Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
REC324-4293 | 17 - Assets and technology | Essential services and floodplain infrastructure: That, to minimise disruption to essential services (power, communications, water, sewerage) and to ensure flood infrastructure is fully serviceable before flooding, Government ensure: |
REC324-4312 | 17 - Assets and technology | Impact to essential services: That, to minimise disruption to essential services, including outages which compromise basic communication coverage, and to ensure access to safe water supply and power during flood events, Government work directly or together with the Australian and other state governments and/or their relevant power and telecommunications regulatory, policy and market bodies to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC323-4258 | 39 - Disaster Risk Management | That the NSW Government significantly increase its investment in flood mitigation and preparation, including its support of local governments to do the same, by: • increasing ongoing, long term funding and access to technical guidance and assistance for local councils • ensuring that land-use planning and development takes a risk-based approach. |
REC323-4286 | 17 - Assets and technology | That the NSW Government advocate through the National Cabinet for the Bureau of Meteorology to review its rain data infrastructure and flood modelling tools, to ensure forecasting locations, rain and flood gauges and other infrastructure are appropriately placed, maintained and updated. |
REC323-4256 | 17 - Assets and technology | That the NSW Government work with relevant agencies and local landowners to find ways to improve the management of drainage channels including looking for recommendations to reduce red and green tape. |
REC323-4263 | 17 - Assets and technology | That the NSW Government prioritise support for the full restoration of sewage treatment facilities on the Richmond River, for the benefit of communities in the Northern Rivers region. |
REC323-4290 | 20 - Role of police | That the NSW Government embed into its emergency plans the appointment of a senior police officer with combat experience to lead recovery efforts following natural disasters. |
REC323-4282 | 16 - Training and behaviour | That the NSW Government invest in the required personnel, training and vessels to ensure that all agencies involved in flood rescue can be mobilised to their fullest potential. |
REC323-4285 | 17 - Assets and technology | That the NSW Government, in consultation with telecommunication providers and satellite communication providers, investigate ways to minimise the complete loss of telecommunication services in natural disasters, including: |
Rec-ID | Code | Recommendation |
---|---|---|
REC321-4207 | 25 - Inquiry, audit, lessons management and after action review | We recommend that DELWP reviews its target for the number of fuel hazard assessments conducted and ensures that this measure is evidence based, accurately reflects regional performance, and that the department monitors and reports on each region’s performance against it. |
Rec-ID | Code | Recommendation |
---|---|---|
REC318-4181 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in collaboration with the emergency management sector and as part of the emergency management planning reforms: |
REC318-4178 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in collaboration with the Country Fire Authority and local government – undertake a review of the current residual risk target to ensure that it remains contemporary in terms of its designated percentage value. The review should: |
REC318-4171 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that the State review (and where necessary amend) legislation including but not limited to the Country Fire Authority Act 1958, Forest Act 1958 and Local Government Act 2020 to: |
REC318-4182 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General for Emergency Management recommends that Emergency Management Victoria – in partnership with agencies engaged in state, regional and incident control centres: |
Rec-ID | Code | Recommendation |
---|---|---|
REC316-4020 | 16 - Training and behaviour | EPSDD and ESA work together to develop values officer training and accreditation. |
REC316-4033 | 25 - Inquiry, audit, lessons management and after action review | The BFC Terms of Reference be reviewed to ensure they are contemporary and reflect learnings from this and recent bushfire seasons. |
REC316-4029 | 17 - Assets and technology | ACT Government continues to develop the concept for an ACT specific emergency app whilst also using national coordination mechanisms to support an affordable nationally standard all-hazards mobile app. |
REC316-4018 | 25 - Inquiry, audit, lessons management and after action review | The five year review of the Emergencies Act examine amendments to better define the rationale for a State of Alert / State of Emergency whilst ensuring that the relevant Minister / Chief Minister still has sufficient discretion to make a declaration based on advice from relevant Government officials and committees. |
REC316-4014 | 25 - Inquiry, audit, lessons management and after action review | That Justice and Community Safety Directorate (JACS) lead a working group from across relevant organisations to undertake the five year review of the Emergencies Act in conjunction with a wholistic review of the Emergency Plan and relevant sub-plans; and recommendations from this review, to the extent they are accepted by Government. Bringing together a small Taskforce of staff from across government for a set period would assist the working group in delivering the work needed to address these and other recommendations. |
REC316-4042 | 25 - Inquiry, audit, lessons management and after action review | ACT Government undertake a detailed legislative review to ensure that information regarding vulnerable community members can be appropriately accessed, provided and used during an emergency event. |
REC316-4037 | 17 - Assets and technology | Consideration be given to developing alternate website contingency in the event of a critical failure and an assurance review across all community facing Government websites. |
REC316-4038 | 25 - Inquiry, audit, lessons management and after action review | The CCIP be reviewed in conjunction with the review of the Emergency Plan and the two synchronised. A workable approach to delivering operational emergency communications and strategic WhoG communications is developed with simple and clear reporting arrangements. |
REC316-4030 | 17 - Assets and technology | Continue to explore options in the short term to improve the functionality and relationship with NSW RFS ‘Fires Near Me’ with respect to ACT specific information before the 2020-21 bushfire season. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC315-3843 | 17 - Assets and technology | That, in order to improve early fire suppression, the NSW RFS trial initial aerial dispatch in areas of high bush fire risk. The trial should identify the most appropriate and cost-effective mix of aircraft, and any associated infrastructure improvements that would be required. |
REC315-3855 | 7 - Inter-agency communication | That, in order to ensure all agencies have a clear understanding of cross-border communication channels during bush fires, all MoUs between state or territory agencies include an agreed protocol about how agencies will communicate across borders and that these are reflected in Incident Action Plans. |
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. |
REC315-3837 | 17 - Assets and technology | That, in order to improve firefighter safety, Government fire authorities: |
REC315-3854 | 7 - Inter-agency communication | That, in order to ensure emergency response agencies can communicate across state and territory borders, the Commonwealth Government allocate 10 + 10 MHz as a dedicated spectrum for Public Safety Mobile Broadband (PSMB) at no cost to states and territories. |
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. |
REC315-3861 | 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. |
REC315-3836 | 17 - Assets and technology | That, in order to ensure frontline personnel have appropriate personal protective clothing during bush fires: |
REC315-3849 | 17 - Assets and technology | That, in order to enhance NSW’s fire fighting capacity, Government trial aerial fire fighting at night in the 2020-21 season with a view to full implementation if successful. |
REC315-3853 | 7 - Inter-agency communication | That, in order to ensure the State Emergency Operations Centre (SEOC) can maintain communications during emergencies, the Government provide the SEOC with independent Public Safety Network functionality. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3830 | 39 - Disaster Risk Management | That as a matter of urgency, in order to accelerate and finalise a State-wide strategic fire trail network, the NSW RFS Commissioner and Bush Fire Coordinating Committee (BFCC): |
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. |
REC315-3815 | 17 - Assets and technology | That, in order to equip NSW RFS with comprehensive information on all structures and assets at risk of bush fire, Government ensures that: |
REC315-3848 | 17 - Assets and technology | That, in order to enhance NSW’s ability to improve situational awareness, Government expand FRNSW’s Remotely Piloted Aerial Systems (RPAS) capability (both capital assets and trained operators) to major regional centres and ensure the NSW RFS and other NSW government agencies can access this capability as required. |
REC315-3852 | 7 - Inter-agency communication | That, in order to improve fireground communications between NSW agencies and interstate personnel: a) Government ensure all NSW fire authority personnel and vehicles can access and utilise the Public Safety Network (PSN). This should include access to NSW RFS Private Mobile Radio networks where PSN coverage is not yet available. |
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. |
REC315-3825 | 39 - Disaster Risk Management | That Government, acknowledging that a strategic approach to planning for bush fire will take time, and in order to protect, prepare and build resilience into existing communities better, should immediately: |
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: |
REC315-3873 | 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. |
REC315-3847 | 17 - Assets and technology | That, in order to ensure Australia’s fire fighting aerial capacity capitalises on existing assets and is made up of the right mix, Government: |
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2402 | 17 - Assets and technology | Explore better options for call and dispatch, telecommunications and information sharing capability across the emergency management portfolio including the adoption of a multi-agency emergency management operations complex |
REC302-2398 | 17 - Assets and technology | As a matter of priority commence the roll out of AVL capability for the Rural Fire Service fleet, completing as much work as possible before the 2018/19 bushfire season, capitalising where necessary on current and future work undertaken with the NSW Government Radio Network to ensure both officer safety and situational awareness |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC002-4009 | 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. |
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC299-1344 | 25 - Inquiry, audit, lessons management and after action review | That a review of the cross‑tenure approach be undertaken to determine its effectiveness and to address issues that arise in fire prevention on private and public land. |
REC299-1343 | 25 - Inquiry, audit, lessons management and after action review | That the Government conduct a review of fire prevention |
Rec-ID | Code | Recommendation |
---|---|---|
REC292-2348 | 17 - Assets and technology | I recommend that if it has not already done so, the New South Wales Police Force acquires the audio surveillance technology that in similar circumstances would allow a device to be monitored in the Police Forward Command Post and/or the Police Operations Centre and that the organisation ensures that its capacity in this regard keeps pace with technological advances in the area. |
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. |
REC292-2337 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC274-1412 | 20 - Role of police | That Victoria Police assesses and where practical addresses limitations to available data and trials the use of response times for internal performance measurement. |
REC274-1408 | 7 - Inter-agency communication | That the Department of Health & Human Services uses Emergency Services Telecommunications Authority Computer Aided Dispatch data to report ambulance emergency response time performance. |
Rec-ID | Code | Recommendation |
---|---|---|
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
Rec-ID | Code | Recommendation |
---|---|---|
REC263-1097 | 16 - Training and behaviour | CFA should: improve Brigade Operational Skills Profiles to reflect volunteer activity and availability |
Rec-ID | Code | Recommendation |
---|---|---|
REC262-1485 | 7 - Inter-agency communication | That Victoria Police implements the recommendations relating to protective services officers in the Service Demand and Dispatcher Capacity Analysis dated September 2013 and: |
REC262-1484 | 7 - Inter-agency communication | That Ambulance Victoria: |
REC262-1483 | 7 - Inter-agency communication | That the Emergency Services Telecommunications Authority includes Victoria State Emergency Service vehicle capability details in the Computer Aided Dispatch database. |
REC262-1491 | 7 - Inter-agency communication | That Emergency Management Victoria expedites the expansion of the Rural Mobile Radio network to all emergency services organisations. |
REC262-1487 | 7 - Inter-agency communication | That the Emergency Services Telecommunications Authority, assisted by the Inspector-General for Emergency Management and responder agencies, improves the process for changing call-taking and dispatch procedures by comprehensively appraising the costs, benefits and operational impacts of these changes and agreeing a plan for their implementation with all affected agencies. |
REC262-1486 | 7 - Inter-agency communication | That Emergency Management Victoria novates the head contract for the StateNet Mobile Radio network to the Emergency Services Telecommunications Authority. |
Rec-ID | Code | Recommendation |
---|---|---|
REC261-1513 | 17 - Assets and technology | 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. |
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 |
---|---|---|
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. |
REC260-1060 | 7 - Inter-agency communication | That the Rural Fire Service and National Parks and Wildlife Service review the procedures for requesting aerial support in ‘severe’ or worse fire conditions to ensure that delays in providing it are reduced to the minimum time possible. |
REC260-1057 | 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 |
---|---|---|
REC250-0796 | 25 - Inquiry, audit, lessons management and after action review | The Department of Premier and Cabinet should lead: x the development of an evaluation framework, based on work undertaken to date by the Department of Human Services, to be used in assessing the impact of relief and recovery programs in the recent floods and in future disaster events x an evaluation of the impact of relief and recovery programs in the recent floods, using this framework. |
REC250-0790 | 25 - Inquiry, audit, lessons management and after action review | The Department of Justice should review the current model for rapid impact assessment to improve the quality of the information collected. |
Rec-ID | Code | Recommendation |
---|---|---|
REC248-2587 | 16 - Training and behaviour | Victoria Police should adequately train all frontline police managers to handle complex personal matters involving staff. |
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 |
---|---|---|
REC228-1614 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the ACT Bushfire Council, should conduct a review of the ACT Bushfire Council against its recently developed terms of reference (July 2013) within two years. |
REC228-1609 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency should undertake audits to meet the requirements in the Strategic Bushfire Management Plan for the preparation, sharing and publication of annual progress reports. Annual progress reports should be made available to the ACT Bushfire Council. |
REC228-1620 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the Territory and Municipal Services Directorate, should review the Farm FireWise Program, including: |
Rec-ID | Code | Recommendation |
---|---|---|
REC217-1840 | 25 - Inquiry, audit, lessons management and after action review | The state government implement the Victorian Floods Review recommendation 8, to review the flood gauging network. As part of the review, consideration should also be given to the use of portable telemetered river gauges, and to the replacement of manual gauges with telemetered gauges over time and where appropriate. |
REC217-1826 | 39 - Disaster Risk Management | A revised Victoria Flood Management Strategy should identify and assign roles and responsibilities for the management and ongoing maintenance of Victoria’s waterways, for the purposes of flood protection and flood mitigation: |
Rec-ID | Code | Recommendation |
---|---|---|
REC215-1877 | 39 - Disaster Risk Management | Regulators can help to achieve improved outcomes by considering the issues identified by this review |
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
REC215-1876 | 39 - Disaster Risk Management | Fire services can improve outcomes by initiating discussions with landfill operators about fire management planning and emphasising the critical importance of water supplies and early intervention |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0410 | 17 - Assets and technology | the state take the necessary measures to upgrade existing manual stream and rain gauges and ensure that all future gauges provide a seamless transfer of data from the gauges to the Bureau of Meteorology. |
REC199-0453 | 20 - Role of police | Victoria Police revise coordinator arrangements to ensure: • a coordinator presence is maintained at the place where incident control is being exercised • effective control is established and is maintained until the response phase has concluded • key control roles may be performed by personnel from agencies other than the designated control agency • that the timely compilation and distribution of an appropriate Incident Action Plan is recognised as a fundamental component of establishing effective control • those performing the coordinator role at an Incident Control Centre be suitably trained, skilled and experienced in emergency management and where possible possess a degree of local knowledge of the relevant area; and • that the revised coordinator arrangements are reflected within the State Emergency Response Plan |
REC199-0446 | 7 - Inter-agency communication | the state commit to securing effective multi-agency interoperable communications as a high level priority and that all future communications projects and upgrades incorporate compliance provisions mandating interoperability requirements. |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0418 | 7 - Inter-agency communication | the state develop an efficient process to ensure that, during flood events, temporary construction of flood mitigation works, such as levees, is controlled so as not to unacceptably impact on flood intelligence. |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0458 | 7 - Inter-agency communication | the state ensure: • a common, functional and accessible system be introduced to enable effective Municipal Emergency Coordination Centre and Incident Control Centre communications • a regime of regular Municipal Emergency Coordination Centre exercising is introduced with oversight by an appropriate independent body. Such exercising should include testing of systems utilised for Incident Control Centre and Municipal Emergency Coordination Centre communications • those required to perform Emergency Management Liaison Officer roles have undertaken appropriate training; and • resource requesting arrangements are clarified and documented so that control and coordination functions do not overlap. |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0449 | 7 - Inter-agency communication | the state ensure that interoperable information management practices are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0452 | 17 - Assets and technology | the state ensure that any new systems and equipment purchased by state emergency management agencies are interoperable with other relevant agencies to the fullest extent possible. This should involve the state establishing a procurement gateway process with input from the Emergency Services Commissioner. |
REC199-0447 | 7 - Inter-agency communication | the state ensure that common and interoperable resource management systems are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
Rec-ID | Code | Recommendation |
---|---|---|
REC198-2904 | 16 - Training and behaviour | The CFA, in collaboration with the other agencies develop a case study of the response to and recovery from the TriTech fire as a training and development opportunity. |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1755 | 16 - Training and behaviour | The CFA examine options to enable sufficient training materials to be available to ensure effective training delivery. As part of this examination, the CFA explore the feasibility of utilising the TAFE system. |
REC197-1763 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review the process for RCC and RPL with the view to making that process transparent, efficient and fair. |
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
REC197-1754 | 16 - Training and behaviour | The CFA proceed with the update of facilities and infrastructure at Fiskville to enable its better utilisation by volunteers and employees for training. Where necessary, the Government support this update when determining CFA funding. |
REC197-1762 | 16 - Training and behaviour | The CFA provide greater opportunities for leadership training for volunteers at all levels but particularly at the brigade level. The CFA, as far as practicable, endeavour to ensure that persons appointed to positions of leadership have the necessary capability. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1768 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby more volunteers are qualified to participate in Incident Management Teams. |
REC197-1753 | 16 - Training and behaviour | The CFA continue the Mobile Training Infrastructure Project and the Fixed Training Infrastructure Project. Where necessary, the Government support these initiatives in determining CFA funding. |
REC197-1761 | 16 - Training and behaviour | The CFA continue the development of key principles in relation to training, in consultation with volunteers and paid personnel. In the development of those principles, account should be taken of matters raised by volunteers to this Inquiry and the comments that I have made about training delivery. Account should also be taken of principles contained in any statement of Vision, Mission and Values adopted by the CFA. |
REC197-1747 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review its arrangements with respect to First Aid training and maintenance of currency of qualifications, with a view to the delivery of such training and maintenance best meeting brigade needs. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
REC197-1757 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, examine options to enable the engagement of an adequate instructor strength to serve the training needs of volunteers. Those options should include making more use of volunteers as instructors. |
REC197-1765 | 16 - Training and behaviour | The CFA continue the development of Vector Command Training and its availability and utilisation by volunteers. The feasibility of this training being provided online be explored by the CFA as part of the consideration of the use of the NBN. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1751 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to training budgets and, in particular, with respect to what relates to volunteer training and what relates to career staff training. |
REC197-1756 | 16 - Training and behaviour | CFA develop an individual training pathway for operational volunteers to enable volunteers to be able to better identify their career and training options and pursue a pathway that meets their expectation. |
REC197-1764 | 16 - Training and behaviour | A. The CFA, in consultation with volunteers, employees, the VFBV and the UFU, examine the feasibility of utilising the TAFE system for training delivery. |
REC197-1750 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to the identification and meeting of training demand, and plans to meet such demand. |
Rec-ID | Code | Recommendation |
---|---|---|
REC196-0233 | 16 - Training and behaviour | Further train Incident Controllers in the management of the Information Section and its roles. |
REC196-0232 | 16 - Training and behaviour | Increase the regularity of training for ICC Information Section staff and encourage pre-season drilling and trials in the use of OSOM and Emergency Alert particularly under critical capacity conditions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC195-0310 | 16 - Training and behaviour | The Fire Services Commissioner ensures that there is a comprehensive understanding of the State Command and Control Arrangements for Bushfires in Victoria across the Fire Services. |
REC195-0336 | 20 - Role of police | Victoria Police, under the auspice of the Regional Emergency Response Plan, lead a task force to ensure that the Princes Highway is treated as an asset of significance and an appropriate risk-based approach is adopted to minimise the impact of fire. This approach is to be integrated into regional and municipal fire management plan |
REC195-0322 | 7 - Inter-agency communication | The Fire Services investigate the reported technical communication issues for this fire |
REC195-0321 | 7 - Inter-agency communication | The Fire Services move towards a common and more disciplined approach to fireground communications. |
REC195-0326 | 16 - Training and behaviour | The Fire Services recognise the specialised role of Information Sections and enhance training and resources accordingly. |
REC195-0319 | 7 - Inter-agency communication | The Fire Services introduce systems, procedures and operational training that promote information sharing and consistent situational awareness at every level, including to and from the fireground. This should include agencies such as police members on duty at roadblocks |
REC195-0314 | 16 - Training and behaviour | The Fire Services enhance and increase joint training and exercise programs at all levels of command and control, including the State Control Centre. (These programs need to enable volunteer participation.) |
Rec-ID | Code | Recommendation |
---|---|---|
REC181-0173 | 7 - Inter-agency communication | The Country Fire Authority review and improve its communications strategy as a matter of priority and develop a program for identifying and responding to black spots in radio coverage. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
REC181-0171 | 17 - Assets and technology | The State, in conjunction with Emergency Management Australia and the Department of Defence, develop an agreement that allows Commonwealth aerial resources that are suitable for firefighting and support activities to be incorporated in preparedness plans and used on days of high fire risk. |
REC181-0185 | 20 - Role of police | Victoria Police continue to pursue a coordinated statewide approach to arson prevention and regularly review its approach to ensure that it contains the following elements: ■ high-level commitment from senior police; ■ a research program aimed at refining arson prevention and detection strategies; ■ centralised coordination that includes comprehensive training, periodic evaluation of arson prevention strategies and programs, and promotion of best-practice prevention approaches; ■ a requirement that all fire-prone police service areas have arson prevention plans and programs, according to their level of risk. |
REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
REC181-0170 | 17 - Assets and technology | The Country Fire Authority and the Department of Sustainability and Environment amend their policies on aerial preparedness and standby arrangements, their dispatch protocols and the management of aircraft in order to do the following: ■ require that at locations that attract the risk assessment or preparedness level A on code red days all personnel needed for air operations must be on standby by 10.00 am; ■ establish a system that enables the dispatch of aircraft to fires in high-risk areas without requiring a request from an Incident Controller or the State Duty Officer. |
REC181-0175 | 16 - Training and behaviour | The Country Fire Authority and the Department of Sustainability and Environment require without exception that all relevant staff be trained in the need for Incident Controller approval to be obtained before a back-burn is lit. |
REC181-0160 | 20 - Role of police | The State clarify whether, during major fires, Victoria Police should discharge its coordination functions from the State Emergency Response Coordination Centre or from the State Control Centre. |
Rec-ID | Code | Recommendation |
---|---|---|
REC179-2978 | 16 - Training and behaviour | The Department of Human Services should make sure relevant senior staff complete recovery training. |
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 |
---|---|---|
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3432 | 17 - Assets and technology | That port/channel managers are required to ensure, through service agreements, licensing, direct acquisition or other means as appropriate, the availability of the critical Level 1declared assets. |
REC158-3431 | 17 - Assets and technology | That port/channel managers are required to identify in the declared asset system (in conjunction with the emergency services) critical Level 1 declared assets and other Level 2 declared assets, that may be required in support of a marine emergency within the port, and that identified resource availability, accessibility and call out time is recorded. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3430 | 17 - Assets and technology | That the nominated marine safety authority is responsible for development of a declared asset system and is required to ensure that port/channel managers utilise and maintain the declared asset system. |
Rec-ID | Code | Recommendation |
---|---|---|
REC156-3495 | 16 - Training and behaviour | The Department of Primary Industries should work through the appropriate Ministerial Councils to seek alignment of competency standards for line workers across jurisdictions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC155-3466 | 25 - Inquiry, audit, lessons management and after action review | A comprehensive review of the effectiveness of the increased prescribed burning target in meeting ecological and bushfire suppression needs should be conducted every three years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3379 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that a thorough review be undertaken of the communications and coordination between the separate agencies which make up the Emergency Services Agency, to assess the extent to which cultural factors are detrimental to the effective operation of the ESA. |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3626 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making. |
REC129-3622 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases. |
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 |
---|---|---|
REC126-1952 | 25 - Inquiry, audit, lessons management and after action review | That regular periodic reviews be undertaken of changes made to the operational and management arrangements for dealing with wildfires and other emergencies in the ACT, to ensure that those arrangements continue to comply with the Australian Inter-Agency Incident Management System Incident Control System |
REC126-1950 | 39 - Disaster Risk Management | That the Emergency Services Agency adopt a more rigorous risk management approach to incident management and prediction – with particular emphasis on the development of improved community information strategies and protocols |
REC126-1987 | 7 - Inter-agency communication | That measures be taken to ensure that ACT and NSW Rural Fire Service radio communications systems are integrated, so that ACT and NSW firefighting units can communicate with each other |
REC126-1955 | 16 - Training and behaviour | That training of all personnel involved with emergency services be under constant review |
REC126-1983 | 16 - Training and behaviour | That the Australian Federal Police and the Emergency Services Agency ensure that personnel in their respective organisations are fully briefed on the agreed policy on evacuations |
REC126-1947 | 25 - Inquiry, audit, lessons management and after action review | That the ACT Government commission a review of coroners’ jurisdiction in order to determine whether that jurisdiction ought to be limited or expanded and, if so, to what extend |
REC126-1961 | 7 - Inter-agency communication | That the Emergency Services Agency review the communications systems used by the four services (the ACT Ambulance Service, the ACT Rural Fire Service, the ACT State Emergency Service and the ACT Fire Brigade), by the Australian Federal Police, by NSW emergency services and by aircraft and ensure the systems are compatible |
REC126-1980 | 16 - Training and behaviour | That public land management agencies ensure that their senior personnel have appropriate experience in fire management and are provided with adequate resources and suitable experienced and trained staff to effectively implement fire management programs |
REC126-1969 | 16 - Training and behaviour | That a review be conducted of the adequacy of training and the numbers of firefighters experienced in performing effective, safe large-scale back-burning operations |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |
REC126-1988 | 39 - Disaster Risk Management | That protocols and arrangements between the ACT and NSW require that each jurisdiction be fully involved in examining and planning for the threat posed by any fire likely to affect one or other jurisdiction and in coordinating the response to that fire |
REC126-1968 | 16 - Training and behaviour | That land managers ensure their staff are properly trained in the effective use of large bulldozers at wildfires and that staff are available to be assigned to supervise bulldozer operations |
REC126-2010 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the extent to which the recommendations in the McLeod report have been implemented in order to ensure implementation of those not yet implemented |
REC126-1986 | 39 - Disaster Risk Management | That the ACT and NSW authorities conduct a comprehensive risk analysis based on the most up to date knowledge relating to fire behaviour and spread in order to establish the degree of risk to each others' jurisdiction from fires ignitting in the other jurisdiction and to ensure that both jurisdictions remain fully informed and participate in risk assessments, the development of suppression strategies, and the development and dissemination of community information messages or warnings |
REC126-1967 | 40 - Equipment and consumables | That the Emergency Services Agency give priority to ensuring it has guaranteed access to an adequate number and type of bulldozers, as well as experienced operators, during the fire season, for immediate deployment as required |
REC126-1957 | 16 - Training and behaviour | That the Emergency Services Agency review the level of understanding among firefighting personnel of the latest information available nationally and internationally about wildfire behaviour and suppression and provide additional training if warranted |
Rec-ID | Code | Recommendation |
---|---|---|
REC125-3897 | 17 - Assets and technology | That agencies assess the cost-effectiveness of establishing a dedicated and proven asset management information system which is integrated with the other information systems used to manage drainage assets. |
REC125-3898 | 25 - Inquiry, audit, lessons management and after action review | That agencies develop a detailed improvement plan and commit resources to its implementation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC124-3890 | 16 - Training and behaviour | Update education and training programs relating to prescribed burning to reflect revised organisational priorities including year round (365 day) fire management program: |
Rec-ID | Code | Recommendation |
---|---|---|
REC123-3877 | 25 - Inquiry, audit, lessons management and after action review | All agencies review formal and informal incident notification processes to ensure they support the earliest possible reporting of emergencies to all stakeholders involved in the Airport Emergency Plan and in so doing, ensure early access to specialist advice and support. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3768 | 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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3717 | 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. |
REC121-3765 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3672 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
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. |
REC121-3670 | 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. |
REC121-3693 | 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. |
REC121-3715 | 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. |
REC121-3757 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3719 | 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. |
REC121-3654 | 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. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
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. |
REC121-3726 | 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. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
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 |
---|---|---|
REC112-3916 | 16 - Training and behaviour | That DPI reviews the work of entry level graduates to ensure career paths are clear and encourage the retention of staff. |
REC112-3912 | 25 - Inquiry, audit, lessons management and after action review | That DPI, as part of the development of the Victorian plant biosecurity strategy, undertake a strategic review of its plant health planning framework so that: • corporate and business unit plans at all levels of the department align to each other and to government policy so that staff have a coherent frame of reference to guide their work • performance indicators are developed, used, reported against and evaluated regularly • all plans (including service agreements with other parts of DPI) are communicated to staff and implemented in their day-to-day activities and responsibilities. |
REC112-3921 | 17 - Assets and technology | That the recommendations of the 2000 DPI report into the reference collection’s storage facility be implemented, to secure the collection in a purpose-built facility. |
REC112-3907 | 25 - Inquiry, audit, lessons management and after action review | That Department of Primary Industries (DPI), in partnership with the Department of Sustainability and Environment, reviews all legislation relating to plant biosecurity with a view to streamlining the legislative framework. |
REC112-3932 | 25 - Inquiry, audit, lessons management and after action review | That DPI conducts and documents debriefs after all incursions, and adopts any improvements that are identified through debriefs. |
REC112-3931 | 16 - Training and behaviour | That DPI ensures that AIIMS training includes information to ensure that everyone understands their role, and how information will be managed internally and externally, in the event of an incursion. |
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |
REC112-3930 | 16 - Training and behaviour | That DPI provides plant incursion-specific AIIMS training for anyone who might be involved in, or providing resources for, an incursion response. This includes senior management, field and research staff, contractors and industry participants. |
REC112-3919 | 25 - Inquiry, audit, lessons management and after action review | That the model for state funding be reviewed to ensure that DPI can confidently build and maintain a core level of diagnostic expertise and research capability. |
Rec-ID | Code | Recommendation |
---|---|---|
REC104-2235 | 16 - Training and behaviour | That DSE and CFA review selection and training programs for Incident Controllers and Incident Management Team members to ensure that they include all necessary competencies in recognition that technical skills are only one component of the required attributes. |
REC104-2264 | 16 - Training and behaviour | That CFA and DSE provide media training to all Level 2 and Level 3 Incident Controllers. |
REC104-2277 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review methods of gathering and processing fire information to ensure all methods are pursued to greatest effect. |
REC104-2293 | 25 - Inquiry, audit, lessons management and after action review | That aviation contractors be required to submit a copy of their annual independent regulatory compliance audit prepared for Civil Aviation Safety Authority to the State Aircraft Unit. |
REC104-2325 | 39 - Disaster Risk Management | That CFA, DSE and MFESB continue to develop the partnership approach for fire safety with Local Government, industry and communities. |
REC104-2286 | 17 - Assets and technology | That CFA, having regard to terrain, continue to review the mix of firefighting appliances currently in service. In particular, consideration should be given to the number and distribution of smaller ‘slip-on’ type equipment. |
REC104-2263 | 16 - Training and behaviour | That the person appointed by DSE or CFA as Incident Controller for any incident should have formal qualifications and accreditation in the Incident Control System, be fully aware of the Victorian emergency management arrangements and have access to local fire prevention and response planning, including the Municipal Fire Management Plan |
REC104-2228 | 25 - Inquiry, audit, lessons management and after action review | That the Government identifies an appropriate body, or bodies, to undertake the audit of the Municipal Fire Management Plans. |
REC104-2292 | 25 - Inquiry, audit, lessons management and after action review | That a systematic performance audit of State Aircraft Fleet contractors be conducted jointly by agency and SAU personnel. |
REC104-2317 | 39 - Disaster Risk Management | That DSE, with adequate resourcing, moves to a 12-month cycle of fire management to establish and maintain a more appropriate and balanced work program of prevention/mitigation and suppression. |
REC104-2260 | 16 - Training and behaviour | That VICSES, with the support of the CFA, includes basic fire safety training as one of the competencies for the VICSES Volunteers. |
REC104-2197 | 25 - Inquiry, audit, lessons management and after action review | That a review of the fuel management zones be implemented with a view to reducing the number of zones so as to focus clearly on (i) asset protection (especially at the Public/Private land interface), and (ii) ecological burns. |
REC104-2284 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA review the management of personnel deployed ensuring that: |
REC104-2189 | 39 - Disaster Risk Management | That DSE and CFA as part of their long term planning, and in conjunction with the Commonwealth Bureau of Meteorology, consider ways in which evidence for climate change and El Niño–Southern Oscillation cycle impacts on the likelihood of unplanned fire, can be better incorporated into preparedness and response planning. |
REC104-2259 | 16 - Training and behaviour | That the MFESB continue to give priority to appropriate bushfire training for its firefighters. |
REC104-2327 | 16 - Training and behaviour | That all fire agencies include a formal mentoring scheme as part of their workforce development programs; and that consideration be given to the use of suitably competent and experienced individuals (such as retired staff), to act as coaches or mentors with inexperienced Incident Controllers. |
REC104-2282 | 25 - Inquiry, audit, lessons management and after action review | That quality control or performance assessments are routinely completed post fire season, to ensure that contractors who have not performed to an agreed standard are not re-engaged for the consequential rehabilitation works. |
REC104-2333 | 25 - Inquiry, audit, lessons management and after action review | That in doing so, this Review must consult with the agencies mentioned above, and others such as VICSES and the Departments of Human Services and Primary Industries. |
REC104-2249 | 16 - Training and behaviour | That DSE and CFA ensure that: |
REC104-2294 | 16 - Training and behaviour | That training and competency programs for Incident Controllers should include aircraft firefighting capability training. |
REC104-2281 | 25 - Inquiry, audit, lessons management and after action review | That DSE and CFA work cooperatively to review the management and application of bulldozers in fire suppression operations to ensure that they are used effectively, appropriately and are adequately supervised. |
REC104-2332 | 25 - Inquiry, audit, lessons management and after action review | That the Review of emergency operations centres by the Departments of Premier and Cabinet and Treasury and Finance and the Office of the Emergency Services Commissioner: |
REC104-2274 | 7 - Inter-agency communication | That when Incident Management Teams implement significant changes to objectives and strategies, these are effectively communicated to firefighters, fire ground supervisors and affected communities, and are incorporated into the broader organisational planning. |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
Rec-ID | Code | Recommendation |
---|---|---|
REC016_3949 | 17 - Assets and technology | It is recommended that the A.R.P. dams or earth tanks be kept filled during possible danger periods. |
REC016_3948 | 16 - Training and behaviour | It is recommended that workers and volunteers generally be instructed in accordance with a pre-arranged plan, as to what they should do in future times of emergency. Since the fighting of fires is for the greater part a matter of voluntary action, some estimate could perhaps be made, after investigation, of the numbers of men in each department who would be willing to volunteer. It would be necessary that each department should become a component part of an over-riding scheme and that it and its members should be fully instructed in the matter of whistle or siren warnings, places of assembly, reception of messages from the director of proceedings, use of equipment, and the various details which would necessarily be parts of an effective scheme. The training need not be onerous. If given once or twice at the beginning of possible danger periods, it would make for some degree of order and efficiency instead of a probable state of confusion. |
REC016_3945 | 16 - Training and behaviour | It is recommended that a large proportion of men employed in and about the open-cut be systematically trained in the use of equipment and in the tactical disposition of it. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC004-3997 | 40 - Equipment and consumables | That suitable metal receptacles be fitted under the spittoons of all smoking compartments of country trains, to receive pipe ashes, lighted tobacco, cigars, cigarettes, matches, or other inflammable matter used by smokers. |
REC004-3996 | 17 - Assets and technology | That the standard pattern of cinder arrester be affixed to the ash-pans in all locomotives during the summer months. |
REC004-3994 | 17 - Assets and technology | That the Railway Department, while gradually reducing the number of different types of locomotives, should steadily keep in view the adoption of English and American railway practice, by providing engines with larger boilers, fire boxers, and smoke-boxes, and with wide blast-pipes, in order to insure ample steaming power with a minimum of forced draught. |
REC004-3992 | 17 - Assets and technology | That the use of a spark-arrester and cinder-arrester by the Railway Department shall not constitute a defence to an action for damage caused by fire escaping from a locomotive, unless the Department proves that such spark-arrester and cinder-arrester were in a thoroughly efficient condition when the fire took place. |