | The Tasmania Fire Service, the Department of Primary Industries, Parks, Water and Environment and Forestry Tasmania continue to encourage the relevant national bodies to further implement the COAG 2004 recommendation, namely: ... that the Australasian Fire Authorities Council and Emergency Management Australia — in partnership with state and territory agencies and other education and research institutions — coordinate a national program of professional development focused on bushfire mitigation and management. Under the program, partners would deliver nationally coordinated professional development services to all jurisdictions. |
REC193-0218 | 16 - Training and behaviour | The Tasmania Fire Service, the Department of Primary Industries, Parks, Water and Environment and Forestry Tasmania pursue funding from the Commonwealth (Department of Education, Employment and Workplace Relations), in line with COAG Recommendation 11.2, namely that the states and territories and the Australian National Training Authority provide additional funding, as necessary, to registered training organisations to support the development and delivery of learning and training resources to all firefighters. |
REC193-0227 | 5 - Hazard reduction burns | Local government councils implement a zoning approach to fuel management as recommended by COAG 2004. |
Rec-ID | Code | Recommendation |
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REC166-3002 | 16 - Training and behaviour | That the Tasmania Fire Service provide additional training in the use of thermal camera imaging: |
REC166-3001 | 16 - Training and behaviour | That the Tasmania Fire Service provide further training in respect to sprinkler systems, namely: |
REC166-3009 | 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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REC164-0075 | 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 |
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REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3650 | 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. |
REC121-3756 | 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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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: |
REC121-3768 | 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. |
REC121-3737 | 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. |
REC121-3717 | 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. |
REC121-3743 | 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”. |
REC121-3713 | 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. |
REC121-3751 | 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. |
REC121-3682 | 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. |
REC121-3711 | 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. |
REC121-3765 | 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. |
REC121-3672 | 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. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3746 | 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. |
REC121-3681 | 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. |
REC121-3709 | 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. |
REC121-3758 | 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. |
REC121-3670 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3740 | 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. |
REC121-3693 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3707 | 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”. |
REC121-3757 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3691 | 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. |
REC121-3719 | 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. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3753 | 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. |
REC121-3654 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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. |
REC121-3677 | 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. |
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 |
---|---|---|
REC013_3975 | 5 - Hazard reduction burns | To burn, where necessary, at least 33 feet where there is a risk of fire, on the outside of the railway fence, in conjunction with the railway employees. |
REC013_3973 | 40 - Equipment and consumables | To arrange for uniform water facilities, where possible, by having large taps attached to elevated tanks, suitable approaches made to dams for filling carts, and convienient gates to approach same. |
REC013_3972 | 40 - Equipment and consumables | To recommend to shire councils the purchase of fire carts and necessary equipment for fire fighting. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |