Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC313-2512 | 38 - Agency/Department Reporting | Documenting results and recommendations from disaster recovery tests. |
REC313-2508 | 25 - Inquiry, audit, lessons management and after action review | Regularly reviewing these plans to ensure that they reflect the current operating environment. |
REC313-2514 | 16 - Training and behaviour | Upskilling IT resources through disaster recovery testing or formal training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC310-2487 | 39 - Disaster Risk Management | The state’s arrangements for disaster management, including recovery, are articulated in the Disaster Management Act (2003), the Queensland Reconstruction Authority Act (2011), the State Disaster Management Plan and the Queensland Recovery Plan. To enable state-level arrangements to better support community-led recovery and to improve Queensland’s recovery governance |
REC310-2481 | 22 - Role of local Gvt | Greater clarity about responsibilities for recovery at the community, local, and district levels should be considered in any future review of the Disaster Management Act (2003). |
Rec-ID | Code | Recommendation |
---|---|---|
REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2474 | 16 - Training and behaviour | The provision of system-wide tools, education, guidance and testing for requests for assistance is strengthened to enhance understanding and outcomes. |
REC309-2473 | 22 - Role of local Gvt | Councils, with the support of stakeholders, continue to develop and promote local disaster dashboards as the ‘point of truth’ for community information and messaging during disaster events. Greater use during recovery should be considered. |
REC309-2472 | 38 - Agency/Department Reporting | A single point of truth be established for accurately capturing and reporting on disaster management group activation levels for any given timeframe. |
REC309-2480 | 22 - Role of local Gvt | Councils should formalise arrangements with entities that have the skills, capability and capacity to effectively manage spontaneous volunteers. These should be documented and integrated into planning and exercising. |
Rec-ID | Code | Recommendation |
---|---|---|
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
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 |
---|---|---|
REC296-1353 | 10 - Infrastructure | Regular annual testing at 100% on a load bank needs to be scheduled into a maintenance schedule. |
REC296-1358 | 10 - Infrastructure | If the existing generator is capable of providing the current essential power requirements then the generator needs a major inspection and overhaul all items that may need to be replaced due to age and condition. This includes checking compression, oil pressure, coolant pumping and all other critical components and may actually require providing a temporary generator while the Hospital generator receives a major inspection and possible re build. A ball park figure to do this would be $50,000.00 plus cranage and transport to Detroit workshop probably another $10,000.00 then a temporary generator would need to be hired and installed which could run into $10’s of thousands of dollars depending on how long the engine was out of service. For the money that would be spent checking and rebuilding the existing engine it would be recommended to replace the generator with a new generator. |
REC296-1363 | 10 - Infrastructure | Due to the age of the generator, reliability and reparability risk due to age and the apparent under capacity of the generator it is recommend to replace the generator with a new generator and associated control system designed for the current load requirements and allowance for some future expansion. |
REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
REC296-1357 | 10 - Infrastructure | Monthly test results need to be accurately recorded. |
REC296-1362 | 10 - Infrastructure | Carry out a detailed audit of the current Hospital essential loads to determine the current load requirements of the Hospital. |
REC296-1351 | 10 - Infrastructure | From the above assessment determine the existing generator load requirements and provide a new generator to meet those loads. |
REC296-1356 | 10 - Infrastructure | Accurate records need to be provided as to what is done for each service. |
REC296-1361 | 10 - Infrastructure | Prepare and carry out a testing regime and testing strategy and ensure testing of the generator is done every month for 4 hours over that month and under full Hospital load with test result recorded every 15 minutes. |
REC296-1350 | 10 - Infrastructure | Remove any loads that do not need to be on essential power. |
REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
Rec-ID | Code | Recommendation |
---|---|---|
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1279 | 10 - Infrastructure | Install UPS on traffic lights on main Central Business District (CBD) and arterial roads to allow an effective movement of traffic during a loss of power. |
REC295-1305 | 18 - Access to fire ground | That the annexure to the State Emergency Management Plan, ‘Traffic management during emergencies’, be updated to include: responsibilities and processes for road closures; and, Department of Planning, Transport and Infrastructure requirements in regards to provision of road closure information, notification of changes in road closure status and publishing of that information. |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1286 | 10 - Infrastructure | That the Attorney General’s Department consult with local government regarding potential for them to provide logistical support associated with backup power supply to SA Government Radio Network towers in the event of an emergency. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-2025 | 41 - Emergency Management exercises | Exercise heatwave arrangements with a focus on the public administration sector and management of vulnerable people |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1441 | 5 - Hazard reduction burns | Continue the Fuel Reduction Program. |
REC286-1469 | 39 - Disaster Risk Management | Actively manage riparian vegetation to manage flood dynamics. |
REC286-2039 | 41 - Emergency Management exercises | Nuance the exercises for flood / dam-break / debris flow to incorporate consideration. |
REC286-2046 | 1 - Land-use and building regs | Incentivising safer sites (charge people less rates and discounts for defensive actions by land managers). |
REC286-2089 | 39 - Disaster Risk Management | Identify and analyse statewide storm hazard risk. |
REC286-1448 | 39 - Disaster Risk Management | Utilise coastal mapping to assess need for coastal defences. |
REC286-2056 | 39 - Disaster Risk Management | Review Ambulance Tasmania surge capacity. |
REC286-1455 | 39 - Disaster Risk Management | Assess options for managed coastal retreat. |
REC286-2023 | 1 - Land-use and building regs | Locate and design new public infrastructure so that it can continue to operate during flood events. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
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. |
REC286-1468 | 39 - Disaster Risk Management | Identify and anlalyse the location of critical infrastructure within defined flood areas. |
REC286-2038 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning reforms to evaluate effectiveness of delivering desired outcomes. |
REC286-2044 | 1 - Land-use and building regs | Develop linkages between landslide risk assessors and building engineers/structural works. |
REC286-2087 | 41 - Emergency Management exercises | Develop and exercise Severe Storm Emergency Management Plan. |
REC286-1447 | 39 - Disaster Risk Management | Assess vulnerability of ecosystems and species to coastal inundation. |
REC286-1478 | 39 - Disaster Risk Management | Review environmental risks associated with hazardous uses within flood prone areas. |
REC286-2052 | 22 - Role of local Gvt | Undertake local level emergency management planning for areas at risk of debris flow. |
REC286-1453 | 1 - Land-use and building regs | Review building controls to ensure they are adaptive to changing coastal inundation risks. |
REC286-2017 | 39 - Disaster Risk Management | Improve maintenance of flood mitigation infrastructure. |
REC286-2066 | 39 - Disaster Risk Management | Advocate for an National Notifiable Diseases Database. |
REC286-1436 | 4 - Fire season preparation | Continue the development and implementation of community level Bushfire Mitigation Plans. |
REC286-1464 | 41 - Emergency Management exercises | Exercise time-critical decision making processes within the context of an earthquake scenario. |
REC286-2037 | 1 - Land-use and building regs | Make property level information on landslide hazards publicly available |
REC286-2043 | 22 - Role of local Gvt | Assessment of council’s capacity to manage land effectively. |
REC286-2084 | 10 - Infrastructure | Establish emergency services ICT redundancy arrangements for damage loss of communications infrastructure. |
REC286-1445 | 41 - Emergency Management exercises | Develop, implement, review and exercise inter-agency community evacuation and recovery plans across the State. |
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2051 | 1 - Land-use and building regs | Establish arrangements to enable the buy-back of specified landslip prone land. |
REC286-1452 | 39 - Disaster Risk Management | Improve understanding of the allocation of ownership across government, business and individuals. |
REC286-2015 | 1 - Land-use and building regs | Build flood capable infrastructure. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-1435 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning and Building System reforms to evaluate effectiveness of delivering desired outcomes. |
REC286-1463 | 39 - Disaster Risk Management | Develop enablers and capacity for Tasmanian earthquake risk owners. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2041 | 22 - Role of local Gvt | Development mechanisms to support small councils to manage treatment across the PPRR spectrum (across all hazards). |
REC286-2082 | 41 - Emergency Management exercises | Undertake inter-agency severe storm exercises. |
REC286-1444 | 16 - Training and behaviour | Maintain adequate seasonal fire crew resources across the fire agencies. |
REC286-1474 | 1 - Land-use and building regs | Raised access routes. |
REC286-2050 | 1 - Land-use and building regs | Ensure landuse planning and building systems, including appeal mechanisms, are transparent, equitable and integrated at the municipal, State and national levels. |
REC286-1451 | 1 - Land-use and building regs | Include consideration of coastal inundation in land use planning for new developments and uses. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
REC286-2061 | 41 - Emergency Management exercises | Review and exercise the Tasmanian Mass Vaccination Plan. |
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. |
REC286-1461 | 39 - Disaster Risk Management | Review all hazards response and recovery plans to ensure they address likely earthquake consequences. |
REC286-2031 | 10 - Infrastructure | Improve information about electricity demand during heatwaves. |
REC286-2081 | 39 - Disaster Risk Management | Engage with industry bodies to explore opportunities to better understand and manage risks. |
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. |
REC286-1471 | 1 - Land-use and building regs | Promote the use of Water Sensitive Urban Design in stormwater systems. |
REC286-2040 | 1 - Land-use and building regs | Further development of Landslide Hazard Banding of the State (MRT). |
REC286-2049 | 39 - Disaster Risk Management | Pro-actively manage landslide areas. |
REC286-1450 | 39 - Disaster Risk Management | Improve the understanding of the vulnerability of critical infrastructure. |
Rec-ID | Code | Recommendation |
---|---|---|
REC285-2525 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania outline what KPIs are measured and provide targets or benchmarks to define what is good or poor performance. |
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. |
REC285-2518 | 38 - Agency/Department Reporting | The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions. |
REC285-2517 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania collects data to allow regular and meaningful comparison of clinical outcomes at the regional level, to better allocate resources and to rapidly identify problems. |
Rec-ID | Code | Recommendation |
---|---|---|
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
REC284-1374 | 10 - Infrastructure | Provide walls around critical electrical infrastructure within the main plant area to provide security and protection from catastrophic water system failures. |
REC284-1368 | 10 - Infrastructure | Improvements to installation to be implemented as follows: - Lighting within the generator enclosure and immediately adjacent to be emergency battery-backed type. - Improvements to the spatial layout within the main generator enclosure should be investigated, including allowance for the control panel door to open 180o (only 90o currently); moving the fuel pumps to a more accessible location, and ensuring clear access to the day tank for manual filling if required. - Improvements to communications facilities between critical areas, including fixed phone line connections between the main control room, main generator control panel in the P (energy) Building, and the generator enclosure, and allowing link to offsite specialist advice. - Where generator maintenance requires operations outdoors (not applicable to main generator, but applicable to others), a shelter over the relevant area should be provided to allow safe work during wet or hot weather. - Written emergency procedures to be prepared covering credible failure scenarios with step by step checklists and recommended actions. |
REC284-1373 | 10 - Infrastructure | Review generator installations details as noted in report and implement physical improvements where possible. |
REC284-1367 | 10 - Infrastructure | Add to generator test procedure a checklist at the end of testing which includes checking that all systems are back to normal positions and includes a requirement to leave the day tank full where there is a bulk tank/day tank arrangement. |
REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
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. |
REC281-1203 | 22 - Role of local Gvt | Impact Assessment Data Sharing The Office of Emergency Management: · with the SEOCON, jointly provides further guidance to Regional Emergency Management Officers about their role in facilitating local council access to the Impact Assessment Data Base · with REMOs and the SEOCON jointly provides further information to local councils about Impact Assessment Data Sharing Arrangements and the data available through this mechanism · includes information about the Impact Assessment Data Sharing Arrangements in the Local Recovery Toolkit · develops a mechanism to allow local councils to have direct access to the collated impact data. |
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 |
---|---|---|
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 |
---|---|---|
REC276-1178 | 16 - Training and behaviour | Within six months, consider improved processes for consulting with and engaging volunteers and continue to work with LGs to improve information sharing and communication. Specifically, DFES should improve communication around its decisions on equipment and training as well as provide better information about access to services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
REC272-1421 | 16 - Training and behaviour | In conjunction with the Queensland Fire and Emergency Services review of guidelines, the Public Safety Business Agency should consider reviewing the cyclone shelter management training package to include guidance to the shelter management team on their roles and responsibilities, and powers available under legislation and how these may be exercised. |
REC272-1419 | 22 - Role of local Gvt | Opportunities should be identified through the Local Government Association of Queensland council to council arrangement to share structural engineers to assess potential places of refuge against the Department of Housing and Public Works’ structure classification criteria. |
Rec-ID | Code | Recommendation |
---|---|---|
REC268-1428 | 16 - Training and behaviour | The Warning and Alert Systems training (including the use of Emergency Alert and the requirements of the guidelines) is delivered to: |
REC268-1424 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Emergency Alert Guidelines is reviewed to reflect current practice and incorporate evidence-based improvements informed by lessons learned and research. |
REC268-1423 | 22 - Role of local Gvt | The State Disaster Coordination Centre Notification Matrix is reviewed to ensure local governments are notified of any event affecting, or likely to affect, their local government area. |
REC268-1422 | 25 - Inquiry, audit, lessons management and after action review | The Queensland State Disaster Management Plan is reviewed to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |
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 |
---|---|---|
REC262-1489 | 10 - Infrastructure | That the Emergency Services Telecommunications Authority reclassifies its State Emergency Communications Centres as critical national infrastructure. |
REC262-1490 | 10 - Infrastructure | That the Emergency Services Telecommunications Authority critically reviews: |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
Rec-ID | Code | Recommendation |
---|---|---|
REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
REC256-1570 | 1 - Land-use and building regs | All governments should put in place best-practice institutional and governance arrangements for the provision of public infrastructure, including road infrastructure. These should include: |
Rec-ID | Code | Recommendation |
---|---|---|
REC255-1579 | 38 - Agency/Department Reporting | The ANAO recommends that the Department of Defence take steps to strengthen the priority afforded by Defence units to meeting these reporting requirements. |
Rec-ID | Code | Recommendation |
---|---|---|
REC252-2566 | 38 - Agency/Department Reporting | Western Australia Health should require service providers to report more comprehensive performance data using additional cost and clinical indicators |
REC252-2565 | 38 - Agency/Department Reporting | Western Australia Health should include in contracts minimum standards for emergency and secondary ambulance services and effective mechanisms to monitor these |
REC252-2571 | 38 - Agency/Department Reporting | St John Ambulance should develop quantitative performance targets for community paramedics and report these to Western Australia Health |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2627 | 4 - Fire season preparation | Government in conjunction with the CFS identify the ownership of disused railway corridors which may pose a significant fire risk and ensure the agency or individual responsible for the land complies with legislative requirements. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2606 | 22 - Role of local Gvt | The Act be amended to require the mandatory appointment of Authorised Officers by each rural council or council that has within its area a Designated Urban Bushfire Risk Area(s) with an option for the CFS Chief Officer to exempt council from this requirement (similar to Section 105B). |
REC244-2605 | 39 - Disaster Risk Management | A thorough consultative process be developed and implemented between the CFS and local government. This will determine how bushfire management planning can enable improved process and practice to mitigate bushfire risk, and ensure that fire permits are issued and complied with. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
Rec-ID | Code | Recommendation |
---|---|---|
REC243-0847 | 4 - Fire season preparation | That the obligation (following the passage of the Fire and Emergency Services (Review) Amendment Bill 2009) for Chief Fire Officers (CFS & MFS) to require State agencies to clean up fire risk on their land, and to make similar requests to Commonwealth agencies, be strongly implemented. |
Rec-ID | Code | Recommendation |
---|---|---|
REC242-2649 | 4 - Fire season preparation | That the obligation (following the passage of the Fire and Emergency Services (Review) Amendment Bill 2009) for Chief Fire Officers (CFS & MFS) to require State agencies to clean up fire risk on their land, and to make similar requests to Commonwealth agencies, be strongly implemented. |
REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC240-2653 | 38 - Agency/Department Reporting | That the Department of Health publicly reports a comprehensive suite of performance information, including: |
REC240-2652 | 38 - Agency/Department Reporting | That the Department of Health enhances management reporting processes over complaints by recording the number and nature of complaints, following up outstanding complaints formally and reporting complaints data to executive management. |
Rec-ID | Code | Recommendation |
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REC239-2691 | 39 - Disaster Risk Management | That the Commissioners of Police and the Queensland Fire and Rescue Service review the current district disaster boundaries as a matter of urgency in-line with the findings and recommendations of the Auditor–General’s report into the Queensland disaster management system. |
REC239-2773 | 38 - Agency/Department Reporting | That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations: |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2688 | 22 - Role of local Gvt | That in establishing new disaster districts, the first guiding principle must be to align with local government boundaries and that divergence should only occur when there is a need to address a unique local circumstance. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2741 | 16 - Training and behaviour | That the annual training calendar identify course, training location and the coordinating authority. |
REC239-2684 | 38 - Agency/Department Reporting | The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance. |
REC239-2771 | 38 - Agency/Department Reporting | That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies. |
REC239-2723 | 1 - Land-use and building regs | That the Queensland Fire and Rescue Service examine alternative contractual arrangements with building owners which would reduce the need for physical attendance at alarm activations. |
REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2740 | 16 - Training and behaviour | That impediments to the publication of an annual training calendar of core skills be removed. |
REC239-2674 | 38 - Agency/Department Reporting | That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures. |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
REC239-2711 | 39 - Disaster Risk Management | That the Inspector General Emergency Management be empowered to provide an assurance to Government that the disaster management system is both appropriate and capable of dealing with complex events. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2729 | 16 - Training and behaviour | That the Queensland Fire and Rescue Service work to change the culture of entitlement so that firefighters recognise firefighting is only one of a range of skills they bring to their core role of emergency management. |
REC239-2673 | 38 - Agency/Department Reporting | That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2692 | 39 - Disaster Risk Management | That the Queensland Police Service Disaster Management Unit is to be permanently located at the State Disaster Coordination Centre to work on a day to day basis with the proposed new Department of Fire and Emergency Services. |
REC239-2774 | 39 - Disaster Risk Management | Those final determinations of disaster management districts include consultation with the Local Government Association Queensland, the Queensland Fire and Rescue Service and other Government departments. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2671 | 16 - Training and behaviour | That all Queensland Corrective Service provision of training should be contestable. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0825 | 1 - Land-use and building regs | That the NSW Rural Fire Service hold discussions with the Department of Planning and Infrastructure and Local Government NSW on ways to improve compliance with development consents under section 76A of the Environmental Planning and Assessment Act 1979. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
Rec-ID | Code | Recommendation |
---|---|---|
REC231-2830 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that the Department of Regional Australia, Local Government, Arts and Sport improve its monitoring of the delivery of the Natural Disaster Recovery Work Plans for Queensland and Victoria by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC230-2831 | 10 - Infrastructure | The committee recommends that the Minister for Broadband, Communications and the Digital Economy issue a Ministerial Direction to the Australian Communications and Media Authority to allocate 20 MHz of contiguous spectrum in the 700 MHz band for the purposes of a public safety mobile broadband network. |
REC230-2833 | 10 - Infrastructure | If recommendation 1 is not supported by the Australian Government, the committee recommends that the Minister for Broadband, Communications and the Digital Economy issue a Ministerial Direction to the Australian Communications and Media Authority to allocate as a minimum requirement, 20 MHz in the 800 MHz band for the purposes of a public safety mobile broadband network. |
REC230-2832 | 10 - Infrastructure | The committee recommends that the Minister for Broadband, Communications and the Digital Economy take appropriate measures to secure, for public service agencies, priority access to an additional 10 MHz of spectrum in the 700 MHz band for public safety purposes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC229-2842 | 1 - Land-use and building regs | The committee recommends that building codes incorporate mitigation measures that take into account foreseeable risks from extreme weather events. |
REC229-2841 | 1 - Land-use and building regs | The committee recommends that credible and reliable flood mapping activities and the development of other information that would best inform landowners or prospective landowners of potential risks from extreme weather events are prioritised and used to inform land use planning laws. |
REC229-2840 | 39 - Disaster Risk Management | The committee recommends relevant authorities work with community service organisations in both planning responses to and responding to extreme weather events, in particular those organisations that provide vital services to vulnerable groups. |
Rec-ID | Code | Recommendation |
---|---|---|
REC222-1853 | 38 - Agency/Department Reporting | The Ministers for Emergency Services, Environment and Police ensure their departments include in their annual reports the expenditure they have incurred on preparing their staff for critical incidents, and for managing their response to these incidents. |
REC222-1867 | 16 - Training and behaviour | The Minister for Emergency Services ensure that the Fire and Emergency Services Authority’s peer support program is rejuvenated as soon as possible with increased funding to provided added training for staff volunteering for this program |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1865 | 16 - Training and behaviour | The Minister for Police immediately instigate processes to ensure that the psychological well-being of officers is at the forefront of the Western Australia Police’s staff planning. These processes should include all officers being trained in psychological first aid, with subsequent regular refresher courses. Senior officers should be the first priority for psychological first aid training. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
REC222-1861 | 41 - Emergency Management exercises | The Ministers for Health, Emergency Services, Environment and Police provide additional funds to their agencies so that a detailed exercise is held on a regular basis based on a disaster that will create the worst outcome for the State. |
REC222-1855 | 22 - Role of local Gvt | Local government authorities incorporate into their Local Emergency Management Plans their procedures for dealing with any trauma experienced by bushfire brigade volunteers, having regard to best practice in managing trauma. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC221-2862 | 38 - Agency/Department Reporting | Housing should use risk based analysis of its tenant and property information, job order data and quality assurance results to better inform target setting for KPIs, job order controls, and the sampling used for completed work inspections before and after payment. This analysis should synthesise information from all sources and include a risk assessment of tenants and properties, as well as consideration of the various types of maintenance work being done (emergency, priority and routine, and planned maintenance). |
REC221-2861 | 38 - Agency/Department Reporting | Housing should further develop its Head Contractor key performance indicators to include quality, cost and tenant satisfaction. Currently performance reporting is focused entirely on timeliness indicators. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
Rec-ID | Code | Recommendation |
---|---|---|
REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1901 | 1 - Land-use and building regs | The Council of Australian Governments’ Building Ministers’ Forum should provide formal direction to the Australian Building Codes Board to: |
REC205-1900 | 1 - Land-use and building regs | As a priority, state and territory governments should ensure that land-use planning systems are sufficiently flexible to enable a risk management approach to incorporating climate change risks into planning decisions at the state, territory, regional and local government levels. Consideration should be given to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC190-1929 | 38 - Agency/Department Reporting | That the Queensland Reconstruction Authority consider extending the suite of internal performance indicators being used as the Authority matures. |
Rec-ID | Code | Recommendation |
---|---|---|
REC180-2970 | 22 - Role of local Gvt | Councils should improve assessments of business continuity risks by: |
REC180-2969 | 22 - Role of local Gvt | Councils should strengthen governance arrangements for business continuity by: |
REC180-2973 | 22 - Role of local Gvt | Local Government Victoria should, further to its work on strengthening the oversight role of audit committees, assist councils to develop good practice approaches to implementing, overseeing and continuously improving business continuity management. |
REC180-2972 | 22 - Role of local Gvt | Councils should strengthen their continuous improvement frameworks by: |
REC180-2971 | 22 - Role of local Gvt | Councils should improve the structure, format and content of their business continuity plans to provide greater clarity on roles and responsibilities for emergencies, more specificity on continuity and recovery responses, and better integration with other council disaster recovery and emergency plans. |
Rec-ID | Code | Recommendation |
---|---|---|
REC179-2978 | 16 - Training and behaviour | The Department of Human Services should make sure relevant senior staff complete recovery training. |
REC179-2977 | 38 - Agency/Department Reporting | The Department of Human Services should create evaluation guidelines for recovery operations, including links to planning. |
REC179-2976 | 41 - Emergency Management exercises | The Department of Human Services should regularly test recovery plans with partner agencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC174-2985 | 25 - Inquiry, audit, lessons management and after action review | To provide adequate assurance on the validity of claims paid for disaster recovery assistance, the ANAO recommends that Centrelink: |
REC174-2984 | 39 - Disaster Risk Management | To improve Centrelink’s preparedness for responding to future disasters, the ANAO recommends that Centrelink include disasters that impact on multiple Areas in its emergency and business continuity test exercise program. |
Rec-ID | Code | Recommendation |
---|---|---|
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
REC170-0055 | 22 - Role of local Gvt | SEMC and EM WA should: monitor and take action to ensure local plans are in place and cover areas where the hazard could occur |
REC170-0054 | 22 - Role of local Gvt | SEMC and EM WA should: work with local government to ensure up-to-date, comprehensive local arrangements are in place |
REC170-0065 | 16 - Training and behaviour | Agencies should: train their staff who will be involved in emergencies in incident management. |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC160-3044 | 38 - Agency/Department Reporting | The ANAO recommends that the Business Continuity, Crisis Management and Security Sub committee: |
REC160-3042 | 38 - Agency/Department Reporting | In order to identify key business processes and provide for the regular comparative assessment of Maximum Allowable Outage periods (MAOs), the ANAO recommends that Centrelink: |
REC160-3045 | 38 - Agency/Department Reporting | The ANAO recommends that Centrelink: |
Rec-ID | Code | Recommendation |
---|---|---|
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
REC159-3055 | 38 - Agency/Department Reporting | ACTAS should implement systems to enable the accurate collection and measurement of non-emergency ambulance service bookings to facilitate monitoring of performance and the provision of accurate advice to Government. |
REC159-3050 | 38 - Agency/Department Reporting | ACTAS should log all emergency calls on CAD to document non-ambulance dispatch decisions, and to provide more complete data on demand. |
REC159-3047 | 38 - Agency/Department Reporting | ACTAS should develop a comprehensive performance management framework that includes key performance indicators and targets aligned to its service delivery activities, to help inform management and stakeholders of its performance. |
REC159-3062 | 38 - Agency/Department Reporting | ACTAS should develop a set of standards to measure and monitor patient satisfaction, so that improvements to the service can be made, based on patient satisfaction information. |
REC159-3059 | 38 - Agency/Department Reporting | ACTAS should establish a clinical information database that: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
Rec-ID | Code | Recommendation |
---|---|---|
REC147-3186 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that, in order to assist management decision making and to inform Parliament about performance, Emergency Management Australia (EMA) develop and report appropriate measures for its key emergency management activities and outcomes. |
REC147-3187 | 16 - Training and behaviour | The ANAO recommends that, in order to maximise the benefit of emergency management training activities, EMA review periodically its approach to delivering individual training courses, to ensure the most appropriate delivery mechanism is used commensurate with training objectives. |
Rec-ID | Code | Recommendation |
---|---|---|
REC146-3193 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the Australian National Audit Office audit CASA's implementation and administration of its Safety Management Systems approach. |
Rec-ID | Code | Recommendation |
---|---|---|
REC145-3222 | 1 - Land-use and building regs | The Committee recommends that the Australian Government: |
REC145-3209 | 39 - Disaster Risk Management | The Committee notes that major initiatives relating to climate change adaptation risk assessment and infrastructure are currently in progress. Given that much of Australia’s infrastructure is in the coastal zone and the particular threats facing the coastal zone from climate change, involving significant socioeconomic costs, the Committee recommends that the Australian Government ensure there is a comprehensive national assessment of coastal infrastructure vulnerability to inundation from sea level rise and extreme sea level events. |
REC145-3215 | 1 - Land-use and building regs | The Committee recommends that the Building Code of Australia, including cyclone building codes, be revised with the objective of increasing resilience to climate change. |
REC145-3203 | 39 - Disaster Risk Management | The Committee recommends that: |
REC145-3214 | 1 - Land-use and building regs | The Committee recommends that the Australian Government consider the benefits of adopting a nationally consistent sea level rise planning benchmark and, if so, whether this be done on a statutory basis or otherwise. The outcomes of this consideration should then be included as part of the action plan for the proposed Intergovernmental Agreement on the Coastal Zone. |
REC145-3199 | 16 - Training and behaviour | The Committee recommends that the Australian Government continue funding under the Climate Change Adaptation Skills for Professionals Program. In addition, the Australian Government should liaise with tertiary institutions to ensure an adequate supply of appropriately skilled coastal planners and engineers. |
REC145-3213 | 1 - Land-use and building regs | The Committee notes the Council of Australian Governments initiative (through the Local Government and Planning Ministers Council) to develop state-specific climate change planning policies by mid 2011, to inform local governments and regional planning responses to climate change. The Committee recommends that the Australian Government ensure that the outcomes of this initiative are included as part of the action plan under the proposed new Intergovernmental Agreement on the Coastal Zone. |
REC145-3231 | 22 - Role of local Gvt | The Committee recommends that the Australian Government request that the Centre for Excellence for Local Government ensure a particular focus on capacity building for coastal local councils. Capacity building should focus on addressing issues relating to: |
REC145-3227 | 39 - Disaster Risk Management | The Committee recommends that coastal based Natural Resource Management bodies seeking funding under the Caring for our Country program have coastal and marine priorities, as well as coastal zone management principles integrated in their management plans. |
REC145-3210 | 39 - Disaster Risk Management | The Committee recommends that the Department of Climate Change, in collaboration with the Queensland Government, CSIRO and Indigenous communities in the Torres Strait, undertake a major study into the vulnerability of the Torres Strait to the impacts of climate change and provide assistance in the development of an adaptation plan. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3385 | 41 - Emergency Management exercises | The Committee recommends that the ESA hold discussions with NSW with a view to developing a joint exercise program with the NSW Rural Fire Service on an ongoing basis. |
REC144-3384 | 41 - Emergency Management exercises | The Committee recommends that the ESA develop a schedule of proposed exercises as a five year rolling plan, in order that all the elements of emergency services are able to be tested over that time and in differing |
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. |
REC144-3393 | 1 - Land-use and building regs | The Committee recommends that the responsibility for land management issues lie within a single portfolio, specifically the Minister for Territory and Municipal Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3574 | 38 - Agency/Department Reporting | Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly. |
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 |
---|---|---|
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC123-3882 | 41 - Emergency Management exercises | The Office of the Emergency Services Commissioner convene a working group of key emergency services and emergency management agencies to develop a flow chart based on scenario testing, to support decision making and the assessment of response requirements to medical, hazardous materials and CBR emergencies including their transition from one type to another. |
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 |
---|---|---|
REC121-3677 | 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. |
REC121-3717 | 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. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3691 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3654 | 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. |
REC121-3715 | 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. |
REC121-3765 | 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. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3684 | 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. |
REC121-3719 | 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. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
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. |
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
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. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
REC119-3648 | 38 - Agency/Department Reporting | It is recommended that providers supply data to the Board: |
Rec-ID | Code | Recommendation |
---|---|---|
REC116-2127 | 39 - Disaster Risk Management | The Working Group recommends that the Australian Government and the States/Territories use the survey templates compiled in each of their jurisdictions during the capability review workshops, and the scenarios to consider their current and future capabilities, to respond to and recover from large scale disasters. |
REC116-2116 | 39 - Disaster Risk Management | The working group recommends that a similar project to the Review of Australia's Ability to Respond to and Recover from Catastrophic Disasters be established to consider the longer term consequences of catastrophic disasters and their resulting recovery implications. Key aspects of such a review would include: |
REC116-2115 | 41 - Emergency Management exercises | The Working Group recommends that the results of the scenario modeling be presented to the Australian Emergency Management Committee (AEMC) upon completion, and that AEMC form Sub Working Groups of State/Territory emergency management representatives as appropriate to be tasked with considering response and recovery capability (both state/territory and national) against the identified consequences. |
REC116-2107 | 10 - Infrastructure | The Working Group recommends that State/Territory emergency management plans should explicitly take the need for rapid assessment of damaged physical infrastructure into account. The importance of rapid physical infrastructure assessment in ensuring the supply of utilities including sewerage and drainage, electricity, water and gas to residential structures and other types should be recognised and considered. |
REC116-2106 | 16 - Training and behaviour | The Working Group recommends that appropriate building/surveyor peak bodies be identified, and that discussions be held between the emergency management sector and those peak bodies at State/Territory and national level with a view to: |
REC116-2129 | 41 - Emergency Management exercises | The Working Group recommends that Emergency Management Australia and the jurisdictions through the AEMC develop a three year rolling national exercise strategy aimed at testing the response and recovery aspects of large scale disasters. |
REC116-2104 | 39 - Disaster Risk Management | The Working Group recommends that in addition to existing disease control and pandemic management plans, States/Territories should consider developing a pandemic emergency management plan that considers the impact of pandemic disease broadly, encompasses all government and private sector agencies and addresses: |
Rec-ID | Code | Recommendation |
---|---|---|
REC111-3937 | 16 - Training and behaviour | To enhance the delivery of disaster management services, it is recommended that the Department of Emergency Services — |
REC111-3941 | 39 - Disaster Risk Management | That the State Disaster Management Group supported by the Department of Emergency Services ensures that State-wide a robust disaster risk management process is established that includes the aggregation of relevant information from local, district, functional and threat specific plans to develop a hazard risk profile for Queensland. |
REC111-3940 | 39 - Disaster Risk Management | To enhance disaster risk management planning processes, it is recommended that the State Disaster Management Group supported by the Department of Emergency Services develop a suitable performance management system to ensure local, district, functional and threat specific Disaster Management Plans are — |
REC111-3939 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the State Disaster Management Group and the Department of Emergency Services review the current disaster district boundary framework and its relevance to the regional boundaries established by other public sector lead entities to ensure that resources within the Disaster Management System are economically, efficiently and effectively allocated across Queensland. |
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. |
REC008-3984 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |